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Anterior Cervical Discectomy and Fusion Case Reports
consultation. The pain radiated to the proximal interscapular region, as well
Figure 1: Case 1 – Sagittal (A) and Axial (B) Pre-operative
as to the shoulder and proximal right upper extremity. She had undergone
Magnetic Resonance Imaging Demonstrating Stenosis at C5–7
multiple sessions of chiropractice, physical therapy, traction and myofascial
release resulting in almost a year’s worth of bi-weekly treatments. Much of A
the therapy was supervised by a physiatrist. Symptoms were aggravated
with extension and rotation of the head and neck. Although she would
have occasional numbness and tingling from the neck down to the hands,
the constant pain was her primary concern. Her past medical history was
significant for smoking. The patient was neurologically intact. An MRI scan
revealed degeneration at C5–C6 and C6–C7, and inflammatory
endplate changes were identified to be worse at C5–C6 (see Figure 5).
There was mild central and foraminal stenosis at C5–C7. She underwent a
cervical epidural steroid injection, but had only moderate temporary relief.
Her pre-operative neck and arm pain scores were 8.0 in severity, and her
pre-operative Oswestry disability score was 50. The patient then underwent
ACDF from C5–C7 with metallic plate instrumentation for a diagnosis of
degenerative disc disease with predominantly axial symptoms (see Figure
6). Post-operatively, she was highly satisfied with the surgical treatment of
her neck condition and at her recent four-year follow-up the patient had
0/10 pain for her neck and upper extremities, her disability score was 0 and
she was off all pain-relief medication.
Case 4
The patient is a 46-year-old female who had minor episodes of neck pain
over the years, but then was in a motor vehicle accident. The patient had
pre-existing congenital narrowing of the spinal canal with multilevel
stenosis. In addition, she had a C4–C5 disc herniation related to her motor
vehicle accident. She underwent multiple sessions of physical therapy,
trials of a transcutaneous electrical nerve stimulator (TENS) unit,
pharmacological treatment and three cervical spinal steroid injections. Due
to the patient’s progressive symptoms, she then underwent ACDF with
decompression at C4–C7 with metallic plate instrumentation and iliac
B
crest bone graft. Her pre-operative neck pain, arm pain and disability
scores were 4.2, 6.0 and 32, respectively. Post-operatively, she had
substantial improvement in her symptoms with neck pain, arm pain and
disability scores of 0.5, 0 and 16, respectively. Fifteen months after her
surgery, she began experiencing severe right upper extremity pain,
numbness, tingling and weakness. An examination identified myelopathic
findings of abnormal gait and clonus and right upper extremity motor and
sensory deficit in a C8 distribution. An MRI scan found a large right C7–T1
disc herniation (see Figure 7). Conservative treatment at that time included
an opioid programme, spinal steroid injections and bracing, which resulted
in some improvement in the weakness of her intrinsic muscles of the right
hand; however, her gait disturbance persisted, as did her sensory deficit.
Due to her continued myelopathic findings and severe pain, the patient diagnosis commonly treated with ACDF. Case 1 is an example of a patient
underwent extension of her ACDF requiring partial plate removal and with stenosis, her long-term five-year follow-up indicating a highly
repeat iliac crest bone grafting with revision of the plate instrumentation satisfactory result. Instrumentation used at the time of ACDF was a ‘static’
(see Figure 8). Post-operatively, the patient did well and considered herself metallic plate. The use of instrumentation leads to higher fusion rates when
to be pain-free, although she would have intermittent numbness and ACDF is performed at more than a single level.
2
Static plates have a higher
tingling in her arms. Since the C7–T1 level may be difficult to visualise on fusion rate than ‘dynamic’ plates and also maintain lordosis.
3
plain radiographs, the patient did have a follow-up high-resolution
computed tomography (CT) scan performed one-year post-operatively, Case 2 is an example of a patient with a disc herniation. The patient had
confirming a solid union from C4 to T1. She returned to work as a mild to moderate symptoms initially, but then suffered an acute
hairdresser, and her self-assessment outcomes scores four years after progression with neurological deficit and disabling symptoms. Patients
revision surgery found all scores improved to zero. of this kind often have the greatest improvement in outcomes scores. In
this one-level case, ACDF may be performed with or without
Discussion instrumentation (plate) with the same fusion rate; however, internal
The first three cases are individuals who represent the three main types of fixation is thought to decrease brace time.
4,5
A recent alternative for
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