Anterior Cervical Discectomy and Fusion and Non-Surgical Options

Ross Hauser, MD

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 and cervical artificial disc replacement.

The information that we present here on our website is, what 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 very comprehensive and complex. Their health journeys, maybe like your 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 for 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:

Section One: The decision to go to surgery

Section Two: ACDF Surgical Outcomes

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

Cervical fusion surgery is a complicated surgery. Plates, rods, or “cages” are used to hold the cervical vertebrae in place. A cervical fusion can be performed in an emergency situation where someone has had a traumatic injury to relieve pressure on the spinal cord and compression on the nerves and blood vessels leading to and from the brain. It can also be recommended to someone suffering from cervical spine degenerative disease.

This is the type of communication we receive from people exploring options for (Anterior Cervical Discectomy and Fusion) ACDF.

I have cervical myelopathy at C5-C6 and osteophytes

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 the sudden loss of taste and smell, Tinnitus, numbness and tingling in the mouth, cognitive issues, constant throat clearing, voice issues, swallowing problems, ear fullness and pain, hearing issues, headaches, and 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.

My neurosurgeon is recommending ACDF, C4-5, and C5-6 based on my most current MRI.

My neurosurgeon is recommending ACDF, C4-5, and C5-6 based on my most current MRI. I have numbness in the left index and middle fingers and some discomfort in the shoulder. It started with a very sharp pain one morning when I woke up. I was on medications for ten days to bring this pain down. This is the second time something like this has happened. Three years prior it was on my right side and even more painful, my right hand was nearly paralyzed for about a week. It finally resolved after about 8 weeks. My primary goal is to avoid surgery on C4-5 and C5-6 if possible. My research indicates that years down the road, one usually requires further surgery on C3 and C7, losing even more mobility.

Three neurologists, three different diagnosis

I have cervical degenerative disc disease C2 – C7. Cervical radiculopathy, Cervical Stenosis, Vestibular Migraines, Persistent Postural-Perceptual Dizziness, vertigo, heart palpitations, migraines. Unable to get a clear diagnosis of the strange symptoms. Three neurosurgeons say I need surgery, ACDF, and posterior decompression, none agree that it will relieve my symptoms. Three neurologists, three different diagnoses.  Multiple rounds of physical therapy and vestibular therapy relief.

For some people, cervical neck surgery may be urgently needed, especially after a traumatic injury. For others, those in chronic conditions, people may think that cervical neck surgery may reach a point where the surgery is urgently needed. But how do you know if you have reached that point when the surgeons may not agree as to what that point is?

Let’s explore some research first on the progression 

A study in the medical journal Spine (1) sought to determine whether cervical degenerative spondylolisthesis is a rapidly degenerating problem and a high-risk threat to patients or if it is 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 (2)  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. This too was suggested in a February 2023 paper in the Asian Spine Journal (3). Here doctors in Japan suggested that “Narrowing the intervertebral disc height did not stabilize the translation of slippage in flexion-extension motion in cervical spondylolisthesis. Instead, narrowing of the disc height was associated with a translation of slippage of 1.8 mm or more in flexion-extension motion in cases of anterior slippage. Therefore, we discovered that degenerative cascade stabilization for cervical spondylolisthesis was difficult to achieve.” In other words, if you tried to even the discs out to prevent the bone from sliding or slipping, you would likely not have great success in stabilizing the cervical spine.

“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 of 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 as a rapidly degenerating situation.

There are times when immediate surgery is necessary. For some people, immediate surgery is one of the few recommendations they receive.

I was told by my Neurosurgeon I had a bulging disc compressing my spinal cord it was emergency surgery

I have had two ACDFs on my neck. I was told by my Neurosurgeon I had a bulging disc compressing my spinal cord it was emergency surgery. He did replace alone disc and put a cage in my neck. About a year and a half later I started having arm shoulder and neck pain. I had a second surgery because the other discs degenerated. I have had the worst tinnitus for 6 years still have pain and now some autoimmune disease. . .  I didn’t have the tinnitus until after my surgery.

There are times when a fusion is needed there are times when a fusion is recommended, however, 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 (4)

“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.”

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 (5) 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 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, (the authors) 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 (grouping) 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.”

For more information of diagnostic testing please see my article: Ross Hauser, MD. Reviews of Diagnostic Imaging Technology for Cervical Spine Instability

Reviews of Diagnostic Imaging Technology for Cervical Spine Instability Ross Hauser, MD.

Section Two: ACDF Surgical Outcomes

The research seeks to prevent people from having an anterior surgical treatment for cervical degenerative radiculopathy that would likely not be successful for them.

In January 2023, (6) researchers at the University of Oslo, in Norway published research seeking to prevent people from having an anterior surgical treatment for cervical degenerative radiculopathy that would likely not be successful for them. In this study of 2022 patients undergoing cervical degenerative radiculopathy surgery and followed for 12 months, doctors sought to find prognostic models for non-success in neck disability and arm pain using multivariable logistic regression analysis (in other words they looked at the many characteristics of patients who had continued pain following cervical surgery to find the common characteristics they may share).

Using two testing models: The neck disability model where patients were asked to fill out questionnaires and the arm pain model (did the patient have relief or arm pain or did arm pain intensify).

Thirty-eight percent of patients experienced non-success in neck disability and 35% in arm pain.

The researchers concluded using these guidelines, individualized risk estimates can be made and applied in shared decision-making with patients referred for surgical assessment.

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.

In the Journal of Neurosurgery Spine, (7) 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 (8): “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.”

There is less of a reoperation rate when the patient has one or two-level fusion.

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 2023 study from the University of Tennessee published in the Archives of Orthopaedic and Trauma Surgery (9) assessed the 2-year rate of reoperation and determined 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 of 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 (10) 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 the 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 for lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.

A November 2022 paper in the Journal of Orthopaedic Surgery and Research (11) “collected the latest published relevant studies, analyzed the risk factors of ninety-day readmission after cervical surgery . . .This study focuses on two research hotspots: (1) What is the rate of ninety-day readmission after cervical surgery? (2) What are the risk factors affecting the ninety-day readmission?

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. (12)

A March 2022 study published in the journal Scientific Reports (13) examined outcomes after four-level anterior cervical discectomy and fusion (ACDF) in twenty-eight patients with a minimum of 12 months follow-up. The average age at surgery was 58.5 years old. About 23 months later radiographic imaging follow-up was done. Cervical lordosis was significantly improved postoperatively as well as significant improvement in pain and function scores.  The most common perioperative complication was transient dysphagia (32%) followed by hoarseness (14%). Four (14%) patients required revision surgery at an average of 11.5 months postoperatively.

Positive outcomes in anterior cervical discectomy and fusion: 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 (14) 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 was created. Patients were subdivided into 2 groups based on the presence or absence of significant preoperative weakness.

Positive outcomes in anterior cervical discectomy and fusion: Return to work after cervical fusion

A November 2018 paper in the journal Neurosurgical Focus (15)  tried to offer a way to better predict which patients would return to work at 3 months after cervical spine surgery.

In this paper, the authors found that among previously employed and working patients, 89.3% returned to work compared to 52.3% among those who were employed but not working (e.g., were on leave) at the time of surgery. They found that patients who were less likely to return to work were older than 56 – 65 years old, were employed but not working; were employed part-time; had a heavy-intensity or medium-intensity occupation compared to a sedentary occupation type; had workers’ compensation; had a higher Neck Disability Index score at baseline.

An August 2022 paper in the journal Cureus (16) determined the rate of return to work and contributing factors after a one- and two-level anterior cervical discectomy and fusion (ACDF).

A May 2022 paper in the Global Spine Journal (17) found that the majority of nonretired patients undergoing surgery for degenerative cervical myelopathy had returned to work 12 months after surgery; active preoperative employment and anterior surgical approach were associated with better return to work averages before surgery.

Comparing different surgeries

Recent Research on Elective Cervical Spine Surgery

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 published in the North American Spine Society journal (18) 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.”

A February 2023 study published in the Journal of Neurosurgery Spine, (19) assessed data from nineteen studies comprising 8340 patients of whom 4118 (49.4%) underwent anterior cervical discectomy and fusion and 4222 (50.6%) underwent posterior decompression. At their one year follow-up pain, function, and disability scores were similar between the groups. In the ACDF group,  operative bleeding, hospital length of stay, surgical site infection, and C5 palsy were lower, the dysphagia was higher in ACDF.

Pseudoarthrosis after cervical fusion

An April 2022 study in the journal Clinical Spine Surgery (20) 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.”

combined anterior and posterior spinal fusion

Combined anterior and posterior spinal fusion

Anterior cervical decompression fusion vs. posterior laminoplasty

A December 2022 paper in the Journal of Neurological Surgery (21) compared anterior cervical decompression fusion and posterior laminoplasty. The authors suggest: “Although anterior or posterior surgery for cervical spondylotic myelopathy (CSM) has been extensively studied, the choice of anterior or posterior approach in 4-segment cervical spondylotic myelopathy remains poorly studied and controversial.” In this study, the researchers compared the clinical and radiographic outcomes of 4-segment cervical spondylotic myelopathy by posterior laminoplasty (LAMP) and anterior cervical decompression fusion (ACDF).

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.(22)

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 and risks. Anterior Cervical Discectomy and Fusion are significantly associated with the longest operative duration and shortest length of stay without an increase in individual or overall complications, readmissions, or reoperations.

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 the 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 videos 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.

Post-cervical fusion headaches and migraines

A frequent problem encountered by patients following cervical fusion surgery is headache. Their stories go something like this.

Neck pain and headaches

I had ACDF surgery on C5/C6 and C6/C7. Since the surgery, I have had tremendous neck pain, spasms, and an unrelenting headache. I was treated for a possible CSF leak, but that did not help. I have had trigger point injections, facet joint nerve block, and botox all of which have not alleviated the pain.

I started having neck pain two years ago. Last year I had ACDF surgery at C5-6. I had a small herniation at this level and my neurosurgeon believed it may be the cause of my symptoms. Almost three months later and no signs of relief. The head pain is actually worse. It radiates to the base of my skull and causes deliberating head pain. It’s bilateral and the headaches are usually one-sided. I have shooting pains that go into my arms and my shoulders have a burning sensation. My arms almost always feel heavy. I have dizziness, brain fog, and a sense of fullness/pressure in my head. Especially when walking. My doctor says it’s muscle pain and said physical therapy may help. I think it’s c2 instability.

In this video presentation, Ross Hauser, MD reviews a digital motion X-ray of a post-cervical fusion patient.

For the full article please go to Post-cervical fusion headaches and migraines.

Swallowing difficulties after cervical fusion

A June 2022 paper in the Journal of Clinical Neuroscience (23) Dysphagia following anterior cervical spine surgery is common. In this research, the investigators aimed to determine if the 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 in 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.

Postoperative dysphagia. ACDF and the posterior approach

A December 2022 paper in The Spine Journal (24) analyzed swallowing function after anterior/posterior surgery for cervical degenerative disorders.

  • A total of 41 consecutive patients who underwent an anterior approach (anterior cervical discectomy/corpectomy (removal of all or part of the vertebrae) and fusion (ACDF, ACCF), hybrid surgery (ACDF+ACCF) and total disc replacement) and 44 consecutive patients who underwent a posterior approach (laminoplasty and laminoplasty/laminectomy with fusion) were compared.

Comparisons were made in pre-and postoperative functional oral intake scale (FOIS – the ability to take in food or liquid), dysphagia severity scale (DSS), esophageal dysphagia, anterior/superior hyoid (the u-shape bone at the base of the throat responsible for the movement of the tongue in swallowing and speech) movement, upper esophageal sphincter opening, pharyngeal transit time (from the time of the swallow to return to the normal non-swallowing position), among other observations.

  • In the anterior approach, dysphagia severity scale, functional oral intake scale, the anterior and superior hyoid movements, and maximum upper esophageal sphincter opening worsened postoperatively.
  • In the posterior approach, dysphagia severity scale, functional oral intake scale, the anterior and superior hyoid movements worsened postoperatively
  • Conclusions: “Each approach may decrease swallowing function, especially because of the limitation on the anterior hyoid movement.”

Dysphonia and Voice Hoarseness after cervical fusion surgery

Following anterior neck surgeries, recurrent laryngeal nerve palsy may occur as a complication due to trauma or irritation of the recurrent laryngeal nerve. A September 2022 paper in the journal World Neurosurgery (25) reiterates: “Recurrent laryngeal nerve injury is a common complication after anterior cervical discectomy and fusion (ACDF).” In this study, the researchers examined this problem by evaluating recurrent laryngeal nerve function during anterior cervical discectomy and fusion surgery using intraoperative recurrent laryngeal nerve monitoring with an electromyography-endotracheal tube (EMG-ET). The goal was to see if electromyography-endotracheal tube (EMG-ET) could alert surgeons of recurrent laryngeal nerve damage occurring during the surgery. These were the observations and outcomes:

  • The study included 85 patients, 58 (68.2%) of whom had undergone surgery without an EMG-ET and 27 (31.8%) with an EMG-ET.
  • Of the no EMG-ET group, 8 (13.8%) and 1 (1.7%) patients had developed immediate postoperative dysphagia and hoarseness, respectively, with complete recovery within 12 months.
  • In the EMG-ET group, 2 (7.4%) and 1 (3.7%) patients had developed dysphagia and hoarseness, respectively, with complete recovery within 3 months for all 3 patients.
  • Persistent postoperative RLN palsy had occurred in 5 patients (8.6%) without the EMG-ET but in none of the patients with the EMG-ET.
  • Conclusions: “The use of an EMG-ET for RLN monitoring during ACDF surgery was helpful in detecting postoperative recurrent laryngeal nerve injury with fair sensitivity and high specificity and resulted in a shorter retractor time, thereby significantly reducing the risk of postoperative recurrent laryngeal nerve injury.”

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 (26) 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.

  • The researchers followed 52,575 patients in which an ACDF was performed of which 1454 admissions had respiratory and pulmonary complications.
    • Older patients were 1.03 times more likely to have respiratory and pulmonary complications
    • African American patients compared to Caucasian patients were 1.44 times more likely to have respiratory and pulmonary complications
    • Obese patients were found to be 1.64 to have respiratory and pulmonary complications.
    • Diabetic patients are 2.07 times more likely to have respiratory and pulmonary complications.
    • Hypertensive patients are 1.91 times more likely to have respiratory and pulmonary complications
    • Patients who underwent multilevel procedures were 1.32 times more likely to experience follow-on respiratory and pulmonary complications. 

The problems created by osteoporosis

In January 2023, doctors writing in The Journal of the American Academy of Orthopaedic Surgeons  (27) examined the impact of osteoporosis, two years after cervical neck fusion. In this study, the doctors followed 136 osteoporosis patients and found that “patients with osteoporosis incurred higher rates of overall medical complication rates and individual surgical complications, such as nonunion. Osteoporosis was associated with medical complications, surgical complications, and (hospital) for two years.

In the image below the caption reads: Instability above a cervical fusion as documented by digital motion x-ray. Looking at the cervical joint above the fusion, an offset can be seen in the neutral position (A) and in extension (C), which is widened during flexion (B). In this patient’s case, Prolotherapy injections helped stabilize the patient’s neck. These injections are discussed below.

Is age a problem in ACDF?

A September 2023 paper (28)  lead by doctors at the Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York followed ACDF patients for eleven years to assess if old age of the patient created more risks for complications. To perform this assessment risk changes among elderly groups such as the difference between elderly (60+) and octogenarian (80+) patients were analyzed. What the researchers found was that “Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.”

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 (29) 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.

Cervical adjacent segment disease: Risks and complications following ACDF.

The subject of Cervical adjacent segment disease requires its own article. I have an extensive article here: Cervical adjacent segment disease: Risks and complications following cervical fusion.

What are we seeing in this image?

In this image, we see adjacent segment disease severely impacting the non-fused C6-C7 area. After two fusion surgeries, this 15-year-old patient’s only natural moving cervical segment is at C1-C2. This unfortunately is a classic case of fusion surgery causing more problems than it helped.

In this image we see adjacent segment disease severely impacting the non fused C6-C7 area. After two fusion surgeries, this 15 year old patient only natural moving cervical segment is at C1-C2. This unfortunately is a classic case of fusion surgery causing more problems than it helped. 

 

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 for 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. (30)

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, (31) 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.

Instability above a cervical fusion as documented by digital motion x-ray.

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 conventional 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, 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

References

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This article was updated September 26, 2023

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