Anterior Cervical Fusion (ACF)
Anterior cervical fusion (ACF) is a spinal fusion surgery in the neck, or cervical, spine. Usually, patients undergoing ACF have already tried other treatments, including physical therapy, oral pain medications (anti-inflammatories, muscle relaxers, pain killers), and sometimes epidural steroid injections.
ACF surgery begins with the anesthesiologist putting the patient to sleep in the operating room. Intraoperative nerve monitoring and x-ray are used to help ensure the safest possible environment. The surgeon and his or her assistants perform the surgery through a small incision on the front of the neck.
The contents of the neck are gently retracted, enabling the front part of the spine to be seen. Important structures, including the trachea (windpipe), esophagus (food pipe), and the large blood vessels in the neck are carefully retracted and protected. Once the cervical spine is visualized, the surgeon carefully removes the diseased disc or discs to take the pressure away from the nerves in the spine itself.
Fluoroscopy is used to determine the correct level(s) before the disc material is removed and the fusion graft is inserted. After the disks have been removed, the surgeon reconstructs the spine to restore its height and promote fusion. A surgical plate is then screwed in place over the fusion level.
- Herniated disc
- Painful disc degeneration
- Radicular syndrome
What to Expect
Once you have decided to have cervical fusion surgery:
- A medical examination.
- Chest X-ray, EKG and blood work.
- You may be asked to have a neurological or psychological examination.
- If taking aspirin or anti-inflammatory medications daily, stop these medications at least one week before cervical fusion surgery.
- If you take prescription medications or other drugs, including herbals, ask your doctor how soon before cervical fusion surgery you should stop taking these.
- Do not have anything to eat or drink for 6 to 8 hours before surgery.
- You will check into the hospital the morning of surgery.
- Prior to surgery, you will be asked to sign permits for surgery, anesthesia, blood and blood products.
Surgery takes approximately 1-2 hours:
- The surgeon makes an incision in the front part of the neck.
- Fluoroscopy (live X-ray) is used to determine the correct level(s) to be operated.
- The contents of the neck are gently retracted to the side so that the spine can be seen.
- Disc tissue is removed.
- A fusion cage or wedge of bone is placed in the disc space.
- Often, a plate is screwed over the operated segment to hold the graft in place and stabilize the area.
You will be in the recovery room from 1 to 1½ hours:
- The surgeon will contact your family while you are in recovery.
- After going to a hospital room, you will be able to use a PCA pump to get medication for pain control. This machine controls the amount of medication that can be received.
- Staff will usually get you out of bed shortly after surgery.
- The hospital stay is usually 1-2 days.
- A brace or collar is prescribed to restrict bending and promote healing of the fused area.
- Most patients will have some difficulty with swallowing after surgery. This generally improves with time.
- You will be given any needed prescriptions and discharge instructions.
- A set of exercises that you can do at home will be provided.
- You will be able to ride in a car or plane upon leaving the hospital.
- It is important to avoid turning your head and bending your neck excessively.
- Physical therapy is usually initiated after the first office visit with your doctor following cervical fusion surgery.
- Recovery from Anterior Cervical Fusion (ACF) varies greatly among patients and is dependent on the extent of the surgery as well as the age and health of the individual. Return to work also varies greatly among patients and is related to overall health and the type of work you do. The type of collar used may limit your ability to drive safely for a period of time
Frequently Asked Questions
Most ACF take 1-2 hours for the surgeon to perform with minimal blood loss.
Most patients who undergo ACF at Texas Back Institute spend just 1 night in the hospital, but some can go home on the same day of surgery as an outpatient. For more extensive ACF procedures, the patient may remain in the hospital for a couple of nights longer.
There are many implants available for the surgeon to use in this procedure. Surgeons choose the right implant for the right patient to reconstruct the spine and promote fusion:
- Cages made of metal or plastic can be used to restore the disc height after the disc has been removed. Some cages can be used with plates, whereas others were designed to use with plates.
- Plates made of metal can be used to stabilize the cervical spine with screws. Cervical plates are placed on the front of the spine after the cages and bone graft are placed within the disc spaces.
- Bone grafts are typically used to promote fusion within each disc space. Most cervical fusions are performed with either donor bone (allograft) or synthetic bone, but bone graft can also be taken from the patient’s own pelvis during the surgery if that is what the patient prefers.
Regardless of which implants are used, the goals of the surgery remain the same: to give the patient the best possible pain relief and the best possible functional outcome in the safest possible way.
ACF are performed at Texas Back Institute by fellowship-trained, board-certified/board-eligible orthopedic spine surgeons and neurosurgeons.
ACF can be performed from 1 to 6 levels, but the vast majority of ACF are performed at 1 or 2 levels. The most commonly affected levels in the cervical spine which require surgery are C5-6 and C6-7.
Most major medical insurance plans, including Blue Cross/Blue Shield, United Healthcare, Aetna, Cigna, and Medicare, cover ACF, but they are still subject to the same deductible and co-payments as other health care procedures.
Surgery may be delayed because many insurance companies require pre-authorization of this surgical procedure, which can take up to 3 weeks.
Anterior cervical fusion is one of the most reliable surgeries that we perform at TBI. Typically fusion rates are 90-95% for each level fused in healthy, non-smoking patients undergoing ACF for the first time.
Neck and arm pain tend to improve quickly over the first 6 weeks after surgery, especially as the patient goes through post-operative physical therapy.
For most patients, our goal after ACF is full unrestricted physical activity, including work, driving, contact sports (football, basketball, skiing), non-contact sports (golf, swimming, tennis, volleyball, running, cycling), dancing, attending social events (sporting events, parties, movies), and taking care of a patient’s family and household (cooking, cleaning, laundry).
The need for a collar depends on the number of levels fused and the quality of the patient’s bone. Some patients undergoing 1 or 2 level fusions require minimal immobilization, whereas those undergoing more extensive surgery may need to wear a collar for 2-3 months after surgery.
The best alternative to ACF is non-operative treatment. At TBI we take the decision to undergo surgery very seriously.
Our philosophy is that surgery is the last resort in most cases only to be used when all other treatments including time, activity modification, oral medications, physical therapy, and injections have failed. If we can get you better without surgery, we will certainly try that option first.
Another alternative is disc replacement. For a small subset of patients who present with neck pain, total disc replacement or artificial disc replacement (ADR or TDR) can be an option to consider.
TBI surgeons have been pioneers in disc replacement since 2001, and we are pleased to offer this as a treatment alternative to ACF in some cases.