====== Anterior cervical discectomy and fusion technique ====== //J.Sales-Llopis// //Neurosurgery Department, Alicante University General Hospital, Alicante, Spain.// ===== Latest News ===== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1nQmw1FvDkC4rz8-pgbp9nZTo0eOx5K2fm5K1fx7d0hWZ9-Q_2/?limit=15&utm_campaign=pubmed-2&fc=20230208163423}} ===== History ===== Several modifications have been described to the original procedure developed by Smith and Robinson for ACDF ((Smith GW , Robinson RA . The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. The Journal of Bone & Joint Surgery. [[1958]];40(3):607–624. doi:10.2106/00004623-195840030-00009)) ---- The earliest descriptions of the technique have always been attributed to [[Ralph Bingham Cloward]], [[George W. Smith]], and Robinson. However, in the French literature, this procedure was also described by others during the exact same time period (in the 1950s). At a meeting in Paris in [[1955]], Belgians Albert Dereymaeker and Joseph Cyriel Mulier, a neurosurgeon and an orthopedic surgeon, respectively, described the technique that involved an [[anterior cervical discectomy]] and the placement of an [[cortical iliac crest autograft]] in the [[intervertebral disc space]]. In [[1956]], a summary of their oral presentation was published, and a subsequent paper-an illustrated description of the technique and the details of a larger case series with a 3.5-year follow-up period-followed in [[1958]]. The list of authors who first described ACDF should be completed by adding Dereymaeker's and Mulier's names. They made an important contribution to the practice of [[spinal surgery]] that was not generally known because they published in French ((Bartels RHMA, Goffin J. Albert Dereymaeker and Joseph Cyriel Mulier's description of anterior cervical discectomy with fusion in 1955. J Neurosurg Spine. 2018 Jan 12:1-6. doi: 10.3171/2017.7.SPINE17182. [Epub ahead of print] PubMed PMID: 29327972. )). ---- Anterior [[cervical]] [[instrumentation]] was initiated by Bagby ((Bagby GW. [[Arthrodesis]] by the [[distraction]]-[[compression]] method using a stainless steel implant. Orthopedics. 1988;11:931–4. )) in a [[horse]] using a [[cage]], in [[1988]]. ===== Consent ===== (in lay terms for the patient – not all-inclusive): a) procedure: [[surgery]] through the front of the [[neck]] to remove the [[cervical disc]] and [[bone spur]]s, and to place a [[graft]] where the disc was, and possibly place a metal plate on the front of the spine. Some surgeons take bone from the hip to replace the removed disc. b) alternatives: nonsurgical management, surgery from the back of the neck, artificial disc (in some cases). c) complications: swallowing difficulties are common but usually resolve, hoarseness of the voice (<4% chance of it being permanent), injury to: foodpipe (esophagus), windpipe (trachea), arteries to the brain (carotid), spinal cord with paralysis, nerve root with paralysis, possible seizures with MEPs ===== Patient Positioning ===== The patient is placed in the [[supine position]] with the head slightly reclined and stabilized in a [[head holder]]. Once the lordotic [[cervical spine]] has been supported, the thorax may be placed on a [[pillow]] to emphasize the reclination of the cervical spine. The arms are fixed along the sides of the body. ===== Exposure of the Intervertebral Space ===== After the [[skin incision]] and preparation, a [[cervical retractor system]] is applied. The blades are available in [[PEEK]] and [[Titanium]]. A counter retractor can be used. The [[subcutaneous tissue]] is separated from the [[platysma]] cranially, caudally and medially, and the platysma is also separated following the direction of its fibres. The margins of the platysma can be held apart with the retractor or with two surgical forceps. Now the medial edge of the [[sternocleidomastoid muscle]] is located and prepared with the index finger in the [[connective tissue]] space over the ventral surface of the cervical spine and under lateralization of the vascular nerve bundle and medialization of the [[trachea]], [[esophagus]] and thyroid gland. After the Langenbeck hooks have been inserted, the ventral surface of the cervical spine, still covered by a thin prevertebral layer of connective tissue, is revealed. This layer can now be exposed by either a blunt [[scissors]] or alternatively through bipolar coagulation in order to expand the tissue cranially and caudally using a swab. A wire is set under X-ray monitoring to mark the intervertebral disc space. ===== Distraction/Discectomy / Preparation of the Endplates ===== The distraction screws are placed in position and the [[CASPAR distractor]] is applied following the CASPAR technique. Complete [[discectomy]] is performed using various rongeurs, rectangular [[curette]]s and bone curettes. While using a high speed drill to remove the posterior rim and / or dorsal osteophytes, care must be taken to avoid damaging the vertebral body endplates. ===== Equipment ===== a) microscope (not used by all surgeons) b) C-arm ===== Cages ===== see [[Cervical cage]]. ===== Anterior cervical plating ===== see [[Anterior cervical plating]]. ===== BMP ===== see [[BMP]] ==== Use of BMP in cervical interbody grafting ==== Current evidence does not support the routine use of rhBMP-2 for cervical arthrodesis (Level C Class II)19 (note: italics added. Use with precautions (see text) may be indicated in cases with high risk of nonunion). Use of BMP in anterior cervical discectomies is not FDA approved but has been used off-label. Complication rates as high as 23–27% have been reported (including post-op swallowing or respiratory difficulties as a result of edema which is usually temporary) compared to 3 % without BMP.19 If used, it is recommended that a smaller dose be employed than in the lumbar spine (25% has been advocated) and to avoid contact of BMP with soft tissues in the neck. ===== Technique ===== see [[Anterior cervical discectomy technique]]. ===== Intraoperative neurophysiological monitoring ===== see [[Intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion]]. ===== Anterior cervical discectomy and fusion complications ===== [[Anterior cervical discectomy and fusion complications]].