What is an Anterior Cervical Discectomy and Fusion (ACDF) procedure for an elderly patient with a history of renal impairment and antibiotic allergy?

What is ACDF (Anterior Cervical Discectomy and Fusion)?

ACDF is a surgical procedure that removes damaged cervical disc material to decompress neural structures, followed by placement of a bone graft or interbody implant and typically a cervical plate with screws to stabilize and fuse one or more vertebral levels in the neck. 1

Procedure Components

The surgery involves three key steps that work together to address cervical spine pathology:

• Discectomy: The surgeon removes the damaged intervertebral disc material through an anterior (front of neck) approach, achieving direct decompression of the spinal cord and nerve roots without crossing neural elements 2

• Fusion: A bone graft (either autograft from the patient's own bone or allograft from a donor) or an interbody cage is placed in the empty disc space to maintain disc height and promote bony fusion between adjacent vertebrae 3, 1

• Instrumentation: An anterior cervical plate with screws is typically applied to provide immediate stability, reduce pseudarthrosis (failed fusion) risk from 4.8% to 0.7%, and improve fusion rates from 72% to 91% in multilevel disease 2

Clinical Indications

ACDF is indicated for specific cervical spine conditions after conservative management has failed:

• Cervical radiculopathy with arm pain, weakness, and sensory loss caused by nerve root compression from disc herniation or spondylotic changes, requiring at least 6 weeks of failed conservative treatment including physical therapy and medications 3, 2

• Cervical myelopathy with progressive spinal cord compression causing hand dysfunction, gait disturbance, and bilateral symptoms, which requires urgent surgical intervention to prevent permanent neurological deterioration 4

• Multilevel cervical spondylosis with moderate to severe stenosis documented on MRI that correlates with clinical symptoms 3, 2

Expected Outcomes

The procedure demonstrates excellent clinical results when appropriately indicated:

• Arm pain relief: 80-90% success rate for radiculopathy symptoms 2

• Functional improvement: 90.9% of patients achieve significant functional gains 2

• Motor recovery: 92.9% of patients experience maintained motor function improvement over 12 months 2

• Fusion rates: 93.4-97% when anterior plating is used with bone graft 2

• Long-term satisfaction: 92% of patients remain satisfied with results at 12-28 years follow-up 5

Special Considerations for Elderly Patients with Comorbidities

For elderly patients with renal impairment and antibiotic allergies, specific perioperative planning is essential:

• Renal function requires careful medication dosing adjustments, particularly for perioperative antibiotics and analgesics, though this does not contraindicate the procedure itself 6

• Antibiotic allergy necessitates preoperative allergy testing and selection of alternative prophylactic antibiotics, as surgical site infection occurs in approximately 0.3-0.9% of cases 6

• Age alone does not contraindicate ACDF, as studies demonstrate favorable outcomes even in younger patients followed long-term, suggesting the procedure is well-tolerated across age groups 5

Complication Profile

Understanding the risk profile helps set realistic expectations:

• Overall complication rate: 7.0% in the largest single-surgeon series of 2,579 procedures 6

• Most common complications: Dysphagia (1.9%), graft/hardware failure (1.3%), and postoperative hematoma (0.9%) 6

• Adjacent segment disease: 10.3% at 10 years, with an annual incidence of 1.1% requiring reoperation 5

• Total reoperation rate: 12.8% at 10 years (excluding early reoperations within 28 days) 5

Surgical Approach Selection

ACDF is specifically preferred over alternative approaches for certain pathologies:

• Disc-level pathology: ACDF demonstrates 73-74% improvement rates for multilevel cervical stenosis and radiculomyelopathy when compression originates from disc herniations or uncovertebral joint osteophytes 4

• Avoid laminectomy alone: This approach carries a 29-37% late neurological deterioration rate and causes progressive deformity, making ACDF superior for long-term outcomes 4, 2

• Multilevel disease: When anterior plating is used, multilevel ACDF achieves 88.3% symptom improvement and 95% fusion rates, comparable to corpectomy techniques 3

Critical Timing Considerations

The timing of surgery significantly impacts outcomes:

• Progressive myelopathy: Surgical decompression should not be delayed, as outcomes are significantly better when symptoms have been present for less than one year 4

• Radiculopathy: Surgery provides more rapid relief (within 3-4 months) compared to physical therapy, though at 12 months outcomes may be comparable if conservative management succeeds 2

• Natural history without surgery: 55-70% of cervical myelopathy patients experience progressive deterioration, emphasizing the importance of timely intervention 2