At a glance
- What the surgery does
- Removes a damaged disc or bone spurs from the front of the neck to relieve pressure on a nerve or the spinal cord, then fuses the bones.
- Why people consider it
- Severe arm pain or weakness from a pinched nerve that hasn't improved, or spinal cord compression causing clumsy hands or balance problems.
- The main choices
- Many pinched nerves improve without surgery.[1][2] Spinal cord compression usually needs surgery.[10] Some people can have an artificial disc instead of fusion.[8]
- What recovery involves
- Often home the same or next day, sore throat and swallowing trouble for a while, and months for the bones to fuse.
- What to ask your surgeon
- Whether the problem is a nerve or the spinal cord, whether you've given non-surgical care enough time, and whether disc replacement is an option.
The short version
- The reason for surgery matters most. A pinched nerve (radiculopathy) often settles without surgery. Spinal cord compression with symptoms (myelopathy) is different: it tends to worsen, and surgery is usually recommended for moderate or severe cases.[1][10]
- In a long-term Minnesota study of people with pinched nerves in the neck, about a quarter had surgery, and 90% ended up with no or only mild symptoms.[1]
- For myelopathy, people improved after surgery across mild, moderate and severe disease in a large North American study.[4]
- Trouble swallowing is common early after surgery from the front of the neck. It affected about half of people at one month and about 1 in 8 at one year in one study, mostly mildly.[6]
- Artificial disc replacement is an alternative for some people. At one to two years it gave similar results to fusion, with differences too small to matter clinically.[8]
What problems ACDF treats
Between each pair of vertebrae in the neck is a disc that cushions and allows movement. With age or injury, a disc can bulge or herniate, and bone spurs can form. These can press on:
- A nerve root, causing cervical radiculopathy: pain, tingling, numbness or weakness running down one arm, often into specific fingers.
- The spinal cord, causing cervical myelopathy: clumsy hands, trouble with buttons or handwriting, balance problems, or changes in bladder control. Pain may be mild or absent.
ACDF removes the disc and spurs from the front of the neck, places a spacer (cage or bone graft) where the disc was, and usually adds a small plate and screws. Over months, the vertebrae fuse into one bone.[12][13][14]
Pinched nerve: do you need surgery?
Many pinched nerves in the neck improve over weeks to months. In a population study from Rochester, Minnesota, 26% of people with cervical radiculopathy had surgery over about five years of follow-up, and 90% ended up with no or only mild symptoms.[1] Physical therapy, medications, activity changes and sometimes steroid injections are common first steps.[11]
The research in detail: What the trials found
In a Swedish trial of 63 people with arm pain and a pinched nerve on MRI, ACDF followed by physical therapy did no better than a structured physical therapy program alone on measures of neck movement, muscle endurance and hand function over two years.[2] An older Swedish trial comparing surgery, physical therapy and a collar found surgery relieved pain faster, but results were similar across groups at one year.[3]
Surgery tends to be considered when arm pain is severe and doesn't improve after several weeks to months, or when there's significant or worsening weakness.[11]
Leg weakness, balance problems, clumsy hands, or new bladder or bowel problems are not typical of a simple pinched nerve. Tell your doctor promptly, because they can be signs of spinal cord compression.
Spinal cord compression (myelopathy)
Myelopathy is treated differently because it often gets slowly worse, and spinal cord damage may not fully recover. International guidelines recommend surgery for people with moderate or severe myelopathy. For mild myelopathy, either surgery or a supervised trial of non-surgical care with close monitoring is reasonable.[10]
In the AOSpine North America study of 278 people with myelopathy, function, disability and quality of life all improved one year after surgery, whether the myelopathy was mild, moderate or severe beforehand.[4]
Front or back of the neck?
Myelopathy can also be treated from the back of the neck (laminectomy with fusion, or laminoplasty). In the US CSM-S trial of 163 people with multilevel myelopathy, surgery from the front didn't give better physical function at one year than surgery from the back. Complications were more common with the front approach (48% vs 24%), mostly due to swallowing trouble.[5] Which approach fits depends on how many levels are involved and the shape of your neck.
Fusion or artificial disc?
Cervical disc replacement (arthroplasty) removes the disc the same way, but puts in a moving artificial disc instead of fusing the bones. The idea is to keep motion and possibly reduce wear on the discs next door.
A Cochrane review of nine trials with 2,400 people found results at one to two years slightly favored disc replacement for arm pain, neck function and nerve outcomes, but the differences were small and not clinically meaningful. Disc replacement did keep motion at the treated level. It hadn't yet been shown to reduce later surgery at neighboring levels.[8] Most trials were industry-funded.
Not everyone is a candidate. Significant arthritis in the facet joints, instability, osteoporosis or multilevel disease may make fusion the better choice. Several artificial cervical discs are FDA-approved.[15] Ask whether you're a candidate and why or why not.
What happens during surgery
ACDF is done under general anesthesia through a small incision, usually in a skin crease on the front of the neck. The surgeon gently moves the windpipe and esophagus aside to reach the spine, removes the disc and any spurs pressing on nerves or the cord, fills the space with a spacer, and often adds a plate.
A single-level ACDF often takes one to two hours. Many people go home the same day or after one night.
Will I need a collar?
Practices vary. A small pilot trial found people who wore a rigid collar for six weeks after ACDF had less neck pain and disability early on, though the trial was too small to look at fusion rates.[9] Follow your surgeon's plan.
Recovery
- First daysSore throat, hoarseness and some trouble swallowing are common. Soft foods help. Arm pain often improves quickly if it was from a pinched nerve.
- Weeks 1 to 2Short walks. Avoid lifting and heavy overhead work. Many people with desk jobs return within a few weeks.
- Weeks 6 to 12Gradual return to more activity and sometimes physical therapy. Fusion is checked on X-rays over several months.
- Months 3 to 12The bones keep fusing. Recovery of spinal cord function after myelopathy can continue for a year or longer.[4]
Call your surgeon or seek urgent care for increasing neck swelling, trouble breathing, worsening swallowing, fever, or new weakness.
Risks and complications
- Swallowing difficulty (dysphagia). In a prospective study of 249 people, about 50% had some trouble swallowing at one month, 18% at six months and 13% at one year. Only about 5% had moderate or severe trouble at six months. It was more common in women and with multiple levels.[6]
- Hoarseness from irritation of the nerve to the voice box. Usually temporary. Lasting vocal cord weakness was found in about 1% at one year in the same study.[6]
- Problems at neighboring levels. In a long-term study, new nerve or cord symptoms at a level next to the fusion developed at about 3% per year, and about a quarter of patients had them within 10 years. Many needed more surgery.[7]
- Nonunion, when the bones don't fuse, more likely in smokers and with multiple levels.
- Rare but serious: spinal cord or nerve injury, injury to the esophagus or arteries, bleeding causing neck swelling, infection.[4][5]
Questions to ask your surgeon
- Is my problem a pinched nerve, spinal cord compression, or both?
Why we ask: They're treated differently. Pinched nerves often settle without surgery. Spinal cord compression with symptoms tends to worsen. What problems ACDF treats
- If it's a pinched nerve, have I given non-surgical treatment enough time?
Why we ask: In a Swedish trial, structured physical therapy alone did as well as surgery plus therapy on function over two years. Pinched nerve
- If it's my spinal cord, what happens if I wait?
Why we ask: Guidelines recommend surgery for moderate or severe myelopathy because cord damage may not fully recover. Spinal cord compression
- How many levels need surgery, and from the front or the back?
Why we ask: For multilevel myelopathy, surgery from the front didn't beat surgery from the back in a US trial, and had more complications. Front or back?
- Am I a candidate for an artificial disc instead of fusion?
Why we ask: Disc replacement keeps motion and gave similar results to fusion at one to two years. Not everyone is a candidate. Fusion or artificial disc?
- How likely is trouble swallowing or hoarseness for me?
Why we ask: Swallowing trouble is common early after surgery from the front, especially with multiple levels. Risks and complications
- Will I need a collar, and for how long?
Why we ask: Practices vary, and the evidence is limited. Ask what your surgeon recommends and why. What happens during surgery
- What is my risk of needing more surgery at another level later?
Why we ask: In a long-term study, about a quarter of patients developed new symptoms at a neighboring level within 10 years. Risks and complications
Print this page or save it to your phone, and write down the answers during your visit.
Understanding your implant options
The companies that make the implants and devices used in this surgery, compared side by side with FDA records and sources, plus recent research and FDA news explained for patients.
Recovery supplies
We list recovery supplies at every budget, from gel ice wraps to cold therapy machines, with what to look for in each.
- Neck comfort and sleep
- Swallowing and soft food
- Bending and reaching aids
- Walking
Sources
- Radhakrishnan K, et al. Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117:325-35. https://doi.org/10.1093/brain/117.2.325
- Peolsson A, et al. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: a prospective randomized study with a 2-year follow-up. Spine. 2013;38:300-7. https://doi.org/10.1097/BRS.0b013e31826d2cbb
- Persson LC, et al. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar: a prospective, randomized study. Spine. 1997;22:751-8. https://pubmed.ncbi.nlm.nih.gov/9106315/
- Fehlings MG, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013;95:1651-8. https://doi.org/10.2106/JBJS.L.00589
- Ghogawala Z, et al. Effect of ventral vs dorsal spinal surgery on patient-reported physical functioning in patients with cervical spondylotic myelopathy: a randomized clinical trial. JAMA. 2021;325:942-51. https://doi.org/10.1001/jama.2021.1233
- Bazaz R, et al. Incidence of dysphagia after anterior cervical spine surgery: a prospective study. Spine. 2002;27:2453-8. https://doi.org/10.1097/00007632-200211150-00007
- Hilibrand AS, et al. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81:519-28. https://doi.org/10.2106/00004623-199904000-00009
- Boselie TFM, et al. Arthroplasty versus fusion in single-level cervical degenerative disc disease. Cochrane Database Syst Rev. 2012;9:CD009173. https://doi.org/10.1002/14651858.CD009173.pub2
- Abbott A, et al. Is there a need for cervical collar usage post anterior cervical decompression and fusion using interbody cages? A randomized controlled pilot trial. Physiother Theory Pract. 2013;29:290-300. https://doi.org/10.3109/09593985.2012.731627
- Fehlings MG, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy. Global Spine J. 2017;7(3 Suppl):70S-83S. https://pubmed.ncbi.nlm.nih.gov/29164035/
- Bono CM, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders (North American Spine Society). Spine J. 2011;11:64-72. https://pubmed.ncbi.nlm.nih.gov/21168100/
- MedlinePlus (US National Library of Medicine). Cervical spondylosis. https://medlineplus.gov/ency/article/000436.htm
- American Association of Neurological Surgeons. Cervical spine. https://www.aans.org/patients/conditions-treatments/cervical-spine/
- OrthoInfo (AAOS). Cervical radiculopathy (pinched nerve). https://orthoinfo.aaos.org/en/diseases--conditions/cervical-radiculopathy-pinched-nerve/
- US Food and Drug Administration. Artificial cervical discs (premarket approvals database). https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm
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