What are the considerations for choosing between Anterior Cervical Discectomy and Fusion (ACDF) and cervical disc replacement for a patient with a cervical spine condition?

ACDF versus Cervical Disc Replacement

Direct Recommendation

For most patients with cervical radiculopathy or myelopathy requiring surgical intervention, ACDF remains the gold standard approach with 80-90% success rates for arm pain relief and 90.9% functional improvement, while cervical disc replacement (TDR) should be reserved for highly selected patients under age 55 with single-level soft disc herniation, no facet arthropathy, no segmental instability, and no recent infection. 1, 2

Patient Selection Algorithm

Choose ACDF When:

• Age >55 years - ACDF demonstrates superior outcomes in older patients with degenerative changes 3
• Spondylotic disease predominates - Facet or uncovertebral joint hypertrophy causing foraminal stenosis responds best to fusion 1, 3
• Multilevel disease - ACDF with anterior plating achieves 88.3% symptom improvement and 95% fusion rates in multilevel constructs 2
• Cervical myelopathy - ACDF provides 90.9% functional improvement in myelopathy patients, whereas TDR data for myelopathy remains limited 4, 5
• Kyphotic deformity present - ACDF with plating maintains cervical lordosis, critical for deformity correction 1, 2
• Osteoporosis or poor bone quality - Fusion provides more predictable outcomes when implant stability is compromised 1

Choose TDR When ALL Criteria Met:

• Age <55 years - Younger patients benefit most from motion preservation 3
• Single-level soft disc herniation - TDR performs best with isolated disc pathology without bony stenosis 1, 3
• No facet arthropathy - Preserved facet joints are essential for successful arthroplasty 1
• No segmental instability on flexion-extension films - Static MRI cannot rule out instability; dynamic radiographs are mandatory 1
• No recent infection - Recent postoperative infection represents absolute contraindication to implant placement 1
• No adjacent level disease after prior fusion - TDR adjacent to fusion lacks FDA approval and long-term outcome data 1
• Preserved disc height - Adequate intervertebral space required for proper implant positioning 3

Comparative Outcomes

ACDF Advantages:

• Proven long-term efficacy - 74-90% improvement rates maintained over 12 months for radiculopathy 1, 2
• Motor function recovery - 92.9% of patients achieve motor recovery maintained over 12 months 1
• Lower revision rates - Only 1.2% revision rate compared to 13.6% for posterior approaches 6
• Predictable fusion rates - Anterior plating improves fusion from 72% to 91% in two-level disease 1
• Applicable to broader patient population - No strict age or pathology restrictions 1, 3

TDR Advantages:

• Motion preservation - Maintains segmental mobility at treated level 1, 3
• Theoretical reduction in adjacent segment disease - Though long-term data remains limited 7, 5
• Avoids fusion-related complications - No pseudarthrosis risk or donor site morbidity 3
• Faster return to activities - Comparable early outcomes to ACDF in selected patients 5

Critical Limitations of TDR:

• Highly selective patient population - Only 4.5% of anterior cervical procedures for degenerative disease involve TDR 5
• Limited myelopathy data - Most evidence supports TDR for radiculopathy, not myelopathy 5
• Contraindicated in common scenarios - Facet disease, instability, infection, osteoporosis all preclude TDR 1
• Requires preserved anatomy - Adequate disc height and absence of deformity necessary 3

Instrumentation Considerations

For ACDF:

• Anterior plating mandatory for multilevel disease - Reduces pseudarthrosis from 4.8% to 0.7% in two-level constructs 1
• Single-level ACDF - Plating reduces graft problems and maintains lordosis, though not absolutely required 1
• Allograft appropriate - Achieves 93.4% fusion rates at 24 months with plating, eliminates 20% donor site pain from autograft 1
• Smoking documentation essential - Cigarette smoking diminishes fusion rates, particularly with allograft 1

Common Pitfalls to Avoid

Patient Selection Errors:

• Performing TDR in patients >55 years - Degenerative changes predict poor arthroplasty outcomes 3
• TDR for spondylotic stenosis - Facet and uncovertebral hypertrophy require fusion, not motion preservation 1, 3
• Skipping flexion-extension films before TDR - Static MRI cannot assess instability; dynamic radiographs mandatory 1
• TDR adjacent to prior fusion - Not FDA-approved and lacks outcome data 1

Surgical Technique Errors:

• Multilevel ACDF without anterior plating - Dramatically increases pseudarthrosis risk 1, 2
• Inadequate conservative treatment documentation - Minimum 6 weeks of structured physical therapy, NSAIDs, and activity modification required before any surgery 1, 2
• Operating on "mild" stenosis - Only moderate-to-severe radiographic pathology with clinical correlation meets surgical criteria 1, 2

Postoperative Management:

• Approach-related dysphagia - Occurs in 20.9% of ACDF patients, typically transient 6
• Late deterioration with laminectomy alone - 29-37% rate of neurological decline, making ACDF preferable for long-term outcomes 8, 1

Evidence Quality Considerations

The guidelines consistently demonstrate that ACDF represents Class II-III evidence with moderate-to-high strength recommendations for both radiculopathy and myelopathy 8, 1. In contrast, TDR evidence remains limited to highly selected radiculopathy patients, with the 2025 database study showing TDR patients were significantly healthier (less obesity, smoking, diabetes) and represented only 4.5% of anterior procedures 5. The most recent high-quality evidence from 2024-2025 confirms ACDF as the gold standard, with TDR reserved for exceptional cases meeting strict criteria 1, 5, 6.