Anterior Cervical Decompression & Fusion

An anterior cervical decompression and fusion (ACDF) is an operation done through the front of the neck (rather than the back) to relieve pressure on the spinal cord and/or nerves, as well as to stabilise the spine.  Usually a Discectomy (removal of the intervertebral disc) is performed to release pressure off the nerves, and a fusion (joining of two or more bones together) is done, usually with a plate and screws, to ensure stability.

Why might I need an anterior cervical discectomy (decompression) and fusion?

An ACDF is usually performed for one or more of the following reasons:

1. To treat pressure on the spinal cord (caused by cervical canal stenosis/spondylosis or an intervertebral disc prolapse).
2. To treat pressure on one or more spinal nerves in the neck (caused by foraminal stenosis, cervical spondylosis, or an intervertebral disc prolapse)
3. To treat instability of the cervical spine (this may occur due to degenerative changes, arthritis, or trauma).

Surgery is usually recommended when all reasonable conservative measures (pain medications, nerve sheath injections, physical therapies, neck collars etc.) have failed. In cases of significant instability or neurological problems, surgery may be the most appropriate first treatment option.

What are the possible outcomes if treatment is not undertaken?

If your condition is not treated appropriately (and sometimes even if it is), the possible outcomes may include:

• Ongoing pain
• Paralysis/weakness/numbness
• Functional impairment (clumsiness, poor fine motor skills and coordination)
• Problems with walking and balance

What are the specific risks of an ACDF?

Generally, surgery is fairly safe and major complications are uncommon,. The chance of a minor complication is around 3 or 4%, and the risk of a major complication is 1 or 2%. Over 90% of patients should come through their surgery without complications.

The specific risks of an ACDF include (but are not limited to):

• Injury to the larynx (voice box), the nerves to the larynx (recurrent laryngeal nerve) causing vocal cord paralysis and a hoarse voice. This is usually temporary but may require further surgery, which can cause infection.
• Injury to the oesophagus (food pipe) which may require further surgery.
• Injury to carotid artery, which can cause a stroke. This can cause paralysis, which may be permanent.
• Injury to the spinal cord resulting in quadriplegia, (paralysis of arms and legs). This may be temporary or permanent and may require further surgery.
• Implant failure, movement or malposition.
• Injury to nerve root causing a weak upper limb, which may be temporary or permanent.
• Infection in the wound causing redness, pain and possible discharge or abscess. (1 in 20 people). This may need antibiotics.
• Ongoing neck or upper limb pain, which may be temporary or permanent.
• Failure of fusion on the bone which may result in pain and may require further surgery.
• Movement of graft or instrumentation resulting in swallowing difficulties, which may require surgery.
• Ongoing upper limb numbness, which may be permanent.
• Small areas of the lungs may collapse, increasing the risk of chest infection. This may need antibiotics and physiotherapy.
• Clots in the legs (deep vein thrombosis or DVT with pain and swelling. Rarely part of this clot may break off and go to the lungs which can be fatal.
• A heart attack because of strain on the heart or a stroke.
• Death is possible due to the procedure
• Increased risk in obese people of wound infection, chest infection, heart and lung
• Adjacent level disease (see below)

What do you need to tell the doctor before surgery?

It is important that you tell your surgeon if you:

• Have blood clotting or bleeding problems
• Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
• Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
• Have high blood pressure
• Have any allergies
• Have any other health problems

What Can I Expect? Before Surgery

• You may not eat anything after midnight, the night before surgery and must cease drinking clear fluids (eg. water, apple juice) 2 hours prior to your admission time (unless otherwise instructed.)
• Note: However, you may continue to take your routine medications (for example, heart and blood pressure medications), on the morning of surgery with a sip of water (unless otherwise directed).  Please bring all your regular medications with you to hospital.
• Consult with your surgeon if you are taking blood-thinning medications, NSAIDs, or Insulin. Examples include Coumadin (Warfarin), Plavix (Clopidogrel), and Aspirin; Nonsteroidal Anti-inflammatory Drugs (NSAIDs) such as Motrin (Ibuprofen), Aleve (Naproxen), Feldene (Piroxicam); or Insulin.
• Carefully read the hospital admission form, complete it and send it to the mater hospital at least one week before your operation.
• Have your blood tests done 3-5 days prior to your date of admission
• Please shower on the morning of admission. Do not use powder, apply perfume, makeup or nail polish and wear cotton underwear if possible.
• Please be sure to take the following to the hospital admission on the day of the operation;
• Surgery consent form
• MRI/Xray/C.T Scans
• On arrival at the hospital, inform the receptionist that you are there to have an operation. You will be taken to the pre-operative area to be prepared for surgery.

Who will perform surgery? Who else will be involved?

Surgery will be carried out by your surgeon. A surgical assistant will be present and an experienced consultant anaesthetist will be responsible for your general anaesthetic.

What are the costs of surgery?

Private patients undergoing surgery will generally have some out-of-pocket expenses.

• A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc. Patients are advised to consult with their Private Health Insurance provider and Medicare to determine the extent of out-of-pocket expenses.

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply. Medical expenses may be tax deductible (you should ask your accountant).

You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What is the consent process?

You will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.

After Surgery

• During your first few hours on the ward, you will be monitored closely by the nursing staff. You will be given fluids by an intravenous drip and may have a drain coming from your wound. This is all normal procedure.  If you have any pain or feel any sickness it is important to inform the nursing staff so they can keep you comfortable and aid your recovery.  The majority of patients are allowed fluids to drink once you are awake, however with some surgery fluids and what you are allowed to eat will be restricted for the first day or so.
• The vast majority of spinal patients are allowed to walk to the bathroom with the help of the nursing staff from when they are fully awake from surgery.  If you want to use the toilet, you must ask the nursing staff for assistance.
• Unless specified by your surgeon, you will commence rehabilitation the day following your surgery.  This means all drips, drains and other appendages will be removed and you will be assisted out of bed on day 1 and walked to the bathroom for a shower.
• You will be sat on the edge of your bed for meals and taken for short walks by the staff. The following day you will increase the amount of walking and may still require some assistance from the staff. You will sit out in the chair for short periods of time (meals etc.) It is very important that you do make every effort to get up and walk during this early stage of your rehabilitation.
• Minor discomfort from the incision is common and can be relieved by pain medication.  You will be given regular pain relief but if this does not keep your pain under control, please speak to the nursing staff. Do not just wait till the next pain medication is due.  Some patients experience mild episodes of muscle spasms in their back and legs (after low back surgery) or in their neck and arms (after neck surgery). Ice/heat packs or muscle relaxants can be used to lessen the discomfort.
• You may continue to experience pain, numbness, and weakness along the path of the nerve that was decompressed by surgery. These symptoms will gradually decrease over time.
• Speak with your surgeon’s office about the timing of your first post-operative office visit.
• The majority of patients discharge home after 2-5 days depending on the type of surgery you have had.

Preparing to Go Home

Post operative care and instructions:

• Keep your dressing dry and clean for 7 days after surgery to prevent infection.  Leave dressings intact unless damp or ooze present from wound. (If dressing damp or wound has oozed, get someone to change it for you with the dressings provided to you from the ward.)
• Ensure they wash hands carefully first.
• You may shower if you cover the incision with plastic wrap to keep it dry.  A shower chair can be used if needed, otherwise use a special non-slip mat.
• It is important if you have a low toilet, to consider loaning a plastic extension, or over the toilet seat. These can be hired from some chemists.
• Steri-strips® (incision tapes) may have fallen off or be removed 7 – 10 days after surgery.
• Incision and dressing care may vary from patient to patient. Please make sure you understand your surgeon’s instructions before you leave the hospital.
• Wear back support provided for you at the hospital as instructed (if supplied).
• Change position regularly, do not lie in one position for too long (you will get stiff and sore).
• Take pain medication regularly as prescribed and advised. (Do not keep taking pain medication unless you really need it once the pain of the operation has worn off).
• No stooping, bending or twisting of your back. Keep your back straight and bend your knees using your thigh muscles.
• No sitting in soft chairs or sofas that allow your back to curve. Sitting may be uncomfortable, so limit your time sitting in a chair (20-30 minutes).
• Sit and stand straight, do not sit slouched or leaning over to one side in a chair.
• No stretching to reach high cupboards or shelves.
• No jogging. Short, frequent short walks are better than long walks.
• No lifting, housework or yard work during the first six (6) weeks or until allowed by your doctor.
• No driving or long car journeys until consulting with your surgeon at the first post-operative visit

What do I need to tell my surgeon about after the operation?

You should notify your surgeon and should also see your GP if you experience any of the following after discharge from hospital:

• Increasing leg pain, weakness or numbness
• Worsening back pain
• Problems passing urine or controlling your bladder or bowels
• Problems with your walking or balance
• Fever
• Swelling, redness, increased temperature or suspected infection of the wound
• Leakage of fluid from the wound
• Pain or swelling in your calf muscles (ie. below your knees) Chest pain or shortness of breath
• Any other concerns

What are the results of surgery?

Overall, 80-90% of patients will obtain a significant benefit from surgery, and this is usually maintained in the long term.