What is the step-by-step procedure for Anterior Cervical Discectomy and Fusion (ACDF) of the C5-C6 interspace for treatment of a Protruded Intervertebral Disc (PIVD)?

From the Guidelines

Anterior Cervical Discectomy and Fusion (ACDF) is the recommended surgical procedure for treating Prolapsed Intervertebral Disc (PIVD) at the C5-C6 level, as it provides effective relief from nerve compression and spinal stability through fusion of the affected segment. The procedure begins with general anesthesia administration and patient positioning supine with slight neck extension. A transverse incision is made along a skin crease on the right or left side of the neck at the C5-C6 level, typically 3-4 cm in length. The platysma muscle is divided, and the surgeon develops a plane between the sternocleidomastoid and strap muscles laterally, and the trachea and esophagus medially. The prevertebral fascia is identified and incised to expose the anterior spine. Retractors are placed to maintain exposure. Fluoroscopy confirms the correct level, and the longus colli muscles are elevated from the vertebral bodies. A complete discectomy is performed at C5-C6, removing the disc material, cartilaginous endplates, and posterior longitudinal ligament to decompress the spinal cord and nerve roots.

The disc space is prepared for fusion by drilling to create a flat surface on the endplates. An appropriately sized cage or bone graft is inserted into the disc space, often filled with autograft, allograft, or bone substitute. An anterior plate spanning C5 and C6 vertebrae is secured with screws for immediate stability. Hemostasis is achieved, and the wound is closed in layers with absorbable sutures for deep tissues and subcuticular closure for the skin. Postoperatively, patients typically wear a cervical collar for 4-6 weeks and undergo physical therapy. Some key points to consider during the procedure include:

• The use of multidetector CT scanning with high-quality multiplanar reformatted images to assess spinal fusion and detect adjacent segment degeneration, as noted in a study published in the Journal of the American College of Radiology 1.
• The importance of accurate imaging to confirm the correct level and to evaluate hardware complications and adjacent segment degeneration in postoperative patients with new or worsening neck pain.
• The potential for CT to alter the treatment plan in patients with persistent symptoms, as seen in a review of 690 patients who underwent ACDF 1.

Overall, the ACDF procedure is a effective treatment option for PIVD at the C5-C6 level, and its success can be optimized with careful patient selection, precise surgical technique, and thorough postoperative care.

From the Research

Procedure Overview

The Anterior Cervical Discectomy and Fusion (ACDF) procedure for PIVD C5 C6 involves several steps, as outlined in the studies 2, 3, 4. The goal of the procedure is to relieve pressure on the spinal cord and nerve roots by removing the damaged disc and fusing the surrounding vertebrae.

Step-by-Step Procedure

• Step 1: Anterior Approach: The surgeon uses an anterior approach to access the cervical spine, typically through the Smith-Robinson approach medial to the sternocleidomastoid muscle and the carotid sheath 2.
• Step 2: Confirmation of Spinal Level: The surgeon confirms the proper spinal level to ensure accurate placement of the graft and instrumentation 2.
• Step 3: Elevation of Longus Colli Muscle: The longus colli muscle is elevated to allow for placement of retractors and access to the disc space 2.
• Step 4: Removal of Disc and Decompression: The involved disc is removed, and the spinal cord and nerve roots are decompressed using disc space distraction, osteophyte removal, and soft disc and anular material removal 2.
• Step 5: Carpentry and Decortication: The end plates are prepared for fusion through carpentry and decortication 2.
• Step 6: Sizing and Insertion of Interbody Graft: The disc space is sized, and an interbody graft is inserted to maintain spinal alignment and promote fusion 2, 4.
• Step 7: Anterior Fixation: Anterior fixation is achieved through the application of a plate-and-screw construct to stabilize the spinal column 2.
• Step 8: Hemostasis and Closure: The surgical site is closed, and hemostasis is achieved to complete the procedure 2.

Considerations for Multilevel ACDF

For multilevel ACDF procedures, such as those involving C5-C6, the surgeon must consider the increased risk of complications and the potential need for additional fixation or instrumentation 5, 6. The use of microsurgical techniques and careful planning can help minimize these risks and ensure a successful outcome 6.