ANTERIOR CERVICAL DISCECTOMY
WITH FUSION (ACDF)
Presented by
Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC
Vice President Neuroscience and Orthopedics
HCA East Florida Division
OBJECTIVES
• Discuss the simple anatomy and physiology of the cervical spine
• Discuss the Nerve Root Level, Function and Radicular Distribution
• Discuss the diagnostic studies completed before ACDF surgery
• Discuss Degenerative Cervical Spine Disorders
• Discuss surgical treatment of the cervical spine with Anterior
approach and fusion (ACDF)
CERVICAL SPINE
Cervical Vertebrae :
• The cervical spine has seven vertebrae.
• The body, or centrum, of the vertebra is located
anteriorly
• The vertebral foramen, referred to as the spinal canal,
is behind the vertebral body.
CERVICAL DISCS
• With the exception of C1–C2, an intervertebral
disc resides between each of the cervical
vertebral bodies.
• Why?
CERVICAL DISC
• Each intervertebral disc provides support and
facilitates movement, while also resisting
excessive movement.
• The disc permits slight anterior flexion,
posterior extension, lateral flexion, rotation,
and some circumduction (Schnuerer, Gallego, & Manuel,
2003).
• The disc is the largest avascular
structure in the body (Anderson & Albert, 2003).
CERVICAL DISC
• Cervical discs are composed of the nucleus pulposus,
an inner capsule with tissue the consistency of
crabmeat, and the annulus fibrosus, a thick outer ring
of tissue much like cartilage.
• Although the nucleus
pulposus is usually
soft and spongy in
younger people, it
tends to dehydrate as
people age.
LIGAMENTS
• Ligaments: Are a band of fibrous tissue connecting
bones or cartilage. It is instrumental in maintaining
cervical
spine alignment
SPINAL CORD AND NERVES
• The spinal cord extends from the foramen magnum to the
upper lumbar spine (usually L1–L2) and gives rise to 31 pairs
of spinal nerves.
• The eight cervical roots exit through intervertebral foramina,
an opening between the vertebrae. The meninges (i.e., dura
mater, arachnoid layer, and pia mater) cover the spinal cord.
• Cerebrospinal fluid bathes the
spinal cord and is found in the
subarachnoid space
NERVE ROOT DISTRIBUTION
NERVE ROOT FUNCTION
CERVICAL DERMATOME
Diagnostic Studies
• Common diagnostic studies used to evaluate the
non-traumatic cervical spine patient:
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Plain Radiographs
Computed Tomography
Magnetic Resonance Imaging
Bone Scan
Myelogram/Postmyelogram CT
Electromyography/Nerve Conduction Velocities
Somatosensory Evoked Potentials
*Neuro Exam compared to diagnostic testing*
What is Radiculopathy?
• Radiculopathy refers to a set of conditions in
which one or more nerves is affected and does
not work properly (a neuropathy).
• The emphasis is on the nerve root (radix =
"root"). This can result in pain/radicular pain.
weakness, numbness, or difficulty controlling
specific muscles.
• The radicular pain that results from a
radiculopathy should not be confused with
referred pain which is different both in
mechanism and clinical features
CERVICAL SPINE DISORDERS
• Neck Pain Without Radiculopathy
• Cervical Radiculopathy: In the cervical spine, the most
common cause of radiculopathy is foraminal narrowing
and impingement onto the spinal nerve.
• Cervical Myelopathy: Myelopathy is the result of spinal
cord compression, which can stem from clinical entities
such as long-standing progressive compression from
spondylosis or ossification of the posterior longitudinal
ligament. It can also be caused by an acute problem
such as acute disc herniation. Myelopathy may be
exhibited in a number of ways,
CERVICAL SPINE DISORDERS
• Intervertebral Disc Herniation—Herniated
Nucleus Pulpous
CERVICAL SPINE DISORDERS
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II. Definitions
A. Bulge: Symmetrical extension of the disc beyond
the endplates
B. Protrusion: Focal area of bulge/disc extension that
is still attached to the disc (annulus fibrosis)
C. Extruded fragment: Nucleus pulposus no longer
connected to the disc
D. Sequestered fragment (i.e., free fragment): Nucleus
pulposus in the posterior longitudinal ligament
E. Radiculopathy: Pain in the distribution of a nerve
root resulting from irritation/compression on that
nerve root
CERVICAL SPINE DISORDERS
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Spondylosis Description and Etiology
• From the Greek word meaning “vertebra,” spondylosis is generally defined
as age- and use-related degenerative changes of the spine
CERVICAL SPINE DISORDERS
• Cervical Spondylotic Myelopathy
• is defined as “spinal cord dysfunction
accompanying typical age-related
degeneration of the cervical spine” (Tortolani
& Yoon, 2004, p. 701).
• Spondylosis is the most common etiology, and
spondylotic myelopathy is the most common
cause of spinal cord dysfunction in persons
older than 55 years.
CERVICAL SPINE DISORDERS
• Cervical Stenosis
• Cervical stenosis, classified as either
congenital or acquired, is a result of either
being born with a narrow spinal canal or
developing a narrow spinal canal as a result of
degenerative changes.
CERVICAL SPINE DISORDERS
• Inflamatory:
– Rheumatoid Arthritis
– Ankylosing Spondylitis
Neoplastic Cervical Spine Disease
Metastatic
Primary
CERVICAL SPINE DISORDERS
• Osteoporosis
• Osteoporosis, the most common metabolic
bone disease, is characterized by low bone
mass and structural deterioration of bone
tissue.
• Congenital Anomalies
• Infection
Non-Surgical Treatment
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Medication
Epidural Steroid Injections
Physical Therapy
Spinal Manipulation (Chiropractic or
Osteopathic)
• Bracing
• Acupuncture
• Back School
SURGICAL TREATMENT ACDF
• Surgical treatment for the patient with a
cervical radiculopathy is indicated for patients
with
– (a) persistent signs and symptoms, despite
approximately 6 weeks of appropriate nonsurgical
treatment or
– (b) a progressive motor deficit and in whom there
is radiographic correlation
SURGICAL TREATMENT ACDF
• Cervical Discectomy With and Without Fusion
• Single/multilevel: The purpose of both anterior
cervical discectomy with fusion (ACDF) and
without fusion (ACD) is to relieve pressure on the
neural elements of the spinal cord and nerve
roots
• More commonly, a fusion is performed utilizing
graft material and anterior plate fixation to
prevent disc collapse and subsequent kyphosis
SURGICAL TREATMENT ACDF
• Traditionally, an autogenous bone graft is
used. This graft typically is harvested from the
patient’s iliac crest.
• Many surgeons now favor the use of interbody
fusion devices (e.g., allograft, synthetic
spacers, cages)with allograft or other fusion
materials.
• The patient’s length of stay is usually 23 hours
or less.
SURGICAL TREATMENT ACDF
ACDF Complications
• Potential Complications–Anterior Cervical Surgery
• Complications, although rare, may include nerve root
injury (2%–3%),
• recurrent laryngeal nerve palsy resulting in hoarse
voice (2%),
• spinal cord injury
(<1%), esophageal perforation (<1%), or instrumentation
• failure, including nonunion
• (<5% for a single level surgery)
POST SURGERY
• After surgery, pain is managed with narcotic
medication. Because narcotic pain pills are addictive,
they are used for a limited period (2 to 4 weeks). As
their regular use can cause constipation, drink lots of
water and eat high fiber foods. Laxatives (e.g.,
Dulcolax, Senokot, Milk of Magnesia) can be bought
without a prescription. Thereafter, pain is managed
with acetaminophen (e.g., Tylenol).
• Hoarseness, sore throat, or difficulty swallowing may
occur in some patients and should not be cause for
alarm. These symptoms usually resolve in 1 to 4 weeks.
POST SURGERY
• Activity
• You may need help with daily activities (e.g.,
dressing, bathing), but most patients are able to
care for themselves right away.
• Gradually return to your normal activities.
Walking is encouraged; start with a short distance
and gradually increase to 1 to 2 miles daily. A
physical therapy program may be recommended.
• If applicable, know how to wear a cervical collar
before leaving the hospital. Wear it when walking
or riding in a car
POST SURGERY
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Most Common Restrictions
If you had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs)
(e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6
months after surgery. NSAIDs may cause bleeding and interfere with bone healing.
Do not smoke. Smoking delays healing by increasing the risk of complications (e.g.,
infection) and inhibits the bones' ability to fuse.
Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
Avoid sitting for long periods of time.
Avoid bending your head forward or backward.
Do not lift anything heavier than 5 pounds (e.g., gallon of milk).
Housework and yard-work are not permitted until the first follow-up office visit.
This includes gardening, mowing, vacuuming, ironing, and loading/unloading the
dishwasher, washer, or dryer.
Postpone sexual activity until your follow-up appointment unless your surgeon
specifies otherwise.
ACDF RESULTS
• What are the results?
• Anterior cervical discectomy is successful in
relieving arm pain in 92 to 100% of patients [3].
However, arm weakness and numbness may
persist for weeks to months. Neck pain is relieved
in 73 to 83% of patients [3]. In general, people
with arm pain benefit more from ACDF than
those with neck pain. Aim to keep a positive
attitude and diligently perform your physical
therapy exercises.
Biblography/ References
• AANN Clinical Practice Guideline Series;
Cervical Spine; A Guide to Preoperative
and Post-Operative Care