Acdf Surgery: Purpose, Procedure, and Benefits and Side Effects

Artificial disc replacement is best suited for patients with cervical disc disease. The procedure reduces pain and improves mobility in patients with cervical radiculopathy and/or myelopathy that have minimal degeneration of the disc.

The spinal discs serve as cushions or shock absorbers for the vertebrae and are situated in between the bones or vertebrae of the spine. The spinal column's flexibility and motion are also facilitated by the discs. The discs are divided into two sections:

The inner portion: soft material

The outer portion: a stronger, fibrous material

Degenerative disc disease can occur when disks become weaker with age and develop tears or fissures in their outer layer. Furthermore, the inner portion may protrude and rub against the outer portion, causing discomfort.

Degenerative disc disease often affects multiple spinal levels at once. Therefore, a patient may require multi-level disc replacement if they need artificial disc replacement at two or more levels. Artificial disk replacement is used to replace a damaged disk while keeping the spine mobile. Depending on patients’ symptoms, one disc (single-level) or more (multi-level) may be removed. Spine surgeries are carried out by an orthopedic or neurosurgeon as this is a specialty area for many spine surgeons.

There are a few methods that are commonly used to treat disc replacement

In order to repair the disc, a surgeon may use patients’ own bone cells from the hip (iliac crest). Due to the presence of bone-growing cells and proteins, this transplant has a higher rate of fusing. The pain you experience after the procedure in your hip bone can be a drawback of this surgery. In parallel with the spine surgery, a hip bone graft is also performed simultaneously by the surgeon. The surgeon takes out the bone and removes the top half layer of it, leaving it about half an inch thick.

In this procedure the bone is harvested from a donor’s body - the cadaver or from the bone-bank where the bones of dead donor’s are kept. As the bone is harvested from a dead donor, this graft does not have bone-growing cells or proteins, however it is easily available and removes the need to take bone from the patient's hip. Allograft has a doughnut-like form, and its interior is jam-packed with shavings of living bone tissue removed during surgery from your spine.

As the name suggests this is a man-made bone majorly made of plastic, ceramic, or bioresorbable compounds. This graft material, also known as cages, is filled with shavings of living bone tissue removed from your spine during surgery.

In order to straighten the spine and provide room for the nerve roots that go from it to the arms, shoulders, and chest, an anterior cervical discectomy and fusion (ACDF) is performed. The procedure also helps restrict motion in the injured area of the spine and has several benefits that include:

• Smaller surgical incisions
• Lower risk of tissue damage
• Lower risk of infection
• Less recovery period
• Significant relief from pain and other symptoms
• Less or no dependency on pain medication.

A herniated disc in the cervical or neck region is treated surgically with an anterior cervical discectomy with fusion (ACDF). Patients who experience neck pain and numbness that radiates into their arms, chest, and shoulders can benefit from the surgery.

If the pain is left untreated, it could get so bad that it can make it difficult for the patient to hold or grasp objects with their affected hand. To treat the condition the surgeon accesses the spine anteriorly from the front of the patients’ neck to remove any bony growths or damaged spinal discs that are compressing a patient's nerve roots.

The ACDF surgery may be appropriate for you if you;

• Have substantial weakness in your hand or arm
• Have neck discomfort that is worse than arm pain
• Symptoms that have not improved with physical therapy or medicines
• Your diagnostic testing; MRI, CT, myelogram shows conditions that need surgical intervention by a skilled surgeon.

ACDF may benefit patients with following conditions;

• Herniated disc and bulging disc: A weak spot in the surrounding wall ((annulus) may allow the gel-like material within the disc to rupture or expand. When this substance squeezes out and uncomfortably pushes on a nerve, it results in irritation and swelling.
• Degenerative disc disease: As discs age naturally, bone spurs develop and the facet joints become inflamed. The discs lose their flexibility and cushioning qualities as they dry out and shrink. The disc gaps get smaller. These alterations cause disc herniation or canal stenosis.

Though uncommon, yet as with all surgery there are a number of risks that can occur as a result of a cervical decompression and fusion surgery, including:

• Dysphagia
• Hematoma
• Worsening myelopathy
• Recurrent laryngeal nerve palsy
• CSF leaks
• Wound infection
• Radiculopathy
• Horner's Syndrome
• Respiratory insufficiency
• Esophageal perforation
• Instrument failure

Despite the risks, the ACDF surgery can be a good choice for people with neck pain that is caused by a ruptured disk, arthritis or other degenerative condition or injury. The chances of countering the risks can also be ignored or reduced if the surgery is done by an expert surgeon at Pristyn care.

Speak with a reputable healthcare professional of Pristyn care before the procedure to receive detailed instructions on how to get ready for the surgery. Your medical professional might be able to provide you with information about the pre- and post-surgery preparation and treatment that may include;

• Information of any medications you are taking, including over-the-counter medicines and dietary supplements, should be disclosed to your doctor. These drugs will likely need to be stopped in the days leading up to the surgery
• If you take aspirin or other blood-thinning medications, you may need to discontinue taking them a few days before surgery
• To lower the chance of infection, give up smoking at least 4 weeks ahead
• If you believe you could be pregnant, tell your doctor right away
• Talk about any potential bleeding disorders or other health issues you may have such as allergies, anesthesia reactions, previous surgeries
• In case you require a blood transfusion, blood samples will be taken from you
• Switch to healthy diet weeks before undergoing the surgery
• If you've had any recent operations, have allergies, let your doctor know
• Follow your doctor's advice about what to eat and drink before surgery. The night before surgery, you should probably avoid eating or drinking after midnight. Ask your doctor or nurse for instructions if you typically take your medication in the morning
• As ACDF surgery may require you to stay for one to two nights in the hospital, pack necessary items in your hospital bag such as; a toothbrush, robe, and slippers, to make your stay more comfortableLast but not least, arrange for dependable transportation to and from surgery. After having an ACDF surgery, you won't be allowed to drive.

Procedure for the ACDF surgery includes three processes - Before, during, and after the surgery. Find the procedures below:

• Several lab tests such as blood test, electrocardiogram, chest X-ray may be done few days before surgery to evaluate your health condition
• You might be asked to wash your skin with anti-bacterial soap to reduce surgical site infections
• To finish the required documentation and pre-procedure work-ups, arrive at the hospital two hours before your scheduled surgery time (the surgical center one hour prior). You will speak with an anesthesiologist who will go over the risks and effects of anesthesia
• Before going in to operation theater you will be required to sign consent letter and other forms concerning your medical history
• You will be changed into hospital gown
• For the purpose of administering medicine, an IV (intravenous) line will be inserted into your arm or hand
• To monitor your blood pressure throughout the surgery, a catheter ( small, flexible tube) may be inserted into an artery in your foot, groin, wrist, or elbow
• To reduce pain and discomfort during surgery, you will be administered general anesthesia that will put you to deep sleep and block out any pain throughout the procedure

The process is broken down into seven steps. Usually, the procedure lasts between one and three hours.

Step 1: Prepare the patient
After receiving anesthesia you will be prepared for the surgery as the medical professionals clean your neck region while you are sleeping. Your hip area is also prepared for a bone graft if a planned fusion will be used. The hip incision, however, is not essential in case a donor bone will be used.

Step 2: Make an incision
On either the right or left side of your neck, a 2-inch skin incision is made. The neck muscles are moved aside, and the trachea, esophagus, and arteries are pulled back as the surgeon creates a tunnel to the spine. In order for the surgeon to properly see the bony vertebrae and discs, the muscles that support the front of the spine are finally lifted and set aside.

Step 3: Locate the damaged disc
A small needle is inserted into the disc by the surgeon to identify the damaged vertebra and disc with the help of a fluoroscope, a special X-ray. A specialized retractor is used to spread apart the vertebrae above and below the injured disc.

Step 4: Remove the disc
The disc's exterior wall will now be broken open. The surgeon uses small gripping instruments to remove around two-thirds of your disc before using a surgical microscope to remove the remaining three-quarters. In order to access the spinal canal, the ligament that runs behind the vertebrae would be cut. Disc material that is putting pressure on the spinal nerves is also removed.

Step 5: Decompress the nerve
Your nerve root is freed from the pressure of bone spurs. A drill is used to widen the foramen where the spinal nerve exits. Your nerves are given extra space to exit the spinal canal thanks to foraminotomy.

Step 6. Prepare a bone graft fusion
The top and bottom of the open disc space are prepared using a drill by removing the outer cortical layer of bone to reveal the inner, blood-rich cancellous bone. This will serve as the 'bed' for the bone transplant material that you and your surgeon decided upon:

• Bone graft from your hip: Over the crest of your hip bone, a skin and muscle incision is made. After that, the inner layer (cancellous bone) is reached by cutting through the tough outer layer (cortical bone) using a chisel. The proteins and cells that help the bone develop are found in the inner layer. After that, the bone graft is formed and inserted into the 'bed' between the vertebrae.
• Bone bank or fusion cage: The remaining bone shavings containing bone-growing cells and proteins are placed into a cadaver bone graft or bioplastic cage. Then the graft is plugged into the shelf area.

• Once the surgery is done you will be taken to the postoperative recovery area, where you will stay till the effect of anesthesia wears off and you are awake
• During that time the medical staff will monitor your vitals such as breathing, heart rate, and blood pressure
• Any pain or discomfort will also be addressed at this stage
• Once you are awake, you might be encouraged to do some simple movements like sitting in a chair, walking
• Hip pain may be worse for patients who had bone grafts that is extracted from their hip compared to patients who were treated with neck incision
• The majority of patients who receive a 1 or 2 level ACDF are discharged the same day, however, patients with respiratory issues or unstable blood pressure might have to spend the night at the hospital.

In India, a discectomy may cost anywhere between Rs. 1,40,000 to Rs. 5,000,000. This is an estimated price range, and actual costs may vary depending on a number of variables, including the type of technique utilized during the surgery treatment and the orthopedic doctor's consultation fee, among others.

Following an ACDF surgery, your doctor could advise eating soft food or a clear liquid diet only shortly after the surgery and the day after the surgery as it will be easy to swallow for you. However, you can start eating normally once your doctor tells you so before that for the first several weeks, a balanced diet loaded with essential nutrients to speed the recovery is recommended that includes;

• Prunes
• Yogurt
• Baby food
• Apple sauce
• Frozen dessert bars
• Pineapple
• Papaya
• Soups
• Plenty of water and juices
• Bread for toast
• Low-sodium diet
• Almonds
• Grapes
• Apples
• Apricots
• Berries
• Currants
• Prunes
• Cherries
• Cucumbers
• Pickles
• Tomatoes
• Chinese Black Beans
• Meat

Note: Avoid alcohol and smoking as they can interfere with the medications and are not deemed good for your recovery too.

Following an ACDF surgery, your doctor could advise eating soft food or a clear liquid diet only shortly after the surgery and the day after the surgery as it will be easy to swallow for you. However, you can start eating normally once your doctor tells you so before that for the first several weeks, a balanced diet loaded with essential nutrients to speed the recovery is recommended that includes;

• Prunes
• Yogurt
• Baby food
• Apple sauce
• Frozen dessert bars
• Pineapple
• Papaya
• Soups
• Plenty of water and juices
• Bread for toast
• Low-sodium diet
• Almonds
• Grapes
• Apples
• Apricots
• Berries
• Currants
• Prunes
• Cherries
• Cucumbers
• Pickles
• Tomatoes
• Chinese Black Beans
• Meat

Note: Avoid alcohol and smoking as they can interfere with the medications and are not deemed good for your recovery too.

Artificial disc replacement or ACDF surgery has been found to be safe with an impressive success rate. After recovering from anterior cervical discectomy and fusion surgery, you ought to be able to resume your normal activities with little to no loss of range of motion. Expect to feel less discomfort, which will lead to an improvement in your quality of life.

Since most of the procedure is done by dissecting tissue rather than dividing it, there is only a little amount of postoperative pain associated with the treatment. However, if an iliac crest graft is used, pain at the graft site, where bone is taken from the hip, is more of a worry compared to a needle stick to obtain bone marrow aspirate.

The healing process after ACDF surgery typically takes 4 to 6 weeks. After a few weeks, X-rays can be used to confirm if fusion is taking place. At your follow-up appointment, the surgeon will evaluate your overall recovery and when to give you a go ahead with your office work.

Sometimes during recovery, a cervical collar or brace is worn to offer support and restrict motion as your neck heals or fuses. Once your neck has recovered, your doctor could advise neck stretches, exercises, or physical therapy.

If a bone transplant was taken from your hip, the incision site may be painful, uncomfortable, and stiff. Every 20 minutes, get up and walk around or move about a little. Don't spend a lot of time sitting or lying still.

Neck pain recurrence are typical, hence patients are often advised to adopt the following regime;

• Correct lifting methods
• Proper workout regimen
• Good posture while sitting, standing, moving, and sleeping
• A comfortable workspace
• Lean body mass and a healthy weight
• A healthy attitude and relaxation exercises
• Avoid smoking.

Follow the surgeon's home care recommendations for two weeks after surgery or until your follow-up appointment. Generally, you can do the following to recover fast following ACDF surgery:

Suture care

• You can take a shower the day after surgery if skin glue was used to close your surgical wounds
• Every day, gently cleanse the area with soap and water. Avoid picking or rubbing the glue
• You can take a shower two days following surgery if you have staples, steri-strips, or stitches. Cleanse the area with soap and water everyday
• Cover the incision with a dry gauze dressing if there is drainage and immediately contact your doctor if drainage soaks through two or more bandages in a single day
• Avoid going to pool or saunas as it can wet your dressing
• Avoid putting lotion or cream over the incision
• Follow good hygiene and change into fresh clothes after each shower. Lie down on fresh sheets and allow no pets in the bed
• It's typical for the incision to drain some clear, pinkish fluid. Keep an eye out for separation, colorful discharge, and redness
• At your follow-up session, staples, steri-strips, and sutures will be taken out

Neck care

• Always wear neck brace to support you neck and lessen its movement for faster recovery
• Avoid twisting or bending your neck
• Take proper rest
• Don't lift anything heavier than 5 pounds

Medications

• Take painkillers as prescribed. As your discomfort lessens, cut back on the quantity and frequency. Don't take the painkiller if you don't need it
• Constipation can result from anesthesia used for the procedure, hence consuming foods high in fiber and drinking plenty of water can help with the bowel movement along with some laxatives and stool softeners
• Call your doctor to consider different medications if your painful constipation does not improve
• A doctor's prescription is required before taking NSAIDs like Advil, Aleve as they can hamper the formation of new bone and make your fusion fail

Activity

• Wear your brace (if you were provided one) at all times besides while sleeping, taking a shower, or applying ice
• To lessen pain and swelling, apply ice to your incision three to four times a day for 15-20 minutes each time
• Every three to four hours, get up and go for a 5 to 10 minute stroll. Increase your walking as your stamina improves
• Do not indulge in any strenuous activity including household chores and sex till the time your healthcare provider tells you to do so.
• Moreover, quit smoking and all kinds of nicotine products as it may hamper the fusion of your vertebrae and new bone growth. Also, don't consume alcohol as it thins the blood and makes bleeding more likely. Don't combine booze and painkillers, either.

Artificial disc replacement or ACDF is a minimally invasive surgery to stop the consequences of spinal disc compression and degenerative disc degeneration in order to relieve the patient from chronic neck pain that radiates to the arm or chest. To treat the degenerative disc disease surgeons often perform artificial disc replacement, bone graft (harvested from patient’s hip bone or from dead donor or bone bank) to replace a damaged disk while keeping the spine mobile. ACDF surgery is only done when a patient has exhausted all the medical and physical treatments and his/her lab results favors a surgical intervention.