Anterior cervical discectomy and fusion (ACDF)

In one minute

ACDF (anterior cervical discectomy and fusion) removes a damaged neck disc through a short incision at the front and joins the two vertebrae (the bones of the spine) with a cage and plate. It is the standard operation from the front when the spinal cord is compressed (cervical myelopathy) or when a nerve root is trapped where the endoscope cannot safely reach. It needs general anaesthesia. A one-level operation commonly takes one to two hours. Most patients are walking by the next day; hospital stays vary between countries and hospitals, with a mean of 4.6 days across the studies pooled in a 2025 meta-analysis and study averages from under a day to about two weeks. Desk work commonly resumes within a few weeks. It is not an endoscopic operation; it is chosen when the endoscope is the wrong tool.

What the operation is

The name lists the steps: anterior (from the front), cervical discectomy (removal of the neck disc) and fusion (joining the two vertebrae into one bone). A two-, three- or four-level ACDF treats that many discs through one incision; when the compression sits behind a vertebral body, part of the vertebra is removed instead (a corpectomy).

The surgeon removes the disc, the bone spurs (osteophytes) and any fragment or thickened ligament pressing on the cord or root, and widens the nerve exits (foramina). A cage, a small hollow spacer packed with bone graft, fills the space and a thin plate is screwed to the front of the vertebrae. Over months, bone grows through the cage and the level becomes one solid block.

Who it is for

The first indication is cervical myelopathy, compression of the spinal cord that shows as clumsy hands, unsteady walking or numb, weak limbs. The 2017 AO Spine and Cervical Spine Research Society (CSRS) guideline recommends surgery for moderate and severe myelopathy (a strong recommendation) and suggests surgery or a supervised trial of structured rehabilitation for mild disease, with surgery if the patient deteriorates. For cord compression on MRI (magnetic resonance imaging) without signs or symptoms of myelopathy or radiculopathy, it suggests not operating and following the patient instead.

The second is cervical radiculopathy, arm pain, numbness or weakness from a pinched nerve root. In general practice surgery is considered when the pain has not settled after 6 to 12 weeks of proper non-surgical care, or sooner when there is weakness; that timing is a convention, not a guideline figure. The North American Spine Society (NASS) guideline of 2010 suggests ACDF over posterior foraminotomy when the compression is central or paracentral or comes from spondylotic bone (a work group consensus statement rather than a graded recommendation); for a soft disc herniation in the foramen at one level either operation is graded comparably successful (grade B, which the guideline defines as fair evidence).

We operate on all cervical levels, including multilevel cases. Four-level fusions had lower fusion rates, longer operations, more blood loss and longer stays than three-level ones in a 2026 meta-analysis, with no significant difference in complication or revision rates, so at that length the surgeon weighs a corpectomy, a posterior operation or a hybrid with a disc replacement. ACDF is not for neck pain alone without nerve or cord compression, and it is not the first choice for one lateral fragment in a mobile neck, where a posterior endoscopic foraminotomy or a cervical disc replacement keeps the level moving.

How it is done

You lie on your back under general anaesthesia. Through a short horizontal cut in a skin crease at the front of the neck, the surgeon separates the muscles without cutting them, moves the windpipe and gullet to one side and the carotid artery to the other, and reaches the spine. An X-ray confirms the level. Under the microscope the disc is removed, the spurs are drilled away, any fragment behind the vertebra is lifted out, the ligament over the cord is opened where it compresses, and the nerve exits are widened until the root is free. The cage goes in packed with bone graft, the plate is fixed with four small screws, a final X-ray checks position, and the wound is closed with absorbable stitches, sometimes over a drain.

How it compares with the endoscopic alternative

The endoscopic alternative is the posterior endoscopic cervical foraminotomy, which opens the nerve exit from the back through a 7 mm incision, removes the fragment or spur, and keeps the disc and the neck's movement. It is possible when one nerve root at one level is compressed from the side by a soft fragment or foraminal spur and there is no myelopathy. A 2023 meta-analysis of 24 studies and 1,345 patients, most of them single-arm series pooled side by side rather than direct comparisons, found effective rates of 94.3% for microscopic ACDF and 93.3% for the endoscopic keyhole, complications of 7.1% versus 4.7% and reoperations of 1.8% versus 1.1%, none significantly different. The common complications differed: swallowing difficulty and graft subsidence after ACDF, nerve root palsy (new weakness or numbness in the arm) after the keyhole.

The endoscope is not an option when the cord is compressed from the front by a central disc or a bar of bone, when the compression lies behind the vertebral body, when the neck is kyphotic or unstable, or when several levels are narrowed. ACDF removes that compression directly, restores disc height and alignment, and treats both sides at once.

Risks and how we reduce them

A 2025 meta-analysis of 222 studies and 50,584 patients, most of them retrospective series, gives the honest picture: an overall complication rate of 16%. Excessive neck swelling occurred in 11.3%, failure to fuse (pseudarthrosis) in 10%, difficulty swallowing (dysphagia) in 9.5%, cage or graft subsidence in 9.4%, worsening of myelopathy in 7.7%, hoarseness in 2.3%, palsy of the nerve to the voice box and weakness of the C5 nerve root in about 2% each, wound haematoma in about 1%, and infection, spinal fluid leak and epidural haematoma in under 1% each. Perforation of the gullet and death were reported in about 0.1% each. More fused levels and older age raised the rates.

Dysphagia is what patients notice first: across 14 studies the overall rate was 8.5% and moderate or severe dysphagia 4.4%, about 20% in studies with under a year of follow-up and 7 to 8% in studies that followed patients longer. Multilevel ACDF had a higher rate than single-level (6.6% versus 4%). Adjacent segment disease is the long-term risk: in 374 patients followed for up to 21 years, new symptoms at a neighbouring level appeared at 2.9% per year, in about a quarter within ten years, and more than two-thirds of those needed another operation.

Surgeons reduce these risks in familiar ways: retractors released at intervals to spare the gullet, a low-profile plate, bleeding controlled under the microscope, the airway watched overnight, and no smoking before any fusion. Across all the team's operations our complication figure is well below 1%; that is our own figure and not a comparison with anyone else.

Recovery, week by week

What the evidence says

The AO Spine and CSRS guideline of 2017 recommends surgery for moderate and severe degenerative cervical myelopathy and suggests surgery or supervised rehabilitation for mild disease. The NASS guideline of 2010 grades discectomy with or without fusion comparable, a plate to keep alignment, and ACDF and posterior foraminotomy comparable for a foraminal soft disc (all grade B). Hilibrand 1999 remains the reference for adjacent segment disease at 2.9% per year. The 2025 meta-analysis puts the overall complication rate at 16%, rising with the number of levels and with age.

How we do it at spine.uz

We are Tashkent's first endoscopic spine team, five surgeons operating as one, with 27,600+ endoscopic and spine operations in total. Cervical pages are reviewed by Dr. Akhror Yakubov, neurosurgeon. We operate on all levels, including multilevel cervical cases.

The first step is free: send your MRI on Telegram or WhatsApp and a doctor from the team replies by voice within 48 hours, saying whether the problem is one the endoscope can reach or one that calls for ACDF, and why. After the operation you receive a written conclusion and the team follows you up on Telegram.

Preparing for the operation

Photograph every slice of your cervical MRI, plus any CT (computed tomography) or X-ray, and send it ahead. Bring your list of medicines; tell us about blood thinners and anti-inflammatory drugs, and the surgeon decides when to pause them. Stop smoking. Fast as the anaesthetist instructs and arrange someone to accompany you home.