Anterior Cervical Discectomy and Fusion

This article is on the ACDF procedure. If you do it differently, or have any comments, please share them.

Note: the original post included 50+ step-by-step intraoperative photographs illustrating this technique. Those images are not reproduced here — re-upload from your personal library if you'd like them restored. The text below preserves the full technique description.

1. Introduction

Anterior cervical discectomy and fusion (ACDF) was described over half a century ago by Smith and Robinson in 1955 and Ralph Cloward in 1958. This procedure has stood the test of time and is frequently used to treat cervical spine pathologies with good outcomes when used for the correct indications.

2. Indications

1. Cervical radiculopathy (intractable, recurrent, or progressive)
2. Cervical myelopathy (moderate to severe, or progressive)
3. Specific types of cervical trauma, tumors, or infections where spinal cord decompression and anterior column reconstruction is required

3. Contraindications

1. Posterior spinal cord compression
2. Anterior spinal compression dorsal to the vertebral body
3. Bleeding disorder

4. Preoperative planning

Plain radiographs and MRI are essential. CT myelography may be performed if MRI is contraindicated.

5. Equipment and instruments

1. C-arm fluoroscopy
2. Loupe magnification with headlight or microscope
3. Neuro drill (3 mm diamond burr)
4. Radiolucent operating table (traction pulley and weight optional)

6. Positioning

Nasogastric tube (optional for one-level, recommended for multilevel ACDF), head ring, shoulders taped down, shoulder pad at scapula level for slight neck extension, sandbag under iliac crest if graft harvest planned, arms wrapped and tucked. Optional: Gardner Wells traction; neuromonitoring (mandatory baseline recording before positioning).

7. Anterior cervical spine exposure

A transverse incision is made along Langer's lines to the anterior border of SCM after subcutaneous infiltration with adrenaline solution. The platysma is divided and undermined, the plane medial to SCM is developed, and dissection proceeds bluntly between the viscera (trachea/esophagus) and carotid sheath. Once the prevertebral fascia is reached, discs are identified as "hills" and vertebral bodies as "valleys."

8. Discectomy

Level is confirmed with a prebent spinal needle under fluoroscopy. The disc is incised and cleared using curettes and pituitary forceps; Casper distractor pins are placed and the disc space is gently distracted. The PLL can be taken down at the midline or lateral edge using a nerve hook and 15-blade once the posterior annulus is removed (not mandatory in all cases — we prefer it when disc fragments are suspected behind the PLL).

9. Fusion

Endplates are decorticated with a diamond burr/rasp to convert the disc space into a flat rectangular box. A sizer determines graft/cage size (assessed with distraction released). Cages (e.g., PEEK) are inserted and confirmed on fluoroscopy.

10. Anterior cervical plating

Plate size is chosen so screw holes sit just clear of adjacent endplates, with at least 5 mm clearance from adjacent discs to avoid adjacent segment disease. Variable-angle, unicortical, self-drilling/self-tapping screws are commonly used (fixed-angle for higher instability such as trauma). Screws are locked into the plate.

11. Postoperative care and rehabilitation

• Head elevation
• Airway and oxygen saturation monitoring for 4–6 hours
• Neurological examination every 4 hours
• Sip test after 6 hours, then advance diet as tolerated
• Drain removed on postop day 1 if output <20cc
• X-ray cervical spine AP/lateral before discharge
• Discharge on postop day 1–2 if no dysphagia

12. Complications

• Dysphagia (most common; usually temporary, ~1% permanent)
• Injury to superior laryngeal nerve (pitch loss) or recurrent laryngeal nerve (hoarseness)
• Esophageal injury
• Carotid artery / internal jugular vein / vagus nerve injury
• Vertebral artery injury (far lateral dissection beyond uncovertebral joints)
• Horner's syndrome (sympathetic chain injury)
• Neurological deficit (cord/root injury, implant/graft dislodgement, epidural hematoma)
• CSF leak
• Airway obstruction (prevertebral edema/hematoma)
• Wound infection
• Implant failure or graft dislodgement
• Nonunion (higher risk in smokers, diabetics, multilevel discectomies)