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The Anterior Cervical Discectomy and Fusion (ACDF) is the “workhorse” procedure for disorders of the neck:
The anterior (front) approach is the method which allows the most direct access to the problem disc. Dr Ibrahim prefers to make a 3 cm horizontal incision on the left side of your neck. The dissection is truly an elegant “minimally invasive” approach which allows mobilization of adjacent structures and very little tissue trauma.
The problem disc is then directly visualized and removed. A microscope which allows magnification of disc material and nerve structure is typically used at this point. The spinal cord and exiting nerve roots are directly visualized and decompressed. Problematic adjacent bone spurs are also removed at this point.
Once the disc is completely removed, a vacant space remains between the adjacent vertebral bodies. It is important to fill this space otherwise “collapse” of the vertebral bodies toward each other will occur. This may result in instability and pressure on the nerves from the top and the bottom rather than the front. There are several options with regard to filling this space and keeping the nerves decompressed and stabilizing the cervical spine.
The “gold standard” operation is to fuse this disc space. This is typically done using the patient’s own bone (autograft) or another person’s bone (allograft). There are advantages and disadvantages to both. In Dr Ibrahim’s opinion, nothing heals more reliably than the patient’s own bone. Thus, especially in several level anterior cervical discectomies, Dr Ibrahim prefers to harvest bone from the patient’s pelvis and place this bone in the space where the disc used to be. This necessitates a second incision over the patient’s pelvis. Allograft bone is also a reasonable option which is frequently used by Dr Ibrahim. While the use of allograft avoids the need for a second incision over the patient’s pelvis, this bone does not heal as reliably as autograft does, and is generally not preferred in multiple level fusions.
In certain individuals (typically younger individuals with a one level disc herniation), an anterior cervical disc replacement may be a reasonable option. This is new technology which has recently been FDA approved and results in preservation of motion at the surgical site. However, this technology is unproven and difficult to implement in individuals who require surgery at more than one disc level. Also, if there is little or no motion at a disc level prior to surgery, there is no advantage to using a cervical disc replacement. Anterior cervical discectomy and fusion remains the gold standard operation in these situations.
Finally, bone morphogenic protein, is a substance that is widely used in the lumbar spine to achieve fusion. This protein is found in your body and is the protein which tells bone forming cells to “turn on” and form bone in fractures. Though this substance is promising, its use has been associated with increased complications in the cervical spine and it is not widely used in this type of surgery. However, Dr Ibrahim feels that its use is reasonable in certain situations, when achieving fusion may be difficult. Finally an anterior cervical plate is placed over the disc space(s) to be fused and the adjacent vertebrae. There are two reasons for this in Dr Ibrahim’s practice. The first, is that the use of the plate is associated with a higher rate of fusion, especially when several disc spaces are to be fused. The second is that the use of the plate eliminates motion sufficiently so that long-term immobilization (the use of hard collars) is no longer necessary. Indeed, Dr Ibrahim only immobilizes patients for one to two weeks in order to maximize comfort during recovery. The patient is then encouraged to remove the collar as his/her comfort allows.
Typically, individuals who undergo anterior cervical discectomy and fusion or anterior disc replacement, stay in the hospital for only one night. These patients are typically comfortable enough to go home the day after surgery. Dr Ibrahim supplies the patient with a collar which is to be used for comfort only. The patient is encouraged to discontinue the use of the collar within the first one to two weeks after surgery in order to preserve motion and muscle strength in the neck. Oftentimes after surgery, the patient may complain of a “catch” while swallowing, especially with thicker foods such as steaks. This is because the cervical spine lies directly behind the esophagus (swallowing tube) and it is necessary to move this structure out of the way during surgery. Almost always, this sensation resolves within six weeks after surgery.
Dr Ibrahim encourages early activity as the individual tolerates after surgery. Though there is wide patient variation typically, individuals with non-manual occupations may return to work in some capacity (work from home or part time work) within two weeks of surgery. The patient is seen back in the office at three weeks and six weeks after surgery when x-rays are obtained. Usually a course of physical therapy is beneficial at six weeks in order to strengthen the neck, and occasionally, to reestablish range of motion.
Typically, individuals who undergo anterior cervical discectomy and fusion have a 90% likelihood of having a good or excellent result. At South Denver Spine, your health is our primary concern. Please do not hesitate to contact us with any questions or concerns about your spinal condition.