Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Anterior Cervical Discectomy and Fusion (ACDF)

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with [cervical radiculopathy / cervical myelopathy / both] at [C_-C_] due to [disc herniation / spondylosis / OPLL] presenting with [arm pain/weakness / gait difficulty / hand clumsiness] planned for [single/multi]-level ACDF at [C_-C_].

Figures, Imaging & Video

🎥 Operative video — Inside the OR: Anterior Cervical Discectomy & Fusion · Antonio J. Webb, MD

More operative video: YouTube ▸ · Neurosurgical Atlas ▸

🧭 Operative approach: Anterior cervical (Smith-Robinson) approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · AO Spine / Surgery Reference · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Anterior Cervical Discectomy Fusion — Fig. 1 Fig. 1. Various methods of radiographic measurement and representative of both centering cages, which caused no subsidence, and offset cages, which caused subsidence.a) Radiographic measurements… Source: Radiological Factors Affecting Cage Subsidence after Single-level Anterior Cervical Discectomy and Fusion with Double Titanium Cylindrical Cages — Neurologia medico-chirurgica 2025; CC BY-NC-ND.

Anterior Cervical Discectomy Fusion — FIGURE 1 FIGURE 1. Fusion rate of each group over time. Source: Long-term results comparison after anterior cervical discectomy with BGS-7 spacer (NOVOMAX®-C) and allograft spacer: A prospective observational study — Frontiers in Bioengineering and Biotechnology 2023; CC BY.

Anterior Cervical Discectomy Fusion — FIGURE 2 FIGURE 2. One year post-operative images from CT scan. (A) Sagittal view, (B) coronal view. Source: Long-term results comparison after anterior cervical discectomy with BGS-7 spacer (NOVOMAX®-C) and allograft spacer: A prospective observational study — Frontiers in Bioengineering and Biotechnology 2023; CC BY.

Anterior Cervical Discectomy Fusion — FIGURE 3 FIGURE 3. Representative images of BGS-7 spacer-induced segmental fusion progression after ACDF surgery during 5 years. (A) Pre-OP, (B) 1 month, (C) 3 months, (D) 1 year, (E) present, (F) present… Source: Long-term results comparison after anterior cervical discectomy with BGS-7 spacer (NOVOMAX®-C) and allograft spacer: A prospective observational study — Frontiers in Bioengineering and Biotechnology 2023; CC BY.

Anterior Cervical Discectomy Fusion — FIGURE 4 FIGURE 4. Clinical outcomes for each group after ACDF surgery during 5 years. (A) VAS (cervical), (B) VAS(upper limb), (C) NDI, (D) JOA. Source: Long-term results comparison after anterior cervical discectomy with BGS-7 spacer (NOVOMAX®-C) and allograft spacer: A prospective observational study — Frontiers in Bioengineering and Biotechnology 2023; CC BY.

Anterior Cervical Discectomy Fusion — Fig. 1 Fig. 1. A 53-year-old man who had experienced numbness in both hands and felt stepping on cotton in lower limbs for 1.5 years was diagnosed as cervical spondylotic myelopathy. A Preoperative… Source: Clinical and imaging outcomes of self-locking stand-alone cages and anterior cage-with-plate in three-level anterior cervical discectomy and fusion: a retrospective comparative study — Journal of Orthopaedic Surgery and Research 2023; CC BY.

Anterior Cervical Discectomy Fusion — Fig. 2 Fig. 2. A 63-year-old man who had experienced numbness in both hands and felt stepping on cotton in lower limbs for 3 years was diagnosed as cervical spondylotic myelopathy. A Preoperative… Source: Clinical and imaging outcomes of self-locking stand-alone cages and anterior cage-with-plate in three-level anterior cervical discectomy and fusion: a retrospective comparative study — Journal of Orthopaedic Surgery and Research 2023; CC BY.

Anterior Cervical Discectomy Fusion — Fig. 1 Fig. 1. A 45-year-old female diagnosed with spinal stenosis at C5-6. (A, B) Preoperative magnetic resonance imaging. (C, D) Postoperative radiographs. (E, F) Follow-up radiograph 12 months… Source: Comparative Study of Clinical Outcomes of Anterior Cervical Discectomy and Fusion Using Autobone Graft or Cage with Bone Substitute — Asian Spine Journal 2011; CC BY-NC.

Anterior Cervical Discectomy Fusion — Fig. 2 Fig. 2. A 47-year-old female diagnosed with herniated nucleus pulposus on C5-6. (A, B) Preoperative magnetic resonance imaging. (C, D) Postoperative radiograph. (E, F) Follow-up radiograph taken… Source: Comparative Study of Clinical Outcomes of Anterior Cervical Discectomy and Fusion Using Autobone Graft or Cage with Bone Substitute — Asian Spine Journal 2011; CC BY-NC.

History of Present Illness

Past Medical History

Imaging Review

X-rays (AP, Lateral, Flexion/Extension)

MRI Cervical Spine

CT Cervical Spine

Labs

Neurological Examination

Motor (myotomal)

Sensory (dermatomal)

Reflexes

Myelopathy Signs

Baseline Swallowing Assessment

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Level Selection

Position

Approach: Anterior Cervical (Smith-Robinson)

Side of approach:

Key Surgical Steps

  1. Fluoroscopic level confirmation — mark the incision centered over the target disc space
  2. Transverse skin incision — in a skin crease at the appropriate level
    • C3-4: Hyoid bone
    • C4-5: Superior thyroid cartilage
    • C5-6: Cricoid cartilage
    • C6-7: 1-2 fingerbreadths above clavicle
  3. Platysma division — along skin incision or vertically
  4. Deep dissection: Develop interval between:
    • Medial: Trachea, esophagus, recurrent laryngeal nerve
    • Lateral: Carotid sheath (carotid artery, internal jugular vein, vagus nerve)
    • Retract medial structures MEDIALLY, carotid sheath LATERALLY
  5. Identify prevertebral fascia and anterior longitudinal ligament
  6. Confirm level with fluoroscopy — place needle/marker in disc space
  7. Longus colli muscle dissection — release medially bilaterally from vertebral bodies; place retractor blades under longus colli (NOT on muscle surface — protects esophagus and RLN)
  8. Place self-retaining retractor (Caspar/Trimline distraction pins or table-mounted retractor)
  9. Discectomy:
    • Incise anterior annulus with #15 blade
    • Remove disc material with pituitary rongeurs and curettes
    • Identify and remove posterior annulus
    • Remove cartilaginous endplates (BUT preserve bony endplates for cage support)
    • Uncovertebral joints: Identify bilaterally — marks lateral extent of decompression
  10. Posterior decompression:
    • Remove posterior longitudinal ligament (PLL) to ensure complete decompression
    • Use Kerrison rongeurs and curettes
    • Decompress bilaterally to the uncovertebral joints
    • Foraminotomy: If foraminal stenosis, decompress foramina with Kerrison or high-speed drill
    • Confirm thecal sac and nerve root decompression
  11. Endplate preparation:
    • Remove cartilaginous endplate with curettes (preserve bony endplate)
    • Create flat, parallel surfaces for cage
    • Slight concavity is acceptable
  12. Cage/graft selection and placement:
    • Size: Trial cage for appropriate height (restore disc height and lordosis)
    • Material: PEEK, titanium, allograft, or ACDF-specific interbody
    • Graft: Fill cage with local bone, allograft chips, or bone substitute (BMP controversial in cervical)
    • Place cage under fluoroscopic guidance — posterior edge 2-3 mm from posterior vertebral body line
    • Confirm alignment and position
  13. Plate fixation:
    • Anterior cervical plate spanning fused segments
    • Screws: Bicortical preferred (but unicortical with locking plate acceptable)
    • Ensure screws do not violate adjacent disc spaces (accelerates ASD)
    • Confirm hardware position with fluoroscopy — lateral and AP
  14. Closure:
    • Irrigate
    • Hemostasis (bipolar, Surgicel, bone wax)
    • Consider drain (if concern for hematoma — especially multi-level, coagulopathy)
    • Close platysma with 3-0 Vicryl
    • Skin: Subcuticular 4-0 Monocryl or Dermabond

Critical Anatomy & Structures at Risk

  1. Recurrent laryngeal nerve — runs in tracheoesophageal groove; retract GENTLY medially. Injury → hoarseness (unilateral) or airway compromise (bilateral)
  2. Esophagus — directly anterior to cervical spine; retract medially. Injury → mediastinitis (devastating)
  3. Vertebral arteries — in transverse foramina bilaterally; lateral limits of decompression are the uncovertebral joints
  4. Carotid artery / internal jugular vein — in carotid sheath laterally; retract gently
  5. Superior laryngeal nerve — at risk with high cervical approach (C3-4, above hyoid)
  6. Spinal cord — directly posterior; careful with instruments at posterior vertebral body
  7. Nerve roots — in foramina bilaterally
  8. Sympathetic chain — on longus colli; injury → Horner syndrome
  9. Thoracic duct — at risk with LEFT-sided approach at C7-T1 (drains into left subclavian/IJV junction)

Equipment

Monitoring

Anesthesia Considerations

Potential Complications & Contingencies

  1. Dysphagia — most common complication (up to 50% transient); usually resolves in days-weeks. Minimize retraction time, release periodically
  2. Recurrent laryngeal nerve palsy — hoarseness; usually transient. ENT evaluation if persistent > 6 weeks
  3. Esophageal injury — rare but devastating; irrigate wound, primary repair, drainage, broad-spectrum antibiotics
  4. Vertebral artery injury — rare; pack with hemostatic agents, may need angiography/embolization
  5. Hematoma with airway compromise — EMERGENT — if expanding neck hematoma, open wound at bedside to decompress, then return to OR
  6. Spinal cord injury — careful instrumentation, monitoring, maintain perfusion
  7. Hardware failure / subsidence — appropriate cage sizing, endplate preservation, smoking cessation
  8. Adjacent segment disease — long-term; correlates with number of fused levels

Operative Note Template

Preoperative Diagnosis: Cervical [radiculopathy/myelopathy] at [C_-C_] due to [disc herniation/spondylosis/OPLL]

Postoperative Diagnosis: Same

Procedure: Anterior cervical discectomy and fusion at [C_-C_] [and C_-C_] with interbody cage placement and anterior cervical plating

Surgeon: Assistant: Anesthesia: General endotracheal anesthesia ([fiberoptic intubation])

EBL: Fluids: Specimens: [Disc material / None] Drains: [None / JP drain] Complications: None Implants: [Cage type/size at each level], [Plate type/length, screw sizes]

Indications: The patient is a [age]yo [M/F] with [cervical radiculopathy/myelopathy] at [C_-C_] who failed [conservative management / has progressive myelopathy]. MRI demonstrated [findings]. After discussion of risks, benefits, and alternatives, the patient elected to proceed with ACDF.

Description of Procedure: [Standard: consent verified, site marked, anesthesia induced, monitoring established with stable baselines BEFORE AND AFTER positioning…]

The patient was positioned supine with the neck in slight extension over an interscapular roll. The head was placed on a horseshoe headrest. The arms were tucked at sides and shoulders taped caudally. Monitoring signals were confirmed stable after positioning.

The anterior neck was prepped and draped in sterile fashion. The surgical level was confirmed with lateral fluoroscopy using a spinal needle placed at the target disc space.

Incision: A transverse skin incision was made at the level of [landmark] on the [left/right] side. The platysma was divided [in line with the incision / vertically]. The deep cervical fascia was incised and the interval between the carotid sheath laterally and the tracheoesophageal structures medially was developed with blunt dissection. The prevertebral fascia was identified. The level was confirmed with fluoroscopy.

Exposure: The longus colli muscles were elevated bilaterally off the vertebral bodies with electrocautery. Self-retaining retractor blades were placed under the longus colli muscles. [Caspar distraction pins were placed in the adjacent vertebral bodies.]

Discectomy and decompression: [For each level:] The anterior annulus at [C_-C_] was incised with a #15 blade. The disc material was removed with pituitary rongeurs and curettes. The cartilaginous endplates were removed. Under the microscope [/ with loupes], the posterior annulus and posterior longitudinal ligament were removed with Kerrison rongeurs, decompressing the thecal sac. [Bilateral foraminotomies were performed with a ___ mm Kerrison rongeur / high-speed drill, decompressing the exiting nerve roots.] [An extruded disc fragment was identified [location] and removed.] Complete decompression was confirmed by visualization of the thecal sac and bilateral nerve roots with free passage of a nerve hook.

Fusion: The endplates were prepared with a curette to create a flat surface while preserving the bony endplates. A [type, size] interbody cage packed with [allograft bone / local bone / bone substitute] was placed under fluoroscopic guidance. Appropriate position was confirmed with the posterior edge seated 2-3 mm anterior to the posterior vertebral body line.

Plating: A [type, length] anterior cervical plate was applied spanning [C_ to C_]. [Number] screws were placed at each level. Final fluoroscopic images (lateral and AP) confirmed appropriate hardware position, alignment, and restoration of disc height and lordosis.

Closure: The wound was irrigated. Hemostasis was confirmed. [A drain was placed.] The platysma was closed with 3-0 Vicryl interrupted sutures. The skin was closed with 4-0 Monocryl subcuticular suture and Dermabond. A sterile dressing was applied.

Postoperative: The patient was awakened, extubated [without difficulty / over a tube exchanger], and found to be neurologically [intact / improved from baseline]. Monitoring signals remained stable throughout. The patient was transferred to the PACU in stable condition.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Anterior Cervical Discectomy and Fusion (ACDF):

Common Pimp Questions

Use these to pressure-test preparation for Anterior Cervical Discectomy and Fusion (ACDF):

  1. What neurologic level and root are responsible for the presenting deficit?
  2. What is the decompression target and how will you know it is adequately decompressed?
  3. What instability, deformity, bone-quality, or fusion variable changes the construct?
  4. What vascular, visceral, dural, or neural structure is the main structure at risk?
  5. What postop brace, drain, mobilization, MAP, antibiotic, and DVT plan should be ordered?

Attending Preference Variables

Items that commonly vary by surgeon or institution: