The Analysis of Complications of Anterior Cervical Discectomy and Fusion View PDF

*Abdulrahman Kamal Faisel
Department Of Neurosurgery, Ibn Sina Teaching Hospital, Ibn Sina Teaching Hospital, Ibn Sina Hospital, Mosul, Iraq

*Corresponding Author:
Abdulrahman Kamal Faisel
Department Of Neurosurgery, Ibn Sina Teaching Hospital, Ibn Sina Teaching Hospital, Ibn Sina Hospital, Mosul, Iraq

Published on: 2024-05-24


Background: Anterior cervical discectomy and fusion (ACDF) is the gold standard in the surgical interventions of radiculopathy in cervical inter-vertebral disc herniations or cervical spondylosis. Aim: The study aimed to analyze the complications of ACDF procedures.
Methods: Retrospective work of collected database and assessing cases that underwent an ACDF in period one year. Totally, 104 cases with 133 operated levels were included. All cases had symptomatic degenerative cervical disc diseases or disc herniations between the levels of C-3/4 to C-6/C7. Epidemiological findings, the pathologies’ locations, fixation levels, complications and follow-up variables were collected.
Results: A total of 104 patients with demographic data of 53 males and 51 females (mean age 56 years ranged from 25 - 75 years). C3 - C4 lesion in 20 cases, C4 - C5 in 25 cases, C5 - C6 in 32 cases and 27 cases with more than one level were seen. Neck pain in 104 cases, radiculopathy pain in 90, arms paresthesia in 40, weakness of limbs in 4 and sphincter paralysis in 40 cases. Postoperative dysphagia was found in 104 cases and C5 root lesion in 40 cases, cage dislodgment in one case and hematoma in one case.
Conclusion: Neck Pain is the most common presenting symptom. Dysphagia is the most common postoperative complication and usually transient in most cases. C5 root lesion is not uncommon as complication of ACDF surgery


Radiculopathy pain, Paresthesia, Weakness, Sphincter paralysis, Anterior cervical discectomy


Despite the potential complications associated with ACDF, it remains the gold standard for treating radiculopathy and/or myelopathy caused by cervical intervertebral disc herniation and cervical spondylosis [1]. There are several indications for cervical discectomy, including persistent radiculopathy and myelopathy that do not respond to nonsurgical treatment [1, 2]. Indications are less commonly accepted, such as axial neck pain [3] and headaches [4]. It is possible to approach the pathologic cervical disc either ventrally or dorsally. Over a half century has passed since both approaches were developed [3-8] and are still useful today [2].

Most spine surgeons are familiar with the ventral approach. In most patients, levels C3-4 to C7 - T1 can be reached with the standard ventrolateral approach. Advantages of the ventral approach include central access and bilateral foraminal decompression. Nonunion is still an important clinical problem that may lead to the need for reoperation [4].

But there are many risks and risks associated with back surgery. Implant failure and graft migration often occur anteriorly and may result in neurological symptoms such as partial kyphosis, dysphagia, esophageal perforation, or carotid artery compression [7].

Additionally, increased patient morbidity and the incidence of nonunion have been documented after the use of grafts instead of autologous bone grafts [4-5]. Improper surgical technique during osteophyte removal can lead to dural injury and cerebrospinal fluid leak [6].

Age-related degeneration and trauma can lead to disc pathology that requires surgical removal. Commonly accepted indications for cervical surgery include myelopathy and persistent radiculopathy unresponsive to nonsurgical measures [1, 2]. Less common symptoms include axial neck pain and headaches caused by disc pathology. Pathological cervical discs can move ventrally and dorsally. Both methods have been used for half a century [4-11].

Although some authors have reported good results with external surgery without disc fusion, disc fusion after discectomy has become the standard of care in many centers. Choices include the use of allografts or synthetic intervertebral as well as ventral cervical laminae [12]. Nonunion remains a significant clinical problem that may lead to the need for reoperation [13]. Cervical disc replacement devices are now commercially available for postoperative reconstruction. Although the indications are fewer, positive results have been reported in appropriately selected patients [14].

Examine radiographs in advance to identify anatomical features. It is particularly important to correctly identify existing equipment to ensure that all necessary equipment is available. Knowledge of ventral osteophytes can help the surgeon determine the appropriate level through palpation and visualization during surgery. Vertebrae were marked horizontally and the anteroposterior distance between the vertebral bodies was measured (minus focus) to estimate implant and screw size. Anatomically, the lower cervical spine of the “short” neck is at or below the level of the clavicle, which will alert the surgeon that access to these lower levels will be difficult for the procedure. It may be useful for patients with symptoms (especially left and right symptoms, radiculopathy, or myelopathy), surgery (graded discectomy), and significant comorbidities (smoking, diabetes, etc.). Axial MRI or CT scans of the vertebral artery area should be examined carefully, and any abnormalities carefully noted. The surgical site is marked in a fixed place. ACDF is a procedure designed for the treatment of cervical myelopathy and radiculopathy. This procedure is designed to create nerve decompression and provide segmental stability at the level of symptoms of the cervical spine. The technique has undergone many changes since it was first described approximately 50 years ago [2, 3]. Current techniques combine internal metal barriers with synthetic, allograft, or metal grafts [3-9]. Although the addition of the front plate increases the biomechanical stability of the building and makes fusion more common, it is also associated with prevertebral soft tissue damage and dysphagia [10-14]. The causes of dysphagia after ACDF anterior plate surgery include retraction, direct compression of the esophagus, and irritation of the surrounding tissues [15, 16].

Feeling mild pain or sore throat after abdominal and neck surgery; It is reported to be seen in approximately 50% of patients. Most patients recover without further complications within weeks or months. The most common cause is edema due to endotracheal intubation. However, laryngeal nerve damage can also occur and lead to laryngeal dysfunction [17].

Vertebral artery injury may be due to asymmetry and removal of distal bone and usually occurs with the left standard approach [17]. To prevent damage to the carotid artery, intracranial artery or vagus nerve, care must be taken not to penetrate the carotid sheath. Carotid artery tears may occur due to the sharp blade of the retractor knife or during dissection using sharp instruments.

In most cases, carotid artery ruptures can be treated first. The chain has the potential to cause further injury to the lower ventral portion of the cervical spine because it is closer to the medial border of the longus colli muscle at C6 than at C3 [17]. Differences in neurological deficits after ventral cervical spine surgery. Most spinal cord or nerve root injuries are associated with accidents (including most C5 defects) [17]. During posterior longitudinal ligament resection or drilling, dural tears and cerebrospinal fluid leakage may occur. Direct treatment is usually not possible [17]. Cervical soft tissue hematomas after cervical and abdominal surgery are rare and most can be treated without surgery. However, large hematomas can cause airway obstruction and be lifethreatening. To avoid this problem, careful hemostasis must be achieved before closure. The Jackson-Pratt flow is placed in the prevertebral space before closure [17]. Infectious processes may occur after ventral cervical surgery and affect only the outer layer or deep structures. These complications have been reported in 0.4% to 2% of spinal cord injury patients [17].

The main complications associated with bone grafting are collapse, dislocation, displacement and nonunion of the graft. These may be due to size, vertebral end plate fractures, postoperative trauma, or inadequate fixation. Graft collapse often occurs in adults with osteoporotic bone. If there is doubt about the integrity of autogenous bone, allograft bone can be used. However, in young patients, autografts are more resistant to axial compression than allografts. Most patients with graft infection are asymptomatic and do not require reoperation [17].

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