Anterior Cervical Discectomy and Fusion and Non-Surgical Options

Ross Hauser, MD

Anterior Cervical Discectomy and Fusion

Many people come to Caring Medical because they have issues with cervical neck instability and cervical radicular pain that radiates into their arms and legs. These people are looking for a realistic treatment option for their Anterior Cervical Discectomy and Fusion surgery recommendation. In separate articles we discuss Cervical neck instability, and, Atlantoaxial instability, and how these conditions can send you to Anterior Cervical Discectomy and Fusion. We also discuss other elective cervical surgery options.

The information that we present here on our website we believe to be very comprehensive. Why do we present such comprehensive information? Because of the discoveries and observations of treatment methods we have seen in now almost three decades of helping people with the problems of cervical instability and upper cervical instability. We try to make our information comprehensive because the challenges and health concerns that these people face are themselves very comprehensive and complex. Their health journeys, maybe like you health journey, have been very complex and the many diagnostic tests, while compressive, have not provided insight.

The host of symptoms that cervical instability causes is immense. Everything from symptoms in the leg to whole body neuropathy to diffuse body pain can come from cervical instability in the neck. At our center, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe pain, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.

In this article, we will explore our non-surgical regenerative medicine options to repair and stabilize the cervical spine without surgery.

In this article we are going to cover research from the surgical community addressing these patient concerns:

Article summary:

I have all these symptoms . . .I was told to have cervical fusion surgery

These is the type of communication we receive from people exploring options to ACDF.

I have cervical myelopathy at C5-C6 and osteophytes. I have had two opinions from neurosurgeons and both recommend ACDF due to spinal cord compression. I have no pain but symptoms of sudden loss of taste and smell, Tinnitus, numbness and tingling in mouth, cognitive issues, constant throat clearing, voice issues, swallowing problems, ear fullness and pain, hearing issues, headaches, sense of off balance. I have not been offered any alternative treatments other than surgery. I have seen three ENTs, an allergist, a speech pathologist and primary care, to rule out allergies, ear problems, etc. Nothing has helped any of these issues and they don’t know the cause.

I have no equilibrium. Not vertigo. Just unbalanced and can’t walk a straight line.

The realistic expectation of cervical fusion surgery from the neurosurgeons’ point of view:

In the Journal of Neurosurgery Spine, (1) August 2019, neurosurgeons from some of the leading neurological surgery departments in the nation published these findings on whether or not patients were truly satisfied with their surgical outcomes following anterior cervical discectomy and fusion (ACDF).

Comment: We should note that:

A 2018 study on patients with 1-2-3 level fusions, reported in the Global Spine Journal (2) : “When analyzed for patient satisfaction we found that 65.9% of the patients were satisfied, 28.2% were uncertain, and 5.9% were dissatisfied with the surgical result at 1-year follow-up.”

A follow up to this research on 1 and 2 level cervical fusions

There is less of a reoperation rate when the patient has one or two level fusion. Many patients we see have more than two levels fused. This would appear to be good news. A July 2021 study from the University of Tennessee published in the Archives of orthopaedic and trauma surgery (3) assessed the 2 year rate of reoperation and determine patient-reported outcomes after elective one- and two-level anterior cervical discectomy and fusion.

Here are the learning points:

Results: One hundred and four patients were identified with a final reoperation rate of 2.9% at a mean final follow-up 2 years. No reoperations occurred within 90 days. After 1 year, three patients required reoperation.

A follow up on 1-2-3-4 level cervical fusion at 5 years

An April 2022 study in The spine journal (4) comes to us from the Department of Orthopedics and Rehabilitation, Yale School of Medicine and the Carle Neuroscience Institute. What this study sought to provide information on was patient outcomes after three- and four-level cases, which the authors noted, had significantly less data than the outcomes of one to two level cervical fusions.

Outcome measures: Number of patients who had Ninety-day adverse events and number of patients who needed reoperation within five years.

Reoperation rates at five years:

Conclusions: While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.

Indicators for substantial neurological recovery following elective ACDF

A May 2022 paper from doctors at the Mayo Clinic, Walter Reed National Military Medical Center, and Thomas Jefferson University, published in the medical journal Clinical spine surgery (20) examined the indicators for substantial neurological recovery following elective ACDF.

The researchers noted: “While neck and arm pain reliably improve following anterior cervical discectomy and fusion (ACDF), the frequency and magnitude of motor recovery following ACDF remain unclear.”

In this study a review of 618 patients who underwent 1-4-level ACDF were created. Patients were subdivided into 2 groups based upon the presence or absence of significant preoperative weakness.

Multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF)

A March 2022 paper from the Department of Orthopaedics and Rehabilitation, Yale School of Medicine and published in the North American Spine Society journal (16) compared multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes.

The researchers concluded: “In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.”

While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases.

An April 2022 paper from the Yale School of Medicine published in the Spine journal (20) explores surgical outcomes in patients getting three or four level fusions compared to those getting one to two level fusions. The researchers write of their 97,081 patient case study: “The current study represents one of the largest comparative studies of patients undergoing one-, two-, three-, and four-level ACDF. While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. . . Reoperation rates at five years for one level 13.0%, two level 13.5%, three level 50%, and four-level cases 22.1%”

Possible Anterior Cervical Discectomy and Fusion complications compared to other neck surgeries

Doctors at the Department of Orthopaedics, Columbia University Medical Center in New York published their comparison findings on the different types of cervical spine surgeries for Degenerative Cervical Myelopathy. Here is the summary of their July 2022 research appearing in the Global spine journal.(18)

The researchers compared the short-term outcomes for Cervical laminoplasty, Cervical Laminectomy/fusion, and multi-level Anterior Cervical Discectomy and Fusion. There were 182 patients in each group.

Conclusions: Cervical Laminectomy/fusion carries the highest risk for morbidity, mortality, and unplanned readmissions in the short-term postoperative period. Laminoplasty and Anterior Cervical Discectomy and Fusion cases carry similar short-term complications risks. Anterior Cervical Discectomy and Fusion is significantly associated with the longest operative duration and shortest length-of-stay without an increase in individual or overall complications, readmissions, or reoperations.

Possible pulmonary complications following elective anterior cervical discectomy and fusion

A June 2022 study from the Mayo Clinic published in the Clinical neurology and neurosurgery (19) suggested predictive factors for post-surgical airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.

The researchers write: “While the procedure is generally well tolerated, respiratory and pulmonary complications are an unlikely yet possible complication following ACDF. Few previous studies have specifically identified risk factors associated with respiratory and pulmonary complications following ACDF.

Surgery because your neck will get worse? Researchers suggest that for many people cervical degeneration does not evolve and progress that quickly that surgery should be considered as urgently needed

For some people, cervical neck surgery may be urgently needed. Research suggests that not everyone is in that situation.

A study in the medical journal Spine (5) sought to determine whether cervical degenerative spondylolisthesis is a rapidly degenerating problem and a high-risk threat to patients or is it a more slowly degenerating disease.

Let’s look at the patients of this study:

Their cervical spine problems:

Patient diagnosis

The patient’s history of cervical degenerative anterolisthesis and retrolisthesis seemed to be stable for 2 years to nearly 8 years

How much slippage?

Upwards of 8 years later, how much worse were these patients’ problems?

The suggestion is that some people will experience a very slow degeneration of their cervical spine despite clear MRI documentation that their situation may warrant a surgical recommendation. This is usually where the problems begin, an MRI showing a need for surgery that may not be there.

Aggressive spondylolisthesis and not as aggressive degenerative spondylolisthesis – a question of cervical spine instability

A 2018 study published in the journal Spine Surgery and Related Research (6)  suggested cervical degenerative spondylolisthesis can be classified into two types. The first and more common listhesis occurred adjacent to stiffened levels, and anterior slippage was common in this type. The second and less common listhesis occurred within progressively degenerated segments, and posterior slippage was prominent. Further: “Cervical spondylolisthesis in a flexed or extended neck position possibly suggests inherent instability of the cervical spine.”

The suggestion is that the problem may not be spondylolisthesis, the problem may be instability.

“BUT I was told that if I did not have the cervical fusion surgery, I was at risk for becoming paralyzed”

In the many years of helping patients with neck problems, we have found that a highly motivating factor to have the surgery was fear, fear of paralysis. This is typical when we ask patients “what finalized your decision to have the cervical fusion surgery?” many respond, “I was told that I was at risk for becoming paralyzed. I cannot tell you how much that scared me. Now, looking back, maybe I rushed into the surgery and should have sought out more opinions.” In fact, some people do relate that they had two opinions, one surgeon who said surgery was not necessary and that the patient should continue conservative care therapy and one surgeon who talked about paralysis for a rapidly degenerating situation.

Some people come in after undergoing surgery, looking for ways to get off of the pain medications that they have been using. Other patients come in after successful surgery with new problems of TMJ or difficulty swallowing or dizziness and headaches. They are looking for help with those problems.

What if I get into a car accident?

I was told that I needed an ACDF C3-C7.  I do not want surgery. I was told if I’m in an auto accident it could be serious.

You may be getting cervical fusion surgery because of an MRI reading that may not be accurate

We cannot begin to count the number of patients that we have seen over the many years who begin their conversation with us with “My MRI says I need the surgery.” What is now concerning some doctors is that doctors may be recommending surgery based on an MRI which may not be entirely accurate.

Look at this research from Yale University that was published in the Spine Journal (7)

“MRI findings play an important role in the management of patients with cervical spine conditions. For this reason, consistent descriptions of these findings are essential and physicians should be aware of the relative reliability of these findings. (Our) systematic study developed standardized grading criteria and nomenclature (a catalog) for common clinically significant MRI findings in the cervical spine.

Even in this optimized research setting, we found significant ranges in agreement across these MRI findings. In the clinical setting, inter-and intra-rater agreements may be lower, and the range of agreements between findings may be greater. Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others.”

The MRI looks for a pinched nerve – if it finds one – a cervical fusion surgical recommendation can be made whether surgery is needed or not.

Anterior cervical discectomy and fusion (ACDF or sometimes anterior cervical decompression) is a cervical neck surgery that is recommended to patients that have been diagnosed with a pinched nerve in the neck that is causing pain, weakness, numbness, and other symptoms of cervical radiculopathy.

Surgeons caution against including asymptomatic levels in an anterior cervical fusion surgery

For some people they may have received a cervical fusion that went too far or included segments of their neck that do not need to be included: Doctors at the Department of Neurosurgery and Department of Radiology at the University of Utah published an August 2021 paper (8) in which they write: “Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. We evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation for symptomatic adjacent-segment degeneration (ASD) after the initial Anterior cervical discectomy and fusions.”

What these researchers did was to review the medical charts of patients treated with Anterior cervical discectomy and fusions in 2000-2010 who had MRIs preoperatively and again more than three years after the first fusion surgery to evaluate new neurological symptoms. Patients were grouped by adjacent-segment degeneration severity score, calculated based on MRI features (and interpretations). What they found was that few patients, who had clearly seen degenerative features in the segments adjacent to the fusion pre fusion surgery, did not need further fusion surgery years later. The researchers wrote: “The prevalence of reoperation for adjacent-segment degeneration was low for patients who presented with new symptoms more than 3 years after the initial  Anterior cervical discectomy and fusion. Our findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.”

“even patients with severe imaging abnormalities at the time of the index (first fusion) operation are likely to be managed nonoperatively at long-term follow-up”

Expressing this further, they suggest: “Considering these data, we caution against including asymptomatic levels in an anterior fusion construct, even if severe abnormalities are present on preoperative MRI. Although this population (those with new symptoms returning for an MRI more than 3 years after the index ACDF) may require reoperation (10%, 10/96 patients), after stratifying by the severity of preoperative MRI abnormalities, preoperative findings were only associated with reoperation in patients with the most severe abnormalities. In this group, the prevalence of reoperation was only 16% (5/31 total levels assessed). . . Thus, even patients with severe imaging abnormalities at the time of the index (first fusion) operation are likely to be managed nonoperatively at long-term follow-up.”

A comparison between physical therapy and anterior cervical decompression and fusion


After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. Spinal cervical fusion and decompression seem to offer a solution – short-term. This is supported in the medical literature. In one study in the medical journal Spine,(9 patients with cervical radiculopathy, treated with surgery and physiotherapy resulted in a more rapid patient improvement during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone.

However . . . 

However, the differences between the groups decreased after two years. In this paper where surgery was touted as being so successful – the researchers concluded: “Structured physiotherapy should be tried before surgery is chosen.” After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

That study is from 2013. What has happened in the years since?

In 2017, the same group of doctors in Sweden writing in the Journal of Spine, (10)  evaluated the 5- to 8-year outcome of anterior cervical decompression and fusion (ACDF) combined with a structured physiotherapy program as compared with that following the same physiotherapy program alone in patients with cervical radiculopathy.

Citing the 2013 research above, the doctors noted that no study went beyond two years in describing the comparison effect of surgery vs. physical therapy for cervical radiculopathy.

In this study, Fifty-nine patients were randomized to ACDF surgery with postoperative physiotherapy (30 patients) or to structured physiotherapy alone (29 patients).

RESULTS

People have very successful fusion surgeries – Some do not – some have very successful second fusion surgeries, some do not. A story of C3-C7 fusion and C1-C2 instability.

Often we will get a story. This story has been edited so it could be told in third person and some explanatory notes could be added.

This person had Anterior Cervical Discectomy and Fusion surgery twice (once in 2018/once in 2019) to complete a C3-C7 fusion. All the discs were removed because they were ruptured. This surgery was very successful as far as stabilizing the person’s neck at C3-C7. But then this person started to suffer from neurologic-like, gastrointestinal-like and unexplained symptoms. This person wrote: “Although the ACDF’s gave some result/stability at those levels, the main symptoms remained. It appears to be exactly all these rare symptoms that Dr. Hauser describes in his video’s and (articles). After getting all this info I am 100% sure I have remarkable upper cervical instability. I think that the fusion from C3-C7 could never resolve these symptoms.”

Among these symptoms were:

Some of the symptoms have been checked neurologically and by their specialty but it appears everything is fine, as they say.

Four-level and Five-level anterior cervical discectomy and fusion

Doctors at Rush University Medical Center and the Baxter Regional Neurosurgery & Spine Clinic, in Arkansas assessed patient outcomes in four-level and five-level anterior cervical discectomy and fusion. Here are the summary points of their research published in July 2022 in the journal World neurosurgery.(17)

Airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion

A June 2022 study (14) from the Department of Neurologic Surgery, Mayo Clinic Alix School of Medicine and published in the Clinical neurology and neurosurgery offered insights into which patients would have airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.

In a patient base of 1454 patients who had respiratory and pulmonary complications, the researchers found:

Swallowing difficulties after cervical fusion

A June 2022 paper in the Journal of clinical neuroscience (15) Dysphagia following anterior cervical spine surgery is common. In this research, the investigators aimed to determine if change in intervertebral distraction (vertebral placement) following anterior cervical spine surgery is associated with early dysphagia (swallowing / Quality of Life difficulties). Among the 289 patients of this study, the incidence of dysphagia was 58.1% 1 week after anterior cervical spine surgery. Patients who underwent surgery involving C3/4 or involving three or more levels had worse symptom and function scores.

Pseudoarthrosis after cervical fusion

An April 2022 study in the journal Clinical spine surgery (13) described the problem of pseudarthrosis (failed fusion surgery). “Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to more than 60% and depend heavily on patient factors, approach, and number of levels.” If you have had failed spinal fusion, your doctor may have advised you that you developed pseudoarthrosis. The study continues: “While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy.”

The complication of obesity in Anterior Cervical Discectomy and Fusion

A December 2021 paper from Rush University Medical Center published in the International journal of spine surgery (21) writes: “Body mass index (BMI) serves as a risk factor for complications and poorer outcomes following anterior cervical discectomy and fusion (ACDF). This study investigates the association between BMI and patient reported outcomes of surgery.

Digital motion X-Ray C1 – C2

DMX stands for a digital motion x-ray. If you watch the two videos below you may be somewhat amazed at what the DMX can show as opposed to a convention X-ray or a conventional MRI. The DMX shows your cervical spine in motion. DMX is a tool we rely on to help us treat patients with very difficult chronic neck pain and symptoms.

As opposed to an MRI, DMX, or sometimes referred to as a cineradiography or videofluoroscopy, can show spinal and peripheral joint instability in real-time and how it impacts your quality of life. Whereas MRI is a tool that confirms you need surgery, DMX is a tool that can help confirm that you do not need surgery. The DMX gives us the tool of showing your neck in real-time motion and revealing more clues to the true nature of your problem than a static image can.

The digital motion x-ray is explained and demonstrated below

In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine


Caring Medical research on alternatives to Discectomy and Fusion

In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe pain, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.

Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.

Surgical recommendations are described in a way to the patient that seemingly makes sense as the only solution to their problems.

Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage

In neck and spine surgery, doctors focus on degenerative disc disease and its treatment,   anterior cervical discectomy and fusion, and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves and to fix the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly (behind) to limit their amount of movement.  The goal is to limit pressure on the nerves.

However, it may limit motion to such an extent that patients become completely unable to move that portion of their neck. In addition, fusion operations can accelerate the degeneration of adjacent vertebrae as the motion in the neck is distributed more on these tissues.

In 2014 headed by Danielle R. Steilen-Matias, PA-C, we published these findings in The Open Orthopaedics Journal. (11)

When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.

Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.

Prolotherapy is an injection technique utilizing simple sugar or dextrose.

Stabilizing the unstable neck – degenerative disc disease vs. degenerative ligament disease

Back to our 2014 research headed by Danielle R. Steilen-Matias, PA-C, published in The Open Orthopaedics Journal. Here we outline that the problems of the cervical neck are not always problems of degenerative disc disease but problems of degenerative ligament disease. This explains why traditional treatments focused on the discs will not be successful in the long term.

In another of our published research studies, in the European Journal of Preventive Medicine, (12) we presented the following findings:

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.

Prolotherapy treatment

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

If you have a question about options for an Anterior Cervical Discectomy and Fusion, you can get help and information from our Caring Medical Staff.

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This article was updated June 27, 2022

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