ANTERIOR CERVICAL DISCECTOMY AND FUSION (ACDF)
Anterior Cervical Discectomy and Fusion (ACDF) is a surgical procedure that aims to relieve pain, weakness, or numbness caused by a herniated or degenerated cervical disc. The cervical spine consists of seven vertebrae (C1 to C7) in the neck region, and discs are the cushion-like structures located between each vertebra. These discs can become damaged or worn out over time, leading to issues like herniation, compression of spinal nerves, or spinal cord compression.
The ACDF procedure is performed by approaching the cervical spine from the front (anterior) of the neck.
Recovery from ACDF surgery varies from patient to patient but typically takes several weeks to months. During this period, the patient may be required to wear a cervical collar to restrict neck movement and promote healing. Physical therapy is often recommended to help regain strength and flexibility in the neck muscles.
Anesthetic Implications for ACDF
Anesthesia type: General anesthesia with ETT. Partial or total intravenous anesthesia (TIVA) to optimize neuromonitoring
Airway: Endotracheal tube
Preoperative:
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Baseline neurologic assessment of sensory and motor function
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Assess cervical range of motion
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Patients may be difficult to intubate due to the inability to place in the sniffing position
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Intubate with the head in the neutral position
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Consider having a video laryngoscope or fiberoptic bronchoscopy
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Spinal cord trauma may be associated with loss of sympathetic tone, which can cause peripheral vasodilation and bradycardia
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Fractures above C5 may result in quadriplegia and loss of phrenic nerve function
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Manipulation of the head and neck could produce permanent injury
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If an autograft is being utilized, the hip is also prepped
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Patients are often on chronic pain medications
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Find out if the surgeon wants the patient relaxed by neuromuscular blockers
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Shared airway with surgeon
Intraoperative:
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Gel roll is frequently placed under the shoulders (enhances neck extension and exposure)
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Neurologic monitoring may be used during the ACDF
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Somatosensory evoked potentials (SSEPs) monitoring may be used. SSEPs assess the integrity of the posterior spinal cord
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Volatile anesthetics over 0.5 MAC decrease amplitude and increase the latency of SSEP waveforms (false positive)
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Motor evoked potentials (MEPs) monitoring may be used. MEPs assess the integrity of the anterior spinal artery
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MEPs are affected by neuromuscular blocking agents
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The bispectral index (BIS) monitor can be used
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Tongue lacerations from MEPs can occur. Apply tongue protection
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Duration: 1-1.5 hours per level
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Position: Supine with arms tucked
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EBL 50-500 ml
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Fluoroscopy or portable X-ray is used
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Controlled hypotension may be requested to reduce bleeding
Postoperative:
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Extubation/emergence: Avoid coughing and bucking
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Perform neurologic exam
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Recurrent laryngeal nerve injury is associated with stridor and increased risk of aspiration
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Watch for postoperative hematoma and airway compromise
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Cervical collar may be utilized to allow bone graft healing
Complications:
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Acute spinal cord injury
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Esophageal perforation
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Infection
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Bleeding
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Retropharyngeal edema
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Quadriplegia
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Carotid or jugular injury
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Myelopathy
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Nerve injury
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Recurrent laryngeal nerve injury
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Airway edema
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Tracheal laceration
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Pneumothorax
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Chronic pain
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Thrombophlebitis
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Nonunion of the cervical vertebrae
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Venous air embolism
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Dural tear
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Superior vena cava syndrome
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Postoperative dysphagia
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Horner's syndrome
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Bone graft migration
Sources:
Elisha, S. (2010). Case Studies in Nurse Anesthesia.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.