Post-Operative Management for Anterior Cervical Discectomy and Fusion (ACDF)
Patients should avoid cervical collar use after ACDF with interbody cages as it provides no significant long-term benefits in functional outcomes or fusion rates, though it may temporarily reduce post-operative pain and disability in the first 6 weeks. 1
Immediate Post-Operative Care
- Monitor for dysphagia, which occurs in approximately 9.5% of ACDF patients and is the most common post-operative complication 2
- Watch for post-operative hematoma (5.6% of cases), which requires surgical intervention in 2.4% of cases 2
- Assess for recurrent laryngeal nerve palsy (3.1% of cases), which may present as hoarseness or difficulty swallowing 2
- Less common but serious complications to monitor include esophageal perforation (0.3%), worsening myelopathy (0.2%), and Horner's syndrome (0.1%) 2
Physical Therapy Recommendations
- Formal post-operative physical therapy shows no significant long-term benefits in patient-reported outcomes compared to patients who don't receive formal PT 3
- Physical therapy may be beneficial for specific patients with persistent symptoms, but routine prescription for all ACDF patients is not supported by evidence 3
- If physical therapy is prescribed, focus should be on cervical strengthening and range of motion exercises rather than excessive focus on restoring cervical lordosis 4
Radiographic Follow-up
- CT is the most sensitive and specific modality to assess spinal fusion status 5
- CT altered the treatment plan in 39% of patients with persistent symptoms and in 60% of patients with persistent symptoms plus abnormal radiographs or MRI 5
- MRI is the most sensitive imaging test for detecting soft-tissue abnormalities but may be limited by metal artifact from hardware 5
Technical Considerations for Optimal Outcomes
- When performing ACDF, placing the cage in a relatively posterior position helps preserve the height of the posterior disc space, which is critical for enlarging the foramen and preventing recurrent symptoms 4
- Maintaining the height and width of the intervertebral foramen is more important than excessive focus on restoring cervical lordosis 4
- Stable vertebral slippage without nerve compression does not necessarily require inclusion in the fusion construct 4
Long-Term Outcomes and Expectations
- ACDF has demonstrated good to excellent outcomes in approximately 90% of properly selected patients with cervical radiculopathy 5, 6
- Fusion rates with anterior plating are significantly higher (94% overall) compared to ACDF without plating (88%), with the difference being more pronounced in 2-level procedures (91% vs 72%) 5
- Adjacent segment degeneration is a potential long-term complication that may require monitoring 5
Return to Activities
- Return to work and resumption of driving occur faster with plated ACDF compared to non-plated ACDF (p < 0.05) 5
- Most patients can expect significant improvements in physical function, social function, physical role function, fatigue, and bodily pain following ACDF 5
- Age, smoking status, and Worker's Compensation status do not appear to significantly affect outcomes 5
Management of Complications
- If pseudarthrosis occurs (failure of fusion), posterior revision approaches have higher success rates (94-100%) compared to anterior revision approaches (45-88%) 5
- For patients with persistent or new contralateral symptoms, evaluate for reduction in disc space height at the posterior aspect or slight posterior shift of vertebrae 4