Anterior cervical discectomy and fusion (ACDF)

Anterior cervical discectomy and fusion have become one of the most common neurosurgical procedures

From 1999 to 2008, the annual number of cervical discectomies with subsequent fusion for degenerative disc diseases in the USA increased by 67% 1)

Without special modifications, a routine anterior cervical approach is usually able to access levels C3C7. In patients with short thick necks, access may be even more limited. In some cases, with long thin necks, up to C2C3 or as low as C7-T1 can be approached anteriorly.

In addition, to enhance fusion, anterior cervical plates have been developed. They provide immediate stability and maintain spinal alignment 2) 3).

Advantages over posterior (nonfused) approach:

Safe removal of anterior osteophytes

Fusion of disc space affords immobility (up to 10%incidence of subluxation with extensive posterior approach).

Only viable means of directly dealing with centrally herniated disc.

ACDF procedures improve segmental sagittal alignment, cervical overall shape, and angles, but these changes are inconsistently related to higher quality-of-life scores 4).

Disadvantages over posterior approach: immobility at fused level may increase stress on adjacent disc spaces. If a fusion is performed, some surgeons prescribe a rigid collar (e.g. Philadelphia collar) for 6–12 weeks. Multiple level ACDF can devascularize the vertebral body (or bodies) between discectomies.

Several modifications have been described to the original procedure developed by Smith and Robinson for ACDF 5)

The earliest descriptions of the technique have always been attributed to Ralph Bingham Cloward, George W. Smith, and Robinson. However, in the French literature, this procedure was also described by others during the exact same time period (in the 1950s). At a meeting in Paris in 1955, Belgians Albert Dereymaeker and Joseph Cyriel Mulier, a neurosurgeon and an orthopedic surgeon, respectively, described the technique that involved an anterior cervical discectomy and the placement of an iliac crest graft in the intervertebral disc space. In 1956, a summary of their oral presentation was published, and a subsequent paper-an illustrated description of the technique and the details of a larger case series with a 3.5-year follow-up period-followed in 1958. The list of authors who first described ACDF should be completed by adding Dereymaeker's and Mulier's names. They made an important contribution to the practice of spinal surgery that was not generally known because they published in French 6).

Anterior cervical instrumentation was initiated by Bagby 7) in a horse using a cage, in 1988.


Following ACDF, imaging modalities such as standard radiography and computed tomography (CT) are used to assess the fusion, instrumentation failure, and postoperative change such as adjacent segment disease

No standard algorithm for postoperative imaging following ACDF has been defined formally, and the frequency and type of imaging obtained is left to the surgeon's discretion. Due to their relatively low cost and ease of administration, 8).

Due to their relatively low cost and ease of administration, standard radiographs are often ordered for all patients following ACDF to assess fusion status.

However, the use of such “routine” postoperative radiographs has been found to be unwarranted in asymptomatic patients 9) 10) 11).

The ACDF procedure itself can induce regional slope change (C5-s and C7-s) directly at the surgical level and can also influence upper cervical slope change (C1-s and C2s) indirectly. Then the change in the upper cervical spine can induce a change in the sagittal vertical axis (St-SVA) and spino-cranial angle (SCA) 12).

Flexion-extension radiographs

Flexion-extension radiographs are obtained 6 weeks after the operation in patients with a fusion construct. If evidence of fusion is present and there are no signs of pseudarthrosis, patients are started on exercise therapy at that time. Patients who do not undergo a fusion procedure can start exercise 2 to 3 weeks after surgery.


CT is a more sensitive alternative to plain radiography when assessing fusion because of its ability to detail bridging trabecular bone 13).

CT scans following ACDF are not routinely ordered. A CT results in alteration of the treatment in 60% of patients with an abnormal MRI and/or radiograph and persistent symptoms. In contrast, if the patient only has persistent symptoms, only 39% of them will go onto further intervention, suggesting that CT has a limited utility in this population. The probability of detecting abnormal findings on CT subsequent to ACDF is significantly greater when the patient presents with persistent symptoms or abnormal preliminary imaging. Alterations in the treatment course based on abnormal postoperative CT are dependent on postoperative symptoms. Those patients who undergo CT without indication (i.e., without preimaging symptoms or abnormal imaging) are significantly more likely to have negative findings on CT, and even with abnormal CT findings, they are less likely to have an alteration in the treatment course. As such, postoperative CTs following ACDF should be limited to patients who have persistent debilitating symptoms or those with abnormal imaging. This practice will avoid unnecessary cost and patient exposure to ionizing radiation 14).

For patients who undergo a fusion procedure, anterior and lateral radiographs are obtained in the recovery room to verify the position of the graft, the plate, and the screws. Patients without an internal fixation device wear a rigid collar for 4 to 6 weeks. In patients who receive internal fixation and in those who undergo no fusion, external orthosis is not applied routinely, except to control pain. Patients are discharged the day after surgery. A problem with swallowing is the usual reason why patients are kept longer in the hospital. Within 7 to 10 days of discharge, patients are seen in the office for a “wound check.”

Maki et al. aimed to identify potential relationships between pathological and radiological assessments of bony fusion after anterior cervical discectomy and fusion (ACDF). ACDF can resolve neurological symptoms related to cervical spondylosis, such as myelopathy and radiculopathy. Intervertebral bony fusion is a key outcome for successful ACDF, often assessed on radiography and computed tomography (CT) images. However, the pathological findings of tissues demonstrating bony fusion after ACDF have not been well studied. This report presents the cases of two female patients, aged 62 and 40 years, who underwent additional ACDFs for recurrent cervical radiculopathy. Findings from CT imaging identified intervertebral calcification in the titanium spacers placed in the first ACDF. In both cases, recurrent compression of nerve roots was observed radiologically. Cervical nerve root block identified habitual symptoms related to recurrent radiculopathy. To resolve the clinical symptoms, additional ACDFs were performed in two cases. In the second ACDF, the titanium cases from the prior ACDF were removed. Histopathological examination of the tissues from the removed cages revealed growth of cartilage tissue. This is the first report concerning the histopathological evaluation of the tissue in titanium spacers placed in ACDF. Completion of intervertebral calcification in titanium spacers placed in ACDF may not signify completion of intervertebral bony fusion after ACDF 15).

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Jacobs WC, Anderson PG, Limbeek J, Willems PC, Pavlov P. Single or double-level anterior interbody fusion techniques for cervical degenerative disc disease. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004958. Review. Update in: Cochrane Database Syst Rev. 2011;(1):CD004958. PubMed PMID: 15495130.
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Zaidman N , De Witte O . Cervical sagittal balance: a predictor of neck pain after anterior cervical spine surgery? Br J Neurosurg. 2020:1–5. doi:10.1080/02688697.2020.1850643
Smith GW , Robinson RA . The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. The Journal of Bone & Joint Surgery. 1958;40(3):607–624. doi:10.2106/00004623-195840030-00009
Bartels RHMA, Goffin J. Albert Dereymaeker and Joseph Cyriel Mulier's description of anterior cervical discectomy with fusion in 1955. J Neurosurg Spine. 2018 Jan 12:1-6. doi: 10.3171/2017.7.SPINE17182. [Epub ahead of print] PubMed PMID: 29327972.
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Shau D N, Bible J E, Samade R. et al. Utility of postoperative radiographs for cervical spine fusion: a comprehensive evaluation of operative technique, surgical indication, and duration since surgery. Spine (Phila Pa 1976) 2012;37(24):1994–2000.
Bartels R HMA, Beems T, Schutte P J, Verbeek A L. The rationale of postoperative radiographs after cervical anterior discectomy with stand-alone cage for radicular pain. J Neurosurg Spine. 2010;12(3):275–279.
Ugokwe K T, Kalfas I H, Mroz T E, Steinmetz M P. A review of the utility of obtaining repeated postoperative radiographs following single-level anterior cervical decompression, fusion, and plate placement. J Neurosurg Spine. 2008;9(2):175–179.
Lee HJ, Choi DY, Shin MH, Kim JT, Hong JT. Sequential alignment change of the cervical spine after anterior cervical discectomy and fusion in the lower cervical spine. Eur Spine J. 2016 Jan 28. [Epub ahead of print] PubMed PMID: 26821140.
Selby M D, Clark S R, Hall D J, Freeman B J. Radiologic assessment of spinal fusion. J Am Acad Orthop Surg. 2012;20(11):694–703.
Derakhshan A, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion. Global Spine J. 2015 Oct;5(5):411-6. doi: 10.1055/s-0035-1554773. Epub 2015 Jun 5. PubMed PMID: 26430596; PubMed Central PMCID: PMC4577315.
Maki Y, Kawasaki T, Nakajima K, Takayama M. Pathological Examination of Radiologically Fused Interbody Tissue Five Years After Anterior Cervical Discectomy and Fusion Using the Titanium Cage System: A Report of Two Cases. Cureus. 2022 Aug 16;14(8):e28059. doi: 10.7759/cureus.28059. PMID: 36134104; PMCID: PMC9481214.
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