Anterior cervical discectomy and fusion (ACDF): what the operation involves and what to expect

The cervical spine is the seven vertebrae of the neck. Between the vertebrae are discs, which a North Bristol NHS Trust leaflet describes as having a tough fibrous outer casing and a softer, water-filled, jelly-like centre. Nerves leave the spinal cord between the vertebrae and carry messages to and from the shoulders, arms and hands.

ACDF is a type of cervical decompression. The disc, and sometimes bony outgrowths pressing on a nerve or the spinal cord, is removed through an incision at the front of the neck, which relieves the pressure. The gap is then filled and the vertebrae are encouraged to join together (fuse). The North Bristol leaflet says stabilisation is done using an interbody spacer or spinal cage, or a bone graft taken from the hip, and sometimes a plate and screws are placed to hold and align the bones.

The same service describes alternatives that are discussed with some patients: an artificial disc joint inserted from the front, and operations through the back of the neck such as foraminotomy, laminectomy or posterior fusion. Which is suitable depends on the level and nature of the problem.

The leaflet lists the conditions that may contribute to neck, shoulder and arm symptoms. Degeneration, or wear and tear, reduces disc height and leaves less space for nerves, and bony outgrowths called osteophytes may form. Spinal stenosis is narrowing of the canal, which can trap nerve roots. Disc prolapse is when the disc wall weakens and bulges out, irritating nerves that supply the arm. Cord compression is when any of these problems presses on the spinal cord itself.

The NHS explains that a slipped disc, also called a prolapsed or herniated disc, is when a soft cushion of tissue between the bones of the spine bulges outwards, and that it is painful if it presses on nerves. It also says cervical spondylosis, age-related wear and tear of the bones and discs of the neck, is common in people over 40 and that surgery is considered only if a nerve is being pinched by a slipped disc or bone (cervical radiculopathy) or if there is a problem with the spinal cord (cervical myelopathy). The NHS adds that surgery is not always a cure but may stop symptoms getting worse.

• Pain down the arm or into the hand, pins and needles and numbness, from a trapped nerve.

• Neck, shoulder and arm pain with muscle weakness in the shoulder, arm or hand.

• If the spinal cord is compressed: muscle wasting, difficulty walking, balance problems or unsteadiness and weakness in the legs.

The NHS page on cervical spondylosis says to ask for an urgent GP appointment or get help from NHS 111 if you have severe neck pain that starts suddenly or is getting worse quickly, heaviness or weakness in the arms or legs, or pins and needles in an arm together with neck or arm pain. It says to call 999 for new problems walking, loss of bladder or bowel control, sudden lack of co-ordination such as when buttoning a shirt, or signs of stroke such as a drooping face or difficulty speaking.

For a slipped disc, the NHS says to call 999 or go to A&E if you have back pain with numbness around your bottom or genitals, you cannot pee, you lose feeling in one or both legs, you cannot control when you pee or poo, or it follows a serious accident.

The NHS says a slipped disc can usually be diagnosed from symptoms and a physical examination, and that if symptoms do not get better you may be referred for tests such as an MRI scan. The North Bristol leaflet says an MRI scan is generally performed to confirm the diagnosis and identify the level of the problem, and that X-rays are ordered before surgery if an artificial cervical joint is planned.

Before an operation there is a pre-assessment clinic. The same leaflet describes blood tests, a nasal swab to screen for MRSA and, if problems are identified, further investigations such as a heart trace, echocardiogram or exercise test to decide whether you are suitable for an anaesthetic. If blood pressure is raised, you may be asked to see the GP to confirm it is within acceptable limits.

Non-surgical options come first. The leaflet lists maintaining a healthy weight, posture and strengthening exercises, physiotherapy, painkillers and the passage of time, and notes that nerve root block injections are sometimes useful, both to help diagnosis and as treatment. The NHS says physiotherapy on the NHS may have long waiting times and can also be obtained privately.

Cervical surgery is performed under general anaesthetic, according to the leaflet. After removing the disc and relieving pressure, the surgeon places the spacer or graft, and sometimes a plate and screws. You may return from theatre with a small drain, which the leaflet says is removed after 12 hours. An X-ray is performed after anterior approach surgery to look at the neck alignment before discharge.

The North Bristol leaflet says the skin is usually closed with paper strips left in place for five to seven days, sometimes with clips or sutures removed at about the same point. The wound should be kept dry until healed, and a shower is allowed if it is protected. As a routine, a collar is not advised after anterior or posterior cervical surgery, though a consultant may decide otherwise.

Swallowing and voice changes are the best known effects of surgery from the front. The North Bristol leaflet explains that the oesophagus (food tube) and larynx (voice box) have to be moved to one side, so some people have temporary swallowing difficulty, voice problems or breathing difficulty due to bruising or swelling, which often improve within weeks. The Hull leaflet describes possible voice changes such as hoarseness, a weak or breathy voice, dry or achy throat and a lump in the throat sensation, and says early assessment by a speech and language therapist is important to reduce the risk of food going down the wrong way and choking.

The leaflet says wound pain can last two to three days, a sore throat can last up to a month though usually settles much sooner, and some people feel pain across the shoulder blades and neck because muscles were stretched. Patients usually need painkillers for two to four weeks. It advises paracetamol as first line, codeine or tramadol as additions if still in pain and anti-inflammatory painkillers for relatively short periods, with laxatives because opioid painkillers can cause constipation. When stopping opioids or similar medicines it advises slowly tapering to minimise withdrawal effects.

On driving, the leaflet advises driving at around two weeks when you feel able to control the vehicle safely including carrying out an emergency stop, and says that if you are advised to wear a hard collar you cannot drive while wearing it. Follow your own surgeon's instructions where they differ, and check your insurance.

The leaflet tells people to contact the spinal nurse practitioner or GP immediately if they have constant pain that gets worse, existing numbness that worsens or new numbness, muscle weakness or a change in bladder function. It also says to contact the GP if the wound becomes red, swollen, opens or discharges. Recovery is gradual and "off" days are normal.

On the NHS the route normally runs from a GP, often via NHS community musculoskeletal services or physiotherapy, to an MRI scan and a spinal surgery or neurosurgery clinic if non-surgical treatment has not worked. Some people choose private consultations and surgery to shorten waits. The operation, its aims and its risks are the same in both settings, so ask which surgeon will operate, which implants are planned, who provides follow-up and how problems will be handled after you go home.