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Anterior Cervical Discectomy

Background

Anterior cervical discectomy (ACD) was described in the mid-20th century as a treatment for lateral cervical disc syndrome.
This procedure involved removing the symptomatic disc from an anterior approach without placement of a bone graft. Early studies demonstrated fusion rates that were similar to those of procedures using bone graft.
Multiple larger studies have also shown the ACD procedure to be safe and effective.

With the advent of ACD, anterior cervical discectomy and fusion (ACDF) techniques were simultaneously and independently popularized by Cloward
and Smith and Robinson.
ACDF similarly involves removing the symptomatic cervical disc with an added step of placing bone graft to encourage bony fusion of the upper and lower vertebral body. This added step has been argued to further encourage cervical fusion to maximize stability and maintain disc space height to decrease the likelihood of foraminal stenosis.
However, placement of a bone graft also introduces potential complications of graft dislodgement and failure, as well as donor-site complications if autograft is used. Nonetheless, the ACDF technique has been found to have excellent long-term clinical outcomes.

The anterior cervical discectomy and fusion with instrumentation (ACDFI) technique involves the additional stabilization of the cervical spine with instrumentation. Early instrumentation involved wiring techniques. This was largely modified to cervical plate technology after their introduction and application in the 1980s.
Design has subsequently improved to now include constrained, nonconstrained, rotational, rigid, and dynamic plate subtypes
. Argued benefits of plate instrumentation include reduced graft dislodgements, increased fusion rates, and decreased foraminal stenosis. However, as with the introduction of bone graft, the additional placement of hardware introduces hardware-related complications.

Since their introductions, heated debates have compared ACD, ACDF, and ACDFI. Prospective randomized controlled trials have been performed that demonstrate similar clinical outcomes between the 3 groups, with a decreased rate of cervical fusion and increased incidence of kyphosis in the ACD group.
Guidelines were also published in 2009.
Proponents and detractors for these different procedures can be found throughout the scientific and surgical community.

The purpose of this article is not to compare and contrast these different surgical techniques or plate technologies but to highlight the role of these 3 procedures for treatment of cervical spine disease.

Key considerations

As mentioned above, ACD, ACDF, and ACDFI are different but very similar techniques for the surgical treatment of cervical spine disease. This article discusses the differences between these techniques.

When referring to the ACDFI technique, various plate technologies exist. These can be roughly categorized as rigid versus dynamic versus rotational, nonconstrained versus constrained, and rotational plating systems. Recent biodegradable and single-screw-per-vertebral body systems have also been introduced. The nuances of these plating systems are not discussed in this article.

When referring to the bone graft techniques, namely ACDF and ACDFI, surgical choices of using autograft and allograft exist. The differences between these types of bone graft are not discussed.

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