1. ANTERIOR CERVICAL DISCECTOMY WITH FUSION (ACDF)
Presented by
Robert Nelson BSN, MBA, MHA, SCRN, CNRN, ONC
Vice President Neuroscience and Orthopedics
HCA East Florida Division
AHA – evidenced based information
Acute treatment options
Secondary prevention steps
Stroke program
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2. OBJECTIVES
Discuss the simple anatomy and physiology of the cervical spine
Discuss the Nerve Root Level, Function and Radicular Distribution
Discuss the diagnostic studies completed before ACDF surgery
Discuss Degenerative Cervical Spine Disorders
Discuss surgical treatment of the cervical spine with Anterior approach and fusion (ACDF)

3. CERVICAL SPINE Cervical Vertebrae :
The cervical spine has seven vertebrae.
The body, or centrum, of the vertebra is located anteriorly
The vertebral foramen, referred to as the spinal canal, is behind the vertebral body.

4. CERVICAL DISCS
With the exception of C1–C2, an intervertebral disc resides between each of the cervical vertebral bodies.
Why?

5. CERVICAL DISC
Each intervertebral disc provides support and facilitates movement, while also resisting excessive movement.
The disc permits slight anterior flexion, posterior extension, lateral flexion, rotation, and some circumduction (Schnuerer, Gallego, & Manuel, 2003).
The disc is the largest avascular structure in the body (Anderson & Albert, 2003).

6. CERVICAL DISC
Cervical discs are composed of the nucleus pulposus, an inner capsule with tissue the consistency of crabmeat, and the annulus fibrosus, a thick outer ring of tissue much like cartilage.
Although the nucleus
pulposus is usually
soft and spongy in
younger people, it
tends to dehydrate as
people age.

7. LIGAMENTS
Ligaments: Are a band of fibrous tissue connecting bones or cartilage. It is instrumental in maintaining
cervical
spine alignment

8. SPINAL CORD AND NERVES
The spinal cord extends from the foramen magnum to the upper lumbar spine (usually L1–L2) and gives rise to 31 pairs of spinal nerves.
The eight cervical roots exit through intervertebral foramina, an opening between the vertebrae. The meninges (i.e., dura mater, arachnoid layer, and pia mater) cover the spinal cord.
Cerebrospinal fluid bathes the
spinal cord and is found in the
subarachnoid space

9. NERVE ROOT DISTRIBUTION

10. NERVE ROOT FUNCTION

11. CERVICAL DERMATOME

12. Diagnostic Studies
Common diagnostic studies used to evaluate the non-traumatic cervical spine patient:
Plain Radiographs
Computed Tomography
Magnetic Resonance Imaging
Bone Scan
Myelogram/Postmyelogram CT
Electromyography/Nerve Conduction Velocities
Somatosensory Evoked Potentials
*Neuro Exam compared to diagnostic testing*

13. What is Radiculopathy?
Radiculopathy refers to a set of conditions in which one or more nerves is affected and does not work properly (a neuropathy).
The emphasis is on the nerve root (radix = "root"). This can result in pain/radicular pain. weakness, numbness, or difficulty controlling specific muscles.
The radicular pain that results from a radiculopathy should not be confused with referred pain which is different both in mechanism and clinical features

14. CERVICAL SPINE DISORDERS
Neck Pain Without Radiculopathy
Cervical Radiculopathy: In the cervical spine, the most common cause of radiculopathy is foraminal narrowing and impingement onto the spinal nerve.
Cervical Myelopathy: Myelopathy is the result of spinal cord compression, which can stem from clinical entities such as long-standing progressive compression from spondylosis or ossification of the posterior longitudinal ligament. It can also be caused by an acute problem such as acute disc herniation. Myelopathy may be exhibited in a number of ways,

15. CERVICAL SPINE DISORDERS
Intervertebral Disc Herniation—Herniated Nucleus Pulpous

16. CERVICAL SPINE DISORDERS
II. Definitions
A. Bulge: Symmetrical extension of the disc beyond
the endplates
B. Protrusion: Focal area of bulge/disc extension that
is still attached to the disc (annulus fibrosis)
C. Extruded fragment: Nucleus pulposus no longer
connected to the disc
D. Sequestered fragment (i.e., free fragment): Nucleus
pulposus in the posterior longitudinal ligament
E. Radiculopathy: Pain in the distribution of a nerve
root resulting from irritation/compression on that
nerve root

17. CERVICAL SPINE DISORDERS
Spondylosis Description and Etiology
From the Greek word meaning “vertebra,” spondylosis is generally defined as age- and use-related degenerative changes of the spine

18. CERVICAL SPINE DISORDERS
Cervical Spondylotic Myelopathy
is defined as “spinal cord dysfunction accompanying typical age-related degeneration of the cervical spine” (Tortolani & Yoon, 2004, p. 701).
Spondylosis is the most common etiology, and spondylotic myelopathy is the most common cause of spinal cord dysfunction in persons older than 55 years.

19. CERVICAL SPINE DISORDERS
Cervical Stenosis
Cervical stenosis, classified as either congenital or acquired, is a result of either being born with a narrow spinal canal or developing a narrow spinal canal as a result of degenerative changes.

20. CERVICAL SPINE DISORDERS
Inflamatory:
Rheumatoid Arthritis
Ankylosing Spondylitis
Neoplastic Cervical Spine Disease
Metastatic
Primary

21. CERVICAL SPINE DISORDERS
Osteoporosis
Osteoporosis, the most common metabolic bone disease, is characterized by low bone mass and structural deterioration of bone tissue.
Congenital Anomalies
Infection

22. Non-Surgical Treatment
Medication
Epidural Steroid Injections
Physical Therapy
Spinal Manipulation (Chiropractic or Osteopathic)
Bracing
Acupuncture
Back School

23. SURGICAL TREATMENT ACDF
Surgical treatment for the patient with a cervical radiculopathy is indicated for patients with
(a) persistent signs and symptoms, despite approximately 6 weeks of appropriate nonsurgical treatment or
(b) a progressive motor deficit and in whom there is radiographic correlation

24. SURGICAL TREATMENT ACDF
Cervical Discectomy With and Without Fusion
Single/multilevel: The purpose of both anterior cervical discectomy with fusion (ACDF) and without fusion (ACD) is to relieve pressure on the neural elements of the spinal cord and nerve roots
More commonly, a fusion is performed utilizing graft material and anterior plate fixation to prevent disc collapse and subsequent kyphosis

25. SURGICAL TREATMENT ACDF
Traditionally, an autogenous bone graft is used. This graft typically is harvested from the patient’s iliac crest.
Many surgeons now favor the use of interbody fusion devices (e.g., allograft, synthetic spacers, cages)with allograft or other fusion materials.
The patient’s length of stay is usually 23 hours or less.

26. SURGICAL TREATMENT ACDF

29. ACDF Complications Potential Complications–Anterior Cervical Surgery
Complications, although rare, may include nerve root injury (2%–3%),
recurrent laryngeal nerve palsy resulting in hoarse voice (2%),
spinal cord injury
(<1%), esophageal perforation (<1%), or instrumentation
failure, including nonunion
(<5% for a single level surgery)

30. POST SURGERY
After surgery, pain is managed with narcotic medication. Because narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks). As their regular use can cause constipation, drink lots of water and eat high fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) can be bought without a prescription. Thereafter, pain is managed with acetaminophen (e.g., Tylenol).
Hoarseness, sore throat, or difficulty swallowing may occur in some patients and should not be cause for alarm. These symptoms usually resolve in 1 to 4 weeks.

31. POST SURGERY
Activity
You may need help with daily activities (e.g., dressing, bathing), but most patients are able to care for themselves right away.
Gradually return to your normal activities. Walking is encouraged; start with a short distance and gradually increase to 1 to 2 miles daily. A physical therapy program may be recommended.
If applicable, know how to wear a cervical collar before leaving the hospital. Wear it when walking or riding in a car

32. POST SURGERY Most Common Restrictions
If you had a fusion, do not use non-steroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin; ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve) for 6 months after surgery. NSAIDs may cause bleeding and interfere with bone healing.
Do not smoke. Smoking delays healing by increasing the risk of complications (e.g., infection) and inhibits the bones' ability to fuse.
Do not drive for 2 to 4 weeks after surgery or until discussed with your surgeon.
Avoid sitting for long periods of time.
Avoid bending your head forward or backward.
Do not lift anything heavier than 5 pounds (e.g., gallon of milk).
Housework and yard-work are not permitted until the first follow-up office visit. This includes gardening, mowing, vacuuming, ironing, and loading/unloading the dishwasher, washer, or dryer.
Postpone sexual activity until your follow-up appointment unless your surgeon specifies otherwise.

33. ACDF RESULTS What are the results?
Anterior cervical discectomy is successful in relieving arm pain in 92 to 100% of patients [3]. However, arm weakness and numbness may persist for weeks to months. Neck pain is relieved in 73 to 83% of patients [3]. In general, people with arm pain benefit more from ACDF than those with neck pain. Aim to keep a positive attitude and diligently perform your physical therapy exercises.

34. Biblography/ References
AANN Clinical Practice Guideline Series; Cervical Spine; A Guide to Preoperative and Post-Operative Care