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Anterior Cervical Discectomy and Fusion Complications

| | Neck (Cervical Spine)
ACDF procedure

ACDF stands for Anterior Cervical Discectomy and Fusion. It is a surgical procedure to treat cervical spine (neck) problems such as herniated disc, degenerative disc disease, or spinal stenosis. In this article, we will review what this surgery is and discuss anterior cervical discectomy and fusion complications.

A brief overview of what the surgery entails:

During the procedure, the surgeon makes a small incision in the front of the neck and carefully moves aside the tissues and muscles (mostly vital vessels such as the carotid artery, vagus, and phrenic nerve, the nerves to the heart and lungs) to access the cervical spine. Then, the damaged or diseased disc is removed from between the affected vertebrae to relieve pressure on the spinal cord and/or nerve roots.

After removing the disc, the surgeon inserts a bone graft or a small metal plate with screws into the empty disc space to fuse the two adjacent vertebrae together. The fusion process typically takes several months, during which the bone graft will grow and merge with the surrounding vertebrae to create a single, stable piece of bone.

ACDF surgery may be performed using general anesthesia and typically takes a few hours. Patients are usually required to stay in the hospital for a day or two after the surgery and may need to wear a neck brace for several weeks or months after the procedure to help support the healing process. Rehabilitation and physical therapy may also be required to help restore neck mobility and strength.

Effectiveness Of ACDF Surgery

Effectiveness can vary for ACDF and depends on the severity of pain and instability. Most publications and systemic reviews recommend ACDF when moderate to severe cervical conditions exist in myelopathy (progressive weakness).

Yes, there have been several randomized controlled trials (RCTs) that have investigated the effectiveness of ACDF surgery for cervical spine conditions. RCTs are considered the gold standard in clinical research, as they provide high-quality evidence of the effectiveness of medical interventions.

Some RCTs on ACDF surgery have shown that it can be an effective treatment option for conditions such as cervical radiculopathy and myelopathy. For example, a 2013 systematic review and meta-analysis of RCTs on ACDF surgery found that it was associated with significantly greater improvements in neck pain, arm pain, and functional outcomes than non-surgical treatments.

However, other RCTs have suggested that the benefits of ACDF surgery may be less clear in certain cases. For example, a 2016 RCT found that while ACDF surgery was associated with greater improvements in arm pain and quality of life compared to non-surgical treatment for patients with cervical spondylosis and radiculopathy, it did not significantly reduce neck pain.

Overall, the results of RCTs on ACDF surgery suggest that it can be an effective treatment option for certain cervical spine conditions, but it may not be the best option for everyone.

In my own medical practice, I see too often patients getting surgery too soon and not getting second opinions!  Data suggests only having an ACDF for progressive weakness.  If the only symptoms we have is pain (neck pain or arm pain or both), then long-term surgery has a high failure rate. 

And the worst I see is that on imaging, there exists severe pathology, BUT the patient has very mild or limited symptoms, and the surgeon convinces the patient they need the surgery because of the risk of paralysis…evidence and recommendations would suggest otherwise:

“We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (3)

What To Expect Post-Surgery

Postoperative expectations following ACDF surgery can vary depending on the individual patient’s condition, the extent of the surgery, and other factors such as age and overall health. Here are some general expectations:

  1. Pain relief: ACDF surgery is typically performed to relieve neck and arm pain caused by a cervical spine condition such as a herniated disc or spinal stenosis. Patients can expect to experience a reduction in pain following the surgery, but it may take several weeks to months to fully recover, depending on the amount of nerve damage. 
  1. Improved function: Patients may also experience improved function following ACDF surgery, including increased range of motion, strength, and mobility. Reasoning for having the surgery is because of progressive weakness, so ideally, once the compression of the nerve is relieved, then the function should slowly return. 

Recovery Time 

Recovery time can vary depending on the extent of the surgery, but most patients can return to light activities within a few weeks of the procedure. However, it may take several months for the bone to fully fuse and for the patient to return to normal activities.


Patients may be required to participate in rehabilitation and physical therapy after ACDF surgery to help improve strength, mobility, and range of motion. Rehabilitation may include exercises and stretches that can be performed at home or with a therapist.

Follow-up Care

Patients will typically need to attend follow-up appointments with their surgeon to monitor their progress and ensure that the fusion is healing properly.

It is important for patients to follow their surgeon’s postoperative instructions carefully, including any restrictions on physical activity, medications, and rehabilitation, to ensure the best possible outcome from the surgery.

Life After ACDF Surgery

Life after an ACDF surgery can be different for each patient, depending on various factors such as their age, overall health, and the extent of the surgery. Here are some general things to expect:

  1. Restrictions on physical activity: Patients may need to avoid certain activities, such as heavy lifting or bending, for a period of time following surgery to allow the spine to heal properly. Possibly never return to activity level of prior to fusion
  2. Medications: Patients may need to take pain medication and other medications to manage symptoms and prevent complications following surgery.
  3. Lifestyle changes: Patients may need to make certain changes in their lifestyle, such as quitting smoking or losing weight, to reduce the risk of complications and promote healing after surgery. Some surgeons won’t even do the surgery unless patients have bought into getting the best outcome.
  4. Limitations on neck motion: Following ACDF surgery, patients may experience a limited range of motion in the neck, particularly in the first few weeks to months after the procedure. However, with time and proper rehabilitation, many patients can regain a significant degree of neck motion.

Overall, life after ACDF surgery can be challenging; once you change the anatomy of your spine, it may never be the same again! In my day-to-day practice, I see many patients that have had a fusion, and it’s about 50/50 – some patients wish they had sought alternatives, while others say it was a game changer and are glad they went through with it!

Adjacent Segment Disease

Adjacent segment disease (ASD) is a condition in which degenerative changes occur in the spinal segments adjacent to the site of a previous spinal fusion surgery, such as ACDF. The time frame in which ASD occurs after ACDF surgery can vary, and there is no definitive answer to this question.

Some studies have suggested that ASD can occur within the first few years after ACDF surgery, while others have reported that it may take up to 10 years or more for ASD to develop. The rate of occurrence of ASD also varies among studies, with some reporting rates as high as 25% at 10 years after surgery, while others have reported rates as low as 4%.

Factors that may increase the risk of developing ASD after ACDF surgery include age, smoking, obesity, and a history of previous spinal surgery.

To reduce the risk of developing ASD after ACDF surgery, some surgeons may use techniques such as dynamic stabilization or cervical disc replacement instead of fusion to preserve motion in the adjacent spinal segments. It is important for patients to discuss the potential risks and benefits of different surgical options with their doctor before undergoing surgery.

While ASD is a potential complication of ACDF surgery, it is important to note that not all patients will develop this condition. By following postoperative instructions and attending regular follow-up appointments with their doctor, patients can help minimize the risk of developing ASD and other complications after ACDF surgery.

Risk Factors For Complications

As with any surgical procedure, there are risks associated with ACDF surgery. Some factors may increase the risk of complications during or after the procedure. Here are some common risk factors:

  1. Previous neck surgery: Patients who have undergone previous surgery in the cervical spine may be at higher risk for complications, including nerve injury and poor bone healing.
  2. Smoking: Smoking can increase the risk of complications following surgery, including infection, poor wound healing, and failure of the bone to fuse properly.
  3. Age: Older patients may be at higher risk for complications due to age-related changes in the body.
  4. Obesity: Obesity can increase the risk of surgical complications, including wound infections, blood clots, and respiratory problems.
  5. Other medical conditions: Patients with other medical conditions, such as diabetes, high blood pressure, or heart disease, may be at higher risk for complications during and after surgery.
  6. Inadequate bone density: Patients with osteoporosis or other conditions that cause decreased bone density may be at increased risk for complications related to bone healing.
  7. Poor nutrition: Patients with poor nutrition may have a harder time healing after surgery and may be at higher risk for complications.
  8. Surgeon experience: Surgeon experience and skill can also play a role in the risk of complications. Patients may wish to seek out a surgeon who is experienced in performing ACDF surgery to minimize the risk of complications.

Before undergoing ACDF surgery, patients should have a discussion with their surgeon regarding their individual risk factors. Maintaining good health and fitness can improve the chances of a smooth recovery after surgery, as is true for any medical procedure. This advice is particularly relevant in the context of biologics – “The best rehab is a good pre-hab!”

Common Complications Associated With ACDF

While ACDF surgery is generally considered a safe and effective treatment option for certain cervical spine conditions, there are potential complications associated with the procedure. Here are some common complications that can occur:

  1. Infection: Infection is a potential risk associated with any surgery and can occur in the incision site, deep within the neck, or in other areas of the body. Which can be as high as 4-5%!
  2. Bleeding: Excessive bleeding can occur during or after surgery and may require additional treatment.
  3. Nerve damage: Nerve damage is a potential risk associated with any spinal surgery and can result in weakness, numbness, or paralysis.
  4. Dysphagia: Difficulty swallowing can occur following ACDF surgery and may be caused by swelling or damage to the esophagus or other structures in the neck.
  5. Hoarseness: Damage to the vocal cords or other structures in the neck can cause hoarseness or other voice changes.
  6. Hardware failure: Hardware used to support the spine during the healing process can sometimes break or shift, which may require additional surgery.
  7. Non-union: In some cases, the bone does not fuse properly following ACDF surgery, leading to ongoing pain and other complications.
  8. Chronic pain: While ACDF surgery is designed to relieve pain, some patients may experience chronic pain following the procedure. This one is a big one!  Studies show up to 25% of all patients have some form of chronic pain post-procedure!

It is important for patients to discuss the potential risks and benefits of ACDF surgery with their doctor before undergoing the procedure. By understanding the potential complications associated with the surgery, patients can make an informed decision about whether ACDF surgery is the right treatment option for them.

Prevention Of Complications

While there is no guaranteed way to prevent complications from ACDF surgery, there are steps that patients and their doctors can take to minimize the risks. Here are some general strategies that can help reduce the risk of complications:

  1. Choose an experienced surgeon: Select a surgeon who is experienced in ACDF surgery and has a good track record of success. This is key for long-term outcomes and good hospitals with low infection rates!
  2. Optimize your health: Before surgery, work with your doctor to optimize your overall health by managing chronic conditions such as diabetes, hypertension, or heart disease. The healthier you are, the better your chances of healing quickly and without too many complications
  3. Quit smoking: Smoking can increase the risk of complications after surgery, so it is important to quit smoking several weeks before the procedure.
  4. Follow postoperative instructions: After surgery, follow your surgeon’s instructions carefully, including taking medications as prescribed, attending follow-up appointments, and following any restrictions on physical activity.
  5. Engage in physical therapy: Participate in rehabilitation and physical therapy after surgery to help improve strength, mobility, and range of motion.
  6. Maintain a healthy lifestyle: Adopt a healthy lifestyle, including eating a balanced diet, exercising regularly, and maintaining a healthy weight.
  7. Report any complications: If you experience any symptoms or complications after surgery, such as fever, increased pain, or difficulty swallowing, notify your surgeon immediately.

By taking these steps, patients and their doctors can work together to minimize the risks of complications associated with ACDF surgery and improve the chances of a successful outcome.

Preoperative Evaluation And Patient Education

Before signing up for an ACDF, please make sure you research all the complications that we have outlined here and what long-term consequences come with the fusion of your spine and the chance of needing repeat surgery or other complications!….

Avoid The Risks And Complications From Invasive Surgeries

Signing up for surgery is not an easy task and while our focus is to do everything in our power to help prevent the need for surgery, sometimes surgery is the best option.  Remember, the main indication for surgery is progressive weakness, BUT if you only have pain that is limiting your function there may be alternatives that exist and other options to explore before having a life-altering surgery. If you are considering surgery and you have not explored Orthobiologics as an alternative, we recommend that you give us a call and set up an evaluation with one of our experts in the cervical spine: Dr. Markle or Dr. Pitts!

Here are some links to review Regenexx Alternative To Cervical Fusion – Centeno-Schultz and encourage them to get a second opinion from Centeno-Schultz.


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Choy WJ, Mobbs RJ, Wilcox B, Phan K. Anterior cervical discectomy and fusion (ACDF) graft selection: a systematic review. J Spine Surg. 2017;3(3):444-463.