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Anterior cervical discectomy and fusion (ACDF) Surgery cost in India

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Anterior cervical discectomy and fusion (ACDF) is a type of neck surgery that involves removing a damaged disc to relieve spinal cord or nerve root pressure and alleviate corresponding pain, weakness, numbness, and tingling. A discectomy is a form of surgical decompression, so the procedure may also be called an anterior cervical decompression.

• ✓Anterior cervical discectomy. The surgery is approached through the anterior, or front, of the cervical spine (neck). The disc is then removed from between two vertebral bones.

• ✓Fusion. A fusion surgery is done at the same time as the discectomy operation in order to stabilize the cervical segment. A fusion involves placing bone graft and/or implants where the disc originally was in order to provide stability and strength to the area.

An ACDF is done with an anterior approach, which means that the surgery is done through the front of the neck as opposed to through the back of the neck. This approach has several typical advantages:

• ✓Direct access to the disc. The anterior approach allows direct visualization of the cervical discs, which are usually involved in causing the stenosis, spinal cord or nerve compression, and symptoms. Removal of the discs results in direct nerve and spinal cord decompression. The anterior approach can provide access to almost the entire cervical spine, from the C2 segment at the top of the neck down to the cervicothoracic junction, called the C7-T1 level, which is where the cervical spine joins with the upper spine (thoracic spine).
• ✓Less postoperative pain. Spine surgeons often prefer this approach because it provides access to the spine through a relatively uncomplicated pathway. The patient tends to have less incisional pain from this approach than from a posterior operation.

After a skin incision is made in the front of the neck, only one thin vestigial muscle needs to be cut, after which anatomic planes can be followed right down to the spine. The limited amount of muscle division or dissection helps to limit postoperative pain following the spine surgery.

You may be a candidate for discectomy if you have:

• ✓Diagnostic tests (MRI, CT, myelogram) show that you have a herniated or degenerative disc
• ✓Significant weakness in your hand or arm
• ✓Arm pain worse than neck pain
• ✓Symptoms that have not improved with physical therapy or medication

ACDF may be helpful in treating the following conditions:

• ✓Bulging and herniated disc: The gel-like material within the disc can bulge or rupture through a weak area in the surrounding wall (annulus). Irritation and swelling occurs when this material squeezes out and painfully presses on a nerve.
• ✓Degenerative disc disease: As discs naturally wear out, bone spurs form and the facet joints inflame. The discs dry out and shrink, losing their flexibility and cushioning properties. The disc spaces get smaller. These changes lead to canal stenosis or disc herniation.

Most herniated discs heal after a few months of nonsurgical treatment. Your doctor may recommend treatment options, but only you can decide whether surgery is right for you. Be sure to consider all the risks and benefits before making your decision. Only 10% of people with herniated disc problems have enough pain after 6 weeks of conservative treatment to consider surgery. Your surgeon will also discuss the risks and benefits of different types of bone graft material. Auto graft is the gold standard for rapid healing and fusion, but the hip incision can be painful and at times lead to complications. Allograft (bone-bank) is more commonly used and has proven to be as effective for routine 1 and 2 level fusions in non-smokers.

• ✓You may be scheduled for pre surgical tests (e.g., blood test, electrocardiogram, chest X-ray) several days before surgery. In the doctor’s office, you will sign consent and other forms so that the surgeon knows your medical history (allergies, medicines/vitamins, bleeding history, anesthesia reactions, previous surgeries).
• ✓Discuss all medications (prescription, over-the-counter, and herbal supplements) you are taking with your doctor. Some medications need to be continued or stopped the day of surgery.
• ✓Stop taking all non-steroidal anti-inflammatory medicines (Naprosyn, Advil, Motrin, Nuprin, Aleve, etc.) and blood thinners (Coumadin, Plavix, etc.) 1 to 2 weeks before surgery as directed by the doctor.
• ✓Additionally, stop smoking, chewing tobacco, and drinking alcohol 1 week before and 2 weeks after surgery because these activities can cause bleeding problems. No food or drink is permitted past midnight the night before surgery.

Smoking

The most important thing you can do to ensure the success of your spinal surgery is quit smoking. This includes cigarettes, cigars, pipes, chewing tobacco, and smokeless tobacco (snuff, dip). Nicotine prevents bone growth and puts you at higher risk for a failed fusion. Patients who smoked had failed fusions in up to 40% of cases, compared to only 8% among non-smokers. Smoking also decreases your blood circulation, resulting in slower wound healing and an increased risk of infection.

There are seven steps to the procedure. The operation generally takes 1 to 3 hours.

Step 1: Prepare the patient
You will lie on your back on the operative table and be given anesthesia. Once asleep, your neck area is cleansed and prepped. If a fusion is planned and your own bone will be used, the hip area is also prepped to obtain a bone graft. If a donor bone will be used, the hip incision is unnecessary.

Step 2:Make an incision
A 2-inch skin incision is made on the right or left side of your neck (Fig. 2). The surgeon makes a tunnel to the spine by moving aside muscles in your neck and retracting the trachea, esophagus, and arteries. Finally, the muscles that support the front of the spine are lifted and held aside so the surgeon can clearly see the bony vertebrae and discs.

Step 3: Locate the damaged disc
With the aid of a fluoroscope (a special X-ray), the surgeon passes a thin needle into the disc to locate the affected vertebra and disc. The vertebrae bones above and below the damaged disc are spread apart with a special retractor.

Step 4: Remove the disc
The outer wall of the disc is cut (Fig. 3). The surgeon removes about 2/3 of your disc using small grasping tools, and then looks through a surgical microscope to remove the rest of the disc. The ligament that runs behind the vertebrae is removed to reach the spinal canal. Any disc material pressing on the spinal nerves is removed.

Step 5: Decompress the nerve
Bone spurs that press on your nerve root is removed. The foramen, through which the spinal nerve exits, is enlarged with a drill. This procedure, is called for aminotomy, gives your nerves more room to exit the spinal canal.

Step 6. Prepare a bone graft fusion
using a drill, the open disc space is prepared on the top and bottom by removing the outer cortical layer of bone to expose the blood-rich cancellous bone inside. This “bed” will hold the bone graft material that you and your surgeon selected:

• ✓Bone graft from your hip. A skin and muscle incision is made over the crest of your hipbone. Next, a chisel is used to cut through the hard outer layer (cortical bone) to the inner layer (cancellous bone). The inner layer contains the bone-growing cells and proteins. The bone graft is then shaped and placed into the “bed” between the vertebrae.
• ✓Bone bank or fusion cage. A cadaver bone graft or bioplastic cage is filled with the leftover bone shavings containing bone-growing cells and proteins. The graft is then tapped into the shelf space.

Schedule a follow-up appointment with your surgeon for 2 weeks after surgery. Recovery time generally lasts 4 to 6 weeks. X-rays may be taken after several weeks to verify that fusion is occurring. The surgeon will decide when to release you back to work at your follow-up visit. A cervical collar or brace is sometimes worn during recovery to provide support and limit motion while your neck heals or fuses. Your doctor may prescribe neck stretches and exercises or physical therapy once your neck has healed.

If you had a bone graft taken from your hip, you may experience pain, soreness, and stiffness at the incision. Get up frequently (every 20 minutes) and move around or walk. Don’t sit or lie down for long periods of time. Recurrences of neck pain are common. The key to avoiding recurrence is prevention:

• ✓Proper lifting techniques
• ✓Good posture during sitting, standing, moving, and sleeping
• ✓Appropriate excercise program
• ✓An ergonomic work area
• ✓Healthy weight and lean body mass
• ✓A positive attitude and relaxation techniques (e.g., stress management)
• ✓No smoking

General complications of any surgery include bleeding, infection, blood clots (deep vein thrombosis), and reactions to anesthesia. If spinal fusion is done at the same time as a discectomy, there is a greater risk of complications. Specific complications related to ACDF may include:

• ✓Hoarseness and swallowing difficulties. In some cases, temporary hoarseness can occur. The recurrent laryngeal nerve, which controls the vocal cords, is affected during surgery. It may take several months for this nerve to recover. In rare cases (less than 1/250) hoarseness and swallowing problems may persist and need further treatment with an ear, nose and throat specialist.
• ✓Vertebrae failing to fuse. There are many reasons why bones do not fuse together. Common ones include smoking, osteoporosis, obesity, and malnutrition. Smoking is by far the greatest factor that can prevent fusion. Nicotine is a toxin that inhibits bone-growing cells. If you continue to smoke after your spinal surgery, you could undermine the fusion process.
• ✓Hardware fracture. Metal screws and plates used to stabilize the spine are called “hardware.” The hardware may move or break before the bones are completely fused. If this occurs, a second surgery may be needed to fix or replace the hardware.
• ✓Bone graft migration. In rare cases (1 to 2%), the bone graft can move from the correct position between the vertebrae soon after surgery. This is more likely to occur if hardware (plates and screws) is not used or if multiple vertebral levels are fused. If this occurs, a second surgery may be necessary.
• ✓Transitional syndrome. Fusion of a spine segment causes extra stress and load to be transferred to the discs and bones above or below the fusion. The added wear and tear can eventually degenerate the adjacent level and cause pain.
• ✓Nerve damage or persistent pain. Any spine surgery comes with the risk of damaging the nerves or spinal cord. Damage can cause numbness or even paralysis. However, the most common cause of persistent pain is nerve damage from the disc herniation itself. Some disc herniations may permanently damage a nerve making it unresponsive to surgery.

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