Anterior cervical discectomy and fusion: Surgical indications and outcomes

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Abstract

Anterior cervical discectomy and fusion (ACDF) remains the most commonly performed surgery for symptomatic disc herniations that have failed conservative treatment. It provides excellent visualization for central and bilateral foraminal decompression without manipulation of neural structures. Reliably excellent outcomes are seen following single-level procedures. Although similar results can frequently be obtained with multi-level ACDF, the pseudarthosis risk is heightened in this setting. However, plate application and smoking cessation minimize the risk.

Introduction

Cervical spondylosis and disk herniation are common problems that can lead to radiculopathy and myelopathy from progressive foraminal or central stenosis. Although the majority of symptomatic patients will improve with conservative therapy, some will have persistent or worsening symptoms that require surgery. Multiple surgical procedures have been developed to treat cervical radiculopathy. Anterior cervical discectomy and fusion (ACDF) was first described by Robinson and Cloward and has now become the most commonly performed procedure for symptomatic cervical disc herniations yielding a long track record of outstanding outcomes.1, 2

Section snippets

Indications

Neural element compression can occur from soft disc herniation (Fig. 1) or osteophyte formation in the setting of spondylosis (“hard disc” herniation, Fig. 2). Frequently these affect the foraminal region, leading to upper extremity radiculopathy. With more midline or paracentral herniations, less well-defined radicular symptoms may be seen or even myelopathy symptoms due to direct cord compression.

The most commonly accepted surgical indications for ACDF include (1) persistent or recurrent arm

Outcomes

Robinson et al.2 published the first large series of ACDF patients in 1962 with poor results in only 6% of the patients. More recent studies have reported even better results, especially for single-level fusions.3, 4 Looking at SF-36 outcomes, comparable improvements are seen following ACDF to that of total hip and knee replacements.5 Yue et al. investigated the durability of ACDF with 5–11-year follow-up from allograft plating with over 95% of patients reporting continued improvement in neck

Summary

Performed on appropriately selected patients, ACDF is a highly reliable surgical procedure for the symptomatic disc herniations that have failed conservative treatment. Both direct and indirect decompression of bilateral neural elements can be achieved, producing excellent results. The risk of nonunion increases with multi-level procedures, but can be minimized by utilizing a plate and encouraging smoking cessation.

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