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Anterior cervical discectomy and fusion

93 citationsUpdated Sep 2026

Overview

Anterior cervical discectomy and fusion (ACDF) is generally preferred for radiculopathy accompanied by significant axial neck pain, central disease, or segmental kyphosis [28]. In contrast, posterior laminoforaminotomy remains an acceptable alternative for lateral soft disk herniations where predominant arm pain is the primary symptom [28]. The procedure allows for the removal of a degenerated disc without disturbing the spinal canal and permits interbody fusion at the specific intervertebral level from which symptoms arise [12]. This anterior approach carries less morbidity than laminectomy with foramen decompression or posterior fusion [12]. Patients with substantial preoperative motor deficits may benefit from earlier surgical intervention [1]. For selected patients with traumatic cervical disc herniation who have no spinal cord injury, fracture, or instability, cervical arthroplasty yields similar clinical improvement to ACDF while preserving segmental mobility [67].

Single-level elective ACDF is associated with low complication rates, and no additional risk is observed when performed as an outpatient compared to an inpatient procedure [6]. Cervical spine surgery can be performed in an ambulatory surgery center for carefully selected patients [53]. A new cervical stand-alone anterior fusion device allows decompression and fusion with low complication rates [14]. While modified ACDF techniques with different resection ranges exhibit different stress areas on the vertebrae [2], three anterior cervical surgical approaches have demonstrated good curative effects on single-level cervical spondylotic myelopathy [3]. Anterior cervical hybrid construction is an acceptable option for managing multilevel cervical degenerative disc diseases and spondylotic spinal stenosis [21]. Anterior cervical corpectomy should be performed with caution in patients who have had a previous laminectomy, given the potential for complications [8].

Cervical disc arthroplasty offers potential advantages over ACDF regarding length of stay, cost, and routine discharge [4]. Patients treated with cervical disc arthroplasty returned to work in significantly fewer days than those treated with ACDF [9]. In terms of overall success, NDI success, neurological success, implant-related serious adverse events, secondary procedures, functional outcomes, patient satisfaction, and superior adjacent segment degeneration, cervical disc arthroplasty is superior to anterior discectomy and fusion for symptomatic cervical disc disease [7]. However, the motion-preserving design of cervical disc arthroplasty may introduce novel complications and failure modalities that are poorly understood [4]. Adjacent-segment disease is a consistent finding after anterior cervical fusion [17], though it induced no neurological manifestations or need for revision surgery in the reported cohort [17]. Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis [5]. Cervical disc replacement is preferable to anterior cervical fusion in reducing the incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up [10]. For patients with one-level cervical degenerative disc disease, total disc replacement has significantly fewer adjacent segment diseases and reoperations compared with ACDF [20].

Anatomy & Pathophysiology

Bony Anatomy

The vertebral column comprises 33 vertebrae divided into five sections: 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 4 coccygeal [78]. The cervical spine consists of seven vertebrae and assumes a lordotic curvature [75]. A typical vertebra comprises an anterior body and a posterior arch that enclose the vertebral canal [78]. The neural arch is composed of two pedicles laterally and two laminae posteriorly that are united to form the spinous process [78]. The vertebral body is a fairly cylindrical mass of bone connected by the pedicles to the posterior arch [70], consisting of an inner region of cancellous bone surrounded by a thin shell of cortical bone [75]. The cervical vertebral body is an oblong structure with a coronal diameter larger than its sagittal diameter [87]. Cervical endplates have a cup-in-saucer configuration, distinct from the normally flat endplates of the thoracic and lumbar vertebrae [87]. The posterior aspect of the cervical transverse process guides the cervical spinal nerves as they exit the spinal canal [87]. The spinal nerves lie posterior to the vertebral artery within the cervical transverse process [87]. The transverse process forms a half-pipe configuration that cradles the exiting spinal nerve [87].

Intervertebral Disc

The intervertebral disc (IVD) separates each successive vertebral body except between the atlas (C1) and the axis (C2) [75]. The IVD provides a unique combination of compressive stiffness and flexibility to support normal spine biomechanics [75]. It is composed of an inner nucleus pulposus (NP) and an outer ring termed the anulus fibrosus (AF) [75]. The nucleus pulposus serves as an osmotic pump to attract water and generate hydraulic pressure when subjected to significant loads [75]. The anulus fibrosus encapsulates the gelatinous nucleus pulposus and provides mechanical support to contain NP pressure and constrain intervertebral rotations [75]. The outer anulus fibrosus is integrated with the vertebral rim via a fibrocartilage enthesis that consists of a thin layer of calcified cartilage, or "tidemark" [75]. The end plate is a bilayer of cartilage and bone that separates the disk from adjacent vertebrae [75]. The cartilage end plate integrates with the inner anulus fibrosus to fully encapsulate the nucleus pulposus [75].

Ligaments and Soft Tissue

Each successive vertebra is connected anteriorly via the IVD and posteriorly via the facet joints [75]. Soft-tissue structures providing passive support include the anterior longitudinal ligament, posterior longitudinal ligament, ligamentum flavum, facet joint capsule, interspinous ligament, and supraspinous ligaments [75]. The spinal column is stabilized by paraspinal muscles including the erector spinae, psoas, and multifidus [75]. The erector spinae runs longitudinally on the dorsal surface of the spinal column and functions to extend the spine [75]. The psoas runs longitudinally on the ventrolateral surface of the spinal column and serves to flex the hip or laterally bend the trunk [75]. The multifidus connects intersegmentally to stabilize the spine by acting like a bowstring to maintain lordosis [75].

Biomechanics and Alignment

Normal cervical alignment is approximately 15° of lordosis [74]. The curvatures of the spine function to keep the head balanced over the pelvis and to transmit axial forces through the spine to the pelvis [74]. The lordotic curvatures of the cervical and lumbar spine develop secondarily later in life to allow the growing child to develop an upright posture [74]. Changes in sagittal balance that shift the center of gravity too far ventrally can result in significant pain and disability [74]. The basic motion segment of the spine, or "functional spinal unit," consists of two vertebrae, the disk between them, and the facet joints and their capsules [74]. Vertebral bodies bear 70% to 90% of the static axial load of the spine [74]. The facet joints support 10% to 20% of axial load in a standing, neutral alignment [74]. In extension, facet joints may bear up to 30% of the axial load [74]. In flexion, facet joints may be burdened with up to 50% of the anterior shear load [74]. As compressive forces are applied to the disk, the nucleus pulposus deforms, redistributing axial forces radially [74]. Radial pressure from the nucleus pulposus is resisted by the tensile properties of the alternating bands of fibers within the anulus fibrosus [74]. The spinous processes and transverse processes act as lever arms, providing mechanical advantage for the muscles that insert along their surfaces [74].

Vascular Anatomy

The cervical spine derives its circulation primarily from the vertebral arteries [79]. The vertebral arteries arise from the subclavian arteries on either side and course superiorly [79]. They typically enter the transverse foramen at the C6 level and run proximally through the transverse foramina to C1 [79]. The vertebral arteries course posteriorly over the superior aspect of the C1 ring before turning proximally and entering the foramen magnum [79]. Segmental branches to each cervical vertebra arise from the vertebral artery and the deep cervical branch of the costocervical trunk [79]. There is a great deal of variability in the anatomy of the vertebral artery, with one side typically being more dominant [79]. The vertebral artery occasionally enters through the transverse foramen of C7 rather than C6 [79]. Anomalous courses of the vertebral artery, such as looping through a cervical vertebral body, are not uncommon [79]. The vascular supply of the spinal cord is primarily from the medullary branches of the segmental spinal arteries [79]. Medullary branches merge to feed the anterior spinal artery, which supplies approximately 80% of the vascular supply to the spinal cord [79]. Three anterior medullary arteries typically supply the cervical region [79]. The arteria medullaris magna (AMM), also known as the artery of Adamkiewicz, is the largest anterior segmental artery [79]. The AMM typically arises on the left side anywhere between the T8 and L1 level [79].

Neural Anatomy

A typical mixed spinal nerve has three distinct components: motor, sensory, and sympathetic [80]. Motor root fibers arise from the anterior horn cells and innervate the skeletal muscles [80]. Sensory fiber cell bodies are located within the dorsal root ganglia [80]. Fibers conveying joint or position sensibility and some tactile fibers turn cephalad in the dorsal columns and do not synapse before reaching the gracile and cuneate nuclei at the cervicomedullary junction [80]. Pain and temperature fibers synapse in the substantia gelatinosa and cross to ascend in the dorsal spinothalamic tract [80]. Tactile fibers enter, synapse, and cross to ascend in the ventral spinothalamic tract [80]. The sympathetic component of all 31 mixed spinal nerves leaves the spinal cord along only 14 motor roots [80]. The cells of origin for sympathetic fibers are in the intermediolateral cell column that extends throughout the thoracic and upper lumbar cord segments [80]. Mixed spinal nerves, having left the intervertebral foramina, receive their sympathetic component and branch into anterior and posterior primary rami [80]. The posterior primary rami supply the paraspinal musculature and the skin along the posterior aspect of the trunk, neck, and head [80]. The upper three cervical posterior rami are larger than their corresponding anterior rami [80]. The anterior primary rami of all the cervical, the first thoracic, and all the lumbosacral nerves join in the formation of plexuses [80]. The upper four cervical anterior rami form the cervical plexus [80]. The lower four cervical and first thoracic anterior rami form the brachial plexus [80]. C1 emerges between the skull and C1 vertebra [76]. C2–C7 spinal nerves emerge superior to the pedicles of their respective vertebrae [76]. The C8 spinal nerve emerges inferior to the pedicle of the C7 vertebra [76]. T1 through coccygeal spinal nerves emerge inferior to the pedicles of their respective vertebrae [76].

Pathophysiology

Degenerative cervical spondylosis can present clinically as axial neck pain, cervical radiculopathy, or cervical myelopathy [31]. Pathoanatomic changes in degenerative cervical spondylosis are generally well visualized on imaging studies and must be correlated with clinical findings [31]. Most patients with axial neck pain, cervical radiculopathy, or mild cervical myelopathy respond well to an initial trial of nonoperative management [31]. The clinical outcome following surgery for cervical myelopathy depends primarily on the duration since the onset of symptoms, the presence and pattern of intramedullary signal changes on MRI, and the adequacy of decompression [31]. Some sagittal balance parameters may be associated with the development of adjacent segment degeneration after anterior cervical surgery [16]. The presence of cervical Modic changes did not impact clinical outcomes in cervical spine procedures [22]. Cervical spinal deformity is a debilitating condition with diverse etiologies [48]. Recent efforts in cervical spinal deformity focus on classification schemes and treatment algorithms to understand outcomes and the relationship between cervical and thoracolumbar spinal alignment [48]. Cervical sagittal parameters have a significant effect on the occurrence of axial neck pain in patients with cervical kyphosis [123]. The backward movement of the head is a compensatory mechanism in cervical sagittal alignment modifications after anterior cervical discectomy and fusion [137]. Hirayama disease patients have differences in cervical biomechanics compared with non-pathological people, which may lead to cervical hypermobility and overload [124]. Endplate thickness and bone density significantly influence biomechanical stability after anterior cervical discectomy and fusion [125]. Preserving endplate integrity and evaluating bone quality is important to mitigate the risk of postoperative subsidence after anterior cervical discectomy and fusion [125].

Classification

Sagittal Alignment: ACDF, LCF, and LP exhibit distinct cervical sagittal alignment changes, surgical correction changes, and postoperative lordosis preservation patterns according to a four-type cervical sagittal alignment classification [168]. Single-level ACDF demonstrates satisfactory postoperative cervical sagittal alignment across different grades of multifidus muscle fatty infiltration [68].

Adjacent Segment Disease: Adjacent-segment disease is a consistent finding after anterior cervical fusion, though it induces no neurological manifestations or need for revision surgery [17]. The incidence of symptomatic non-fusion segment disease following anterior cervical arthrodesis has multifactorial causes [18]. High preoperative Pfirrmann grade at the disk level adjacent to anterior cervical decompression and fusion predicts worse adjacent segment degeneration, specifically decreased disk height at 2 years postoperatively [26]. For patients with one-level cervical degenerative disc disease, total disc replacement results in significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion [20].

Other Considerations: Modified Anterior Cervical Discectomy and Fusion with different resection ranges exhibits different stress areas on the vertebrae [2]. Single-level elective anterior cervical discectomy and fusion carries low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures [6]. Cervical disc arthroplasty is superior over anterior discectomy and fusion for symptomatic cervical disc disease regarding overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and superior adjacent segment degeneration [7]. Two studies report that patients treated with cervical disc arthroplasty return to work in significantly fewer days than those treated with anterior cervical diskectomy fusion [9]. Anterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis [21]. Revision operations for cervical adjacent segment disease are highly heterogeneous and associated with an average direct cost of $27,702 [25]. In deciding between laminoplasty and laminectomy for multi-level cervical spondylotic myelopathy, the risks of surgical and neurological complications, and radiologic and clinical outcome, must be taken into consideration if both options are available [29]. Both superior and inferior adjacent-level groups together with ACDF and ACCF groups maintained favorable clinical results on patients who underwent one-level ACDF for symptomatic new radicular or myelopathic symptoms [38]. During a 16-year study period, 6,721 patients (7.7%) underwent revision after primary subaxial cervical arthrodeses [40]. The median time to revision after primary subaxial cervical arthrodeses was 24.5 months [40]. The probability of undergoing at least one revision by 192 months after primary subaxial cervical arthrodeses was 12.6% [40]. Arthrodeses performed via anterior-only approaches had a significantly higher probability of reoperation compared to other approaches [40]. Hybrid surgery and ACDF provided identified mid-term efficacy, and it was not necessary to use prosthesis on three-level cervical spondylotic myelopathy [63].

Clinical Presentation

Symptomatology and Diagnosis

Pathoanatomic changes in degenerative cervical spondylosis are generally well visualized on imaging studies and must be correlated with the clinical findings [31]. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively [60].

Prognostic Factors and Risk Stratification

Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention [1]. Increased signal intensity (ISI) of the spinal cord on T2WI and high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion [37]. Patients with preoperative anxiety undergoing single-level anterior cervical diskectomy and fusion had significantly higher odds of 90-day adverse events, including severe and minor complications, as well as increased rates of emergency department visits and readmissions [30]. Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease [147].

Historical Outcomes and Patient Selection

Patients with radicular symptoms had a higher rate of improvement than those whose symptoms were non-radicular following cervical discectomy and interbody fusion [44]. A positive correlation was found between satisfactory results and either motor or sensory deficits in patients undergoing cervical discectomy and interbody fusion [44]. Occipital headaches and non-radicular symptoms as the predominant complaints tended to reduce the likelihood of a desirable result after cervical discectomy and interbody fusion [44]. Patients with correlating symptoms and signs of root compression had better results from surgery than those whose treatment resulted in bone fusion, suggesting that the selection of patients for cervical discectomy may be more important than the obtaining of a bone fusion [44]. Patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques [55].

Investigations

MRI: Magnetic resonance imaging is the procedure of choice for screening patients with low back or sciatic pain, offering superior capability to CT for identifying infections, tumors, and degenerative changes within discs [91]. Its high soft-tissue contrast and resolution provide excellent assessment of the spinal cord, intervertebral discs, nerve roots, posterior longitudinal ligament, and intervertebral foramen [90]. A normal intervertebral disc exhibits signal hyperintensity on T2-weighted images, with aging resulting in gradual desiccation and loss of this signal [90]. Disc herniations or extrusions appear as convex or polypoid masses extending posteriorly into the ventral epidural space, frequently maintaining a signal intensity similar to that of the disc of origin [90]. Far lateral disc herniations are best seen on selected axial images localized through disc levels [90]. Free disc fragments appear discontinuous with the intervertebral disc, usually of intermediate T1-weighted signal in contrast to the hypointense cerebrospinal fluid [90]. Edema within the spinal cord is readily demonstrated as hyperintensity with T2 weighting [90]. Sagittal T2-weighted or gradient-echo images create a “myelographic” effect useful for evaluating compromise of the subarachnoid space [90]. Sagittal T1-weighted images should be closely examined to identify narrowing of the neuroforamina, where normal hyperintense perineural fat provides contrast to darker displaced disc material [90]. MRI evidence of disc degeneration has been reported in the cervical spine in 25% of patients younger than 40 years and in 60% of patients 60 years and older [91].

CT: Computed tomography is reserved for patients with contraindications to MRI or equivocal MRI examinations, as it is invasive and more costly than MRI [90]. CT allows for the identification of subtler fractures that might remain undiagnosed on plain radiographs and provides additional three-dimensional detail regarding canal compromise and fracture comminution [92]. Narrowing of the spinal canal is best demonstrated by computed tomography [96]. Destructive lesions of the spine may require both CT and MRI to show the extent of cord involvement [96]. The primary disadvantage of CT imaging compared to MRI is that it does not provide as good a visualization of soft tissues [92].

Plain radiography: The lateral cervical spine view is the most important view in radiographic imaging of the cervical spine [98]. Radiographs, flexion-distraction or neutral, have limited utility in the acute setting because of their high false-negative and false-positive rates [99]. Inadequate imaging will miss over 20% of cervical injuries [98].

Other Considerations: The demonstrated findings on MRI must be carefully correlated with the clinical impression, as imaging alone is insufficient to confirm a diagnosis without concordant symptoms and signs [88]. The best way to obtain meaningful clinical information from MRI is to have a specific question derived from history and physical examination, posed using the parameters of neural compression, instability, and deformity [91]. Failure to interpret an imaging study in the context of specific clinical questions can lead to poor clinical choices and outcomes [91]. In alert, asymptomatic patients without neck pain or distracting injury, with a normal neurological examination and complete range of motion, radiographic evaluation is not recommended and only clinical clearance is necessary [99]. Patients with neck tenderness and pain require multidetector CT, which has a sensitivity of 97% to 100% [99]. Patients with presumed spinal cord injury should undergo MRI to determine the location and severity of the injury and to identify the cause of spinal cord compression [99]. Edema increases with time, reducing the ability to properly evaluate spinal cord lesions on MRI [99]. Ligamentous injury of the cervical spine may not be clearly identifiable from multidetector CT images, but MRI images can reliably identify ligamentous injuries [99]. It is recommended that patients presenting with a Glasgow Coma Scale of less than 15 and midline tenderness with neurological symptoms be evaluated with MRI for possible ligamentous injury [99]. Increased signal intensity (ISI) of the spinal cord on T2-weighted imaging is an independent risk factor for poor neurological recovery after anterior cervical discectomy and fusion [37]. High degree of cranial adjacent disc degeneration is an independent risk factor for poor neurological recovery after anterior cervical discectomy and fusion [37]. The type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of symptoms at presentation nor to clinical outcomes at two years postoperatively in patients with cervical radiculopathy [60]. Diffusion tensor imaging has been reported to demonstrate spinal cord impairment in patients with early stage cervical spondylosis before it is visible on plain MRI scans [94].

Treatment

Non-Operative

The provided evidence does not detail specific conservative management protocols such as weight loss, physical therapy, NSAIDs, or injections. However, preoperative anxiety is associated with significantly higher odds of 90-day adverse events, including severe and minor complications, as well as increased rates of emergency department visits and readmissions in patients undergoing single-level anterior cervical diskectomy and fusion [30]. Spinal surgeons should be aware of the inherent risks of elective cervical spine surgery in patients with poor preoperative functional status when deciding whether to undertake surgery [169].

Operative

Indications: Patients with substantial preoperative motor deficits may benefit from earlier surgical intervention [1]. Surgery yields better results in patients with correlating symptoms and signs of root compression than in those whose treatment resulted in bone fusion [44]. Patients with radicular symptoms had a higher rate of improvement than those whose symptoms were non-radicular [44]. A positive correlation was found between satisfactory results and either motor or sensory deficits, with the correlation being greater when both motor and sensory findings were present [44]. Men tended to have much better results from discectomy than did women [44]. Occipital headaches and non-radicular symptoms as the predominant complaints tended to reduce the likelihood of a desirable result [44]. Patients with apparently normal cervical spines tended to have less desirable results than those with osteophyte formation or narrowing of the interspace or both [44].

Surgical Approach / Technique: The anterior approach allows removal of a degenerated disc without disturbing the spinal canal and permits interbody fusion at the specific intervertebral level from which symptoms arise [12]. This approach has less morbidity than laminectomy and foramen decompression or posterior fusion [12]. Anterior hybrid decompression and segmental fixation is a safe and effective approach for adjacent three-level cervical spondylosis [54]. Hybrid surgery and anterior cervical discectomy and fusion provided identified mid-term efficacy for three-level cervical spondylotic myelopathy, and it was not necessary to use prosthesis [63]. Anterior corpectomy and fusion by a PEEK cage and plate–screw osteosynthesis resulted in clinical improvement in all patients with multilevel cervical spinal stenosis [47]. Application of a stand-alone expandable cage in the cervical spine after one or two-level anterior cervical corpectomy and fusion without additional posterior fixation or anterior plating is a safe procedure that results in fusion [165]. In patients who have persistent symptoms after an anterior cervical arthrodesis, an excellent result can be achieved with repeat anterior decompression and autogenous bone-grafting [19].

Implant Selection: Self-locking stand-alone cages are effective, reliable, and safe for three-level anterior cervical discectomy and fusion, showing significantly lower rates of dysphagia and adjacent segment degeneration compared to anterior cage-with-plate fixation [57]. Both stand-alone titanium cage and cage with plate fixation are effective for managing two-level cervical disc herniation, though each has distinct advantages and limitations [117]. Arthroplasty-fusion is preferred for intervertebral disc degeneration in adjacent upper segments based on finite element analysis of biomechanical effects [162]. Robinson anterior cervical discectomy and arthrodesis with an autogenous iliac-crest bone graft for cervical radiculopathy is a safe procedure that can relieve pain and lead to resolution of neurological deficits in a high percentage of patients [33].

Adjuncts: Steroids have been successfully used in anterior cervical discectomy and fusion to prevent dysphagia [35].

Setting of Care: Outpatient cervical spine surgery is a safe and convenient alternative procedure that decreases the cost of care due to short operative time and moderate postoperative pain [146].

Other Considerations: In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years [15]. The value of discography and myelography was not clearly defined by long-term evaluation, and these methods are of secondary importance to the clinical evaluation [44]. Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding length of stay, cost, and routine discharge, but the motion-preserving design may introduce novel complications and failure modalities that are poorly understood [4]. A sufficiently long follow-up, which has not yet been reached, will be necessary to establish definitively an advantage for total disc replacement, particularly in the cervical spine [65]. While anterior cervical discectomy and fusion remains the most frequent procedure, cervical disc arthroplasty is showing a gradual increase in impact [39]. Posterior minimally invasive surgery is an effective and safe method for the treatment of cervical spondylosis and is a recommended optional surgical procedure for single-segment myelopathy and radiculopathy [24]. After a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy [36]. Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed [13]. The clinical effects of the anterior approach and laminoplasty were similar for cervical ossification of posterior longitudinal ligament, but the anterior approach is superior in cases with spinal canal stenosis ratio >50%, poor cervical curvature, and has a relatively lower rate of postoperative axial symptoms [132]. Percutaneous full-endoscopic anterior transcorporeal cervical discectomy and channel repair is a feasible, safe, and minimally invasive procedure that achieves less damage to disc and retained cervical motion segment [32]. Anterior percutaneous full-endoscopic transcorporeal decompression of the spinal cord via one vertebra with two bony channels is a minimally invasive, feasible, and safe surgical option for patients with adjacent two-segment cervical spondylotic myelopathy, offering advantages of less trauma, faster recovery, fewer complications, and no need for internal fixators [126]. Anterior transcorporeal approach combined with posterior translaminar approach in percutaneous endoscopic cervical discectomy avoids the fusion of the vertebral body for internal fixation, preserves the vertebral motion segments, and avoids medical destruction of the cervical disc to the greatest extent possible [51].

Complications

Adjacent Segment Disease

Long-term surveillance data indicate that adjacent segment pathology remains a significant consideration following anterior cervical discectomy and fusion. In a multicenter retrospective study of 288 patients with a mean follow-up of 14.5 years, the rate of adjacent segment revision was 5.9% [49]. Actuarial analysis in the same cohort predicted a 15-year rate of adjacent segment revision surgery of 6.3% (95% CI, 4–10%) [49]. Implant design influences the risk of degeneration at adjacent levels; self-locking stand-alone cages for three-level anterior cervical discectomy and fusion showed significantly lower rates of adjacent segment degeneration compared to anterior cage-with-plate systems [57]. Comparative evidence suggests that cervical disc arthroplasty is associated with significantly fewer adjacent segment diseases and reoperations compared with anterior cervical discectomy and fusion for one-level cervical degenerative disc disease [20]. Furthermore, cervical disc arthroplasty was superior over anterior discectomy and fusion in terms of superior adjacent segment degeneration [7].

Perioperative and Early Complications

The anterior neck approach carries specific risks, including dysphagia and injury to the laryngeal nerves [31]. In a level-specific comparison at C5-C6, the anterior cervical discectomy and fusion cohort reported 43.6 mL blood loss compared to 24.4 mL in the cervical disc replacement cohort [45]. Anterior cervical discectomy and fusion had an almost 10-minute increased surgical time relative to cervical disc replacement, which translates to an approximate increase of 4% risk of complications [45]. Postoperative pain is a common early complication; in a study of 94 patients undergoing single-level anterior cervical discectomy and fusion, 33 patients (35.1%) showed increased neck pain at 3 days after the surgery [108]. In the same study, 2 patients had persistent postoperative axial pain until 1 year after the surgery [108]. The new cervical stand-alone anterior fusion device allows decompression and fusion with low complication rates [14]. No significant differences were observed among proportions of patients sustaining complications across White, Black, Asian, and other/unspecified racial and ethnic groups undergoing cervical spine surgery [111].

Pseudarthrosis and Fusion Failure

Fusion failure remains a critical outcome metric, particularly in multilevel procedures. Despite achieving fusion in 80% of cases, anterior revision surgery may not result in relevant clinical improvements for patients with pseudarthrosis after anterior cervical discectomy and fusion [69]. The fusion rate in a group of patients undergoing four-level anterior cervical discectomy and fusion with stand-alone anchored cages was 86.5% [104]. In a systematic review of multilevel cervical spondylosis, graft dislodgment was reported as a surgical complication in anterior cervical discectomy and fusion cases [127]. In the same systematic review, infection was reported as a surgical complication in anterior cervical discectomy and fusion cases [127]. Additionally, dysphagia was reported as a surgical complication in anterior cervical discectomy and fusion cases [127], and hoarseness was reported as a surgical complication in anterior cervical discectomy and fusion cases [127].

Long-Term Revision and Outcomes

Sagittal alignment parameters are key predictors of long-term revision surgery. The causes of revision surgery in cervical myelopathic patients after anterior cervical corpectomy and fusion or anterior cervical diskectomy and fusion are multifactorial [177]. (T1S-CL)-C2S mismatch and high C2C7SVA are the best cervical sagittal parameters that increase the odds of revision surgery after anterior cervical fusion [177]. The effect of sagittal parameters on the odds of revision surgery is more enhanced when comorbidities such as smoking, low bone-mineral density, and increased levels of fusion are taken into account [177]. An "overloaded vertebral body" is a unique radiographic phenomenon following multilevel anterior cervical discectomy and fusion characterized by significant reductions in anterior and posterior vertebral height [112].

Comparative Complication Profiles

Cervical disc arthroplasty demonstrated a lower rate of adverse events compared with anterior cervical discectomy and fusion [170]. Cervical disc arthroplasty was associated with fewer secondary surgical procedures compared with anterior cervical discectomy and fusion [170]. After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes that were similar to those of patients not receiving Workers' Compensation in terms of surgery-related complications and reoperations [52]. In a study comparing posterior foraminotomy with anterior discectomy with fusion, patients undergoing posterior surgery initially experienced more neck pain but results were similar to those after anterior surgery as of postoperative week 5 [13].

Recovery

Neurological and Functional Outcomes: Patients with substantial preoperative motor deficits may benefit from earlier surgical intervention for anterior cervical diskectomy and fusion [1]. Increased signal intensity of the spinal cord on T2WI is an independent risk factor for poor neurological recovery after anterior cervical discectomy and fusion [37]. In patients undergoing multilevel anterior cervical decompression with fusion, recovery of cervical kyphosis may contribute to the long-term recovery of neural function [173].

Perioperative and Short-Term Recovery: Dysphagia is a common postoperative complaint following anterior cervical discectomy and fusion, with incidence rates ranging from 1.7% to 71% [50]. Regarding operative metrics, the CDR cohort reported 24.4 mL of blood loss and the ACDF cohort reported 43.6 mL of blood loss [45]. ACDF has an almost 10-minute increased surgical time relative to CDR [45]. This duration difference translates to an approximate increase of 4% risk of complications [45]. Generally, increases in surgical time of just 1 minute led to a 1% increase in complications extending up to a 21% increase in complications for every additional hour in the operating room [45]. Preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery [173]. Short-term axial pain risk may be reduced through moderate cervical curvature recovery in patients undergoing multilevel anterior cervical decompression with fusion [173].

Adjacent Segment Disease and Long-Term Degeneration: Hybrid surgery failed to reduce the incidence of adjacent segment degeneration compared to anterior cervical discectomy and fusion [62].

Revision and Complications: The median time to revision after primary cervical arthrodeses was 24.5 months [40]. The probability of undergoing at least one revision by 192 months after primary cervical arthrodeses was 12.6% [40]. Arthrodeses performed via anterior-only approaches had a significantly higher probability of reoperation [40]. Anterior revision surgery for pseudoarthrosis may not result in relevant clinical improvements for patients despite achieving fusion in 80% of cases [69]. Revision operations for cervical adjacent segment disease are associated with an average direct cost of $27,702 [25].

Postoperative Immobilization and Kinematics: Surgeon motivation for postoperative cervical collar immobilization after completion of fusion procedures is to increase fusion rates and improve postoperative pain and disability [66].

Key Evidence

• [L3] Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention. [1] (10.5435/jaaos-d-16-00606)
• [L5] Modified Anterior Cervical Discectomy and Fusion with different resection ranges exhibited different stress areas. [2] (10.1186/s12891-024-07855-7)
• [L3] Three anterior cervical surgical approaches have good curative effects on single level cervical spondylotic myelopathy. [3] (10.1186/1471-2474-15-233)
• [Paper] Cervical disc arthroplasty offers potential advantages over anterior cervical discectomy and fusion regarding length of stay, cost, and routine discharge, but the motion-preserving design may introduce novel complications and failure modalities that are poorly understood. [4] (10.2106/jbjs.rvw.25.00208)
• [L3] Symptomatic adjacent-segment disease may affect more than one-fourth of all patients within ten years after an anterior cervical arthrodesis. [5] (10.2106/00004623-199904000-00009)
• [L3] Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures. [6] (10.2106/jbjs.m.00767)
• [L1] This meta-analysis showed that cervical disc arthroplasty was superior over anterior discectomy and fusion for the treatment of symptomatic cervical disc disease in terms of overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and superior adjacent segment degeneration. [7] (10.1371/journal.pone.0149312)
• [L4] Anterior cervical corpectomy should be performed with caution and knowledge of the potential complications in a patient who has had a previous laminectomy. [8] (10.2106/00004623-199907000-00007)
• [L2] Two studies reported that patients treated with cervical disc arthroplasty returned to work in significantly fewer days than did patients treated with anterior cervical diskectomy fusion. [9] (10.5435/00124635-201010000-00006)
• [L1] Our review suggests that cervical disc replacement is preferable to anterior cervical fusion in reducing the incidence of symptomatic adjacent-level disease requiring surgery at mid- to long-term follow-up. [10] (10.1186/s13018-020-01957-3)
• [L4] The operation has less morbidity than laminectomy and foramen decompression or posterior fusion, allows removal of a degenerated disc without disturbing the spinal canal, and permits interbody fusion at the specific intervertebral level from which symptoms arise. [12] (10.2106/00004623-195840030-00009)
• [L1] Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed. [13] (10.2106/jbjs.22.01211)
• [L4] The new cervical stand-alone anterior fusion device allows decompression and fusion with low complication rates. [14] (10.1007/s11999-010-1597-9)
• [L1] In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years. [15] (10.2106/jbjs.22.00305)
• [L1] Some sagittal balance parameters may be associated with the development of ASD after anterior cervical surgery. [16] (10.1186/s12891-019-2800-0)
• [L4] Adjacent-segment disease is a consistent finding after anterior cervical fusion but induced no neurological manifestations or need for revision surgery. [17] (10.1016/j.otsr.2014.02.003)
• [L3] The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes. [18] (10.1186/s13018-018-0717-1)
• [L4] In patients who have persistent symptoms after an anterior cervical arthrodesis, an excellent result can be achieved with repeat anterior decompression and autogenous bone-grafting. [19] (10.2106/00004623-199704000-00007)
• [L1] For patients with one-level cervical degenerative disc disease, total disc replacement was found to have significantly fewer adjacent segment diseases and reoperations compared with ACDF. [20] (10.1007/s00402-014-2125-2)
• [L4] Anterior cervical hybrid construction appears to be an acceptable option in the management of multilevel cervical degenerative disc diseases and spondylotic spinal stenosis. [21] (10.1186/s13018-021-02393-7)
• [L1] The presence of cervical Modic changes did not impact clinical outcomes in cervical spine procedures. [22] (10.3390/ijerph191610158)
• [L4] Posterior minimally invasive surgery is an effective and safe method for the treatment of cervical spondylosis and is a recommended optional surgical procedure for single-segment myelopathy and radiculopathy. [24] (10.1186/s13018-022-03274-3)
• [L4] Revision operations for cervical adjacent segment disease are highly heterogeneous and associated with an average direct cost of $27,702. [25] (10.5435/jaaosglobal-d-22-00058)
• [L3] High preoperative Pfirrmann grade at the disk level adjacent to anterior cervical decompression and fusion is predictive of worse adjacent segment degeneration, specifically decreased disk height at 2 years postoperatively. [26] (10.5435/jaaos-d-25-00728)
• [L5] Anterior cervical discectomy and fusion is generally preferred for radiculopathy with significant axial neck pain, central disease, or segmental kyphosis, while posterior laminoforaminotomy is acceptable for lateral soft disk herniations with predominant arm pain. [28] (10.5435/00124635-199911000-00003)
• [L2] In deciding between the two procedures, the risks of surgical and neurological complications, and radiologic and clinical outcome, must be taken into consideration if both options are available in multi-level cervical spondylotic myelopathy. [29] (10.1186/1749-799x-8-45)
• [L3] Patients with preoperative anxiety undergoing single-level anterior cervical diskectomy and fusion had significantly higher odds of 90-day adverse events, including severe and minor complications, as well as increased rates of emergency department visits and readmissions. [30] (10.5435/jaaosglobal-d-24-00204)
• [L5] [31] (10.2106/00004623-200706000-00026)
• [L4] This is a feasible, safe, and minimally invasive procedure that achieves less damage to disc and retained cervical motion segment. [32] (10.1186/s12891-019-2659-0)
• [L3] Robinson anterior cervical discectomy and arthrodesis with an autogenous iliac-crest bone graft for cervical radiculopathy is a safe procedure that can relieve pain and lead to resolution of neurological deficits in a high percentage of patients. [33] (10.2106/00004623-199309000-00005)
• [L4] Steroids have been successfully used in anterior cervical discectomy and fusion (ACDF) to prevent dysphagia, in spinal cord injuries to improve neurological function, in acute back and neck pain for pain control, and in spinal metastasis. [35] (10.5435/jaaos-d-22-00971)
• [L1] This trial demonstrated that, after a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy. [36] (10.2106/jbjs.23.00775)
• [L3] Increased signal intensity (ISI) of the spinal cord on T2WI and high degree of cranial adjacent disc degeneration are independent risk factors for poor neurological recovery after anterior cervical discectomy and fusion. [37] (10.1186/s13018-024-04886-7)
• [L4] Both superior and inferior adjacent-level groups together with ACDF and ACCF groups maintained favorable clinical results on patients who underwent one-level ACDF for symptomatic new radicular or myelopathic symptoms. [38] (10.1186/s13018-016-0341-x)
• [L5] While ACDF remains the most frequent procedure, cervical disc arthroplasty is showing a gradual increase in impact, though more attempts are needed to promote further development. [39] (10.1302/2058-5241.6.210074)
• [L3] [40] (10.2106/jbjs.15.00938)
• [L4] [44] (10.2106/00004623-196850020-00006)
• [L3] [45] (10.5435/jaaos-d-21-01276)
• [L4] Anterior corpectomy and fusion by a PEEK cage and plate–screw osteosynthesis resulted in clinical improvement in all patients. [47] (10.1007/s00402-014-1972-1)
• [L4] Cervical spinal deformity is a debilitating condition with diverse etiologies; recent efforts focus on classification schemes and treatment algorithms to understand outcomes and the relationship between cervical and thoracolumbar spinal alignment. [48] (10.5435/jaaos-d-17-00546)
• [L4] [49] (10.1016/j.otsr.2014.07.004)
• [L2] Dysphagia is a common postoperative complaint following anterior cervical discectomy and fusion (ACDF), with incidence rates ranging from 1.7% to 71%. [50] (10.2106/jbjs.25.00847)
• [L4] It avoids the fusion of the vertebral body for internal fixation, preserves the vertebral motion segments, avoids medical destruction of the cervical disc to the greatest extent possible, and expands the scope of adaptation of full endoscopic technology in cervical surgery. [51] (10.1186/s13018-023-04471-4)
• [L2] After cervical disc arthroplasty, patients receiving Workers' Compensation had outcomes that were similar to those of patients not receiving Workers' Compensation in terms of patient-reported outcomes, surgery-related complications, reoperations, and return-to-work status. [52] (10.2106/jbjs.o.00324)
• [Paper] Cervical spine surgery can be performed in an ambulatory surgery center in carefully selected patients. [53] (10.1016/j.otsr.2018.04.014)
• [L4] Anterior hybrid decompression and segmental fixation is a safe and effective approach for adjacent three-level cervical spondylosis. [54] (10.1007/s00402-010-1181-5)
• [L3] Patients with prolonged preoperative symptom duration due to cervical disk herniation demonstrated notable improvements in physical function, disability, pain, and mental health regardless of fusion versus arthroplasty techniques. [55] (10.5435/jaaos-d-23-00655)
• [L3] Self-locking stand-alone cages are effective, reliable, and safe for three-level anterior cervical discectomy and fusion, showing significantly lower rates of dysphagia and adjacent segment degeneration. [57] (10.1186/s13018-023-03726-4)
• [L2] In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. [60] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
• [L1] Although hybrid surgery maintained cervical kinetics, it failed to reduce the incidence of adjacent segment degeneration. [62] (10.1302/0301-620x.102b8.bjj-2019-1666.r1)
• [L3] Hybrid surgery and ACDF provided identified mid-term efficacy, and it was not necessary to use prosthesis on three-level cervical spondylotic myelopathy. [63] (10.1186/s13018-020-01589-7)
• [L2] A sufficiently long follow-up, which has not yet been reached, will be necessary to establish definitively an advantage for TDR, particularly in the cervical spine. [65] (10.1016/j.otsr.2013.06.018)
• [L3] Surgeon motivation for postoperative cervical collar immobilization after completion of fusion procedures is to increase fusion rates and improve postoperative pain and disability despite this not being fully drawn out in the literature. [66] (10.2106/jbjs.rvw.24.00114)
• [L3] For selected patients with traumatic cervical disc herniation (no spinal cord injury, no fracture, and no instability), cervical arthroplasty yields similar improvement in clinical outcomes to ACDF and preserves segmental mobility. [67] (10.1186/s12891-015-0692-1)
• [L3] The study demonstrates satisfactory postoperative cervical sagittal alignment of patients despite different grades of fatty infiltration of the multifidus muscle following single-level ACDF. [68] (10.1186/s12891-022-05606-0)
• [L3] Despite achieving fusion in 80% of cases, anterior revision surgery may not result in relevant clinical improvements for patients. [69] (10.1186/s12891-023-06819-7)
• [L3] [104] (10.1186/s12891-018-2136-1)
• [L2] [108] (10.1186/s13018-022-02983-z)
• [L4] [111] (10.5435/jaaos-d-21-01017)
• [L3] [112] (10.1186/s13018-023-04365-5)
• [L3] While both approaches are effective for managing cervical disc herniation, each has distinct advantages and limitations. [117] (10.1186/s13018-025-05654-x)
• [L3] Our findings suggest a significant effect of cervical sagittal parameters on the occurrence of axial neck pain in patients with cervical kyphosis. [123] (10.1186/s13018-020-01909-x)
• [L5] Compared with non-pathological people, Hirayama disease patients have differences in cervical biomechanics, which may lead to cervical hypermobility and overload. [124] (10.1186/s13018-022-02984-y)
• [L5] Endplate thickness and bone density significantly influence biomechanical stability after ACDF, highlighting the importance of preserving endplate integrity and evaluating bone quality to mitigate the risk of postoperative subsidence. [125] (10.1186/s12891-025-09255-x)
• [L4] This procedure is a minimally invasive, feasible, and safe surgical option for patients with adjacent two-segment cervical spondylotic myelopathy, offering advantages of less trauma, faster recovery, fewer complications, and no need for internal fixators. [126] (10.1186/s12891-023-06978-7)
• [L3] [127] (10.1007/s00402-011-1402-6)
• [L3] The clinical effects of the anterior approach and laminoplasty were similar, but the anterior approach is superior in cases with spinal canal stenosis ratio >50%, poor cervical curvature, and has a relatively lower rate of postoperative axial symptoms. [132] (10.1016/j.otsr.2017.05.011)
• [L3] The backward movement of head occurs is the compensatory mechanism in cervical sagittal alignment modifications after ACDF. [137] (10.1186/s12891-017-1447-y)
• [L1] Because of short operative time and moderate postoperative pain, outpatient cervical spine surgery is a safe and convenient alternative procedure, which also decrease the cost of care. [146] (10.1186/s40001-016-0229-6)
• [L3] Smoking is associated with poor outcomes following hybrid surgery for multilevel cervical disc disease. [147] (10.1186/s12891-021-04501-4)
• [L5] Arthroplasty-fusion is preferred for intervertebral disc degeneration in adjacent upper segments. [162] (10.1186/s13018-023-03537-7)
• [L4] Application of a stand-alone expandable cage in the cervical spine after one or two-level ACCF without additional posterior fixation or anterior plating is a safe procedure that results in fusion. [165] (10.1186/s12891-021-04883-5)
• [L3] ACDF, LCF, and LP have different cervical sagittal alignment changes, surgical correction changes, and postoperative lordosis preserving according to a four-type cervical sagittal alignment classification. [168] (10.1186/s13018-023-03640-9)
• [L3] Spinal surgeons should be aware of the inherent risks of these procedures in this particular patient population when deciding whether to undertake surgery, advising patients pre-operatively and caring for them post-operatively. [169] (10.1302/0301-620x.99b6.bjj-2016-1149.r1)
• [L1] The meta-analysis revealed that CDA demonstrated superiorities in better neurological success, greater motion preservation at the operated level, lower rate of adverse events and fewer secondary surgical procedures compared with ACDF. [170] (10.1007/s00402-014-2122-5)
• [L3] Overall, preoperative axial neck pain and kyphosis could predict axial neck pain for patients undergoing multilevel anterior cervical decompression with fusion surgery, and recovery of cervical kyphosis may contribute to the long-term recovery of neural function, but may also suffer from risk of short-term axial pain, which could be reduced through moderate cervical curvature recovery. [173] (10.1186/s13018-019-1132-y)
• [L3] The causes of revision surgery in cervical myelopathic patients after anterior cervical corpectomy and fusion/anterior cervical diskectomy and fusion are multifactorial. (T1S-CL)-C2S mismatch and high C2C7SVA are the best cervical sagittal parameters that increase the odds of revision surgery, and the effect is more enhanced when comorbidities such as smoking, low bone-mineral density, and increased levels of fusion are taken into account. [177] (10.5435/jaaos-d-23-00565)

See Also

• Cervical disc replacement
• Cervical radiculopathy
• Cervical myelopathy

References

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