Before Surgery

Workup typically includes a cervical MRI to assess the discs, nerves, and spinal cord, and often CT or flexion-extension X-rays if bone quality, prior fusion, or instability need to be characterized. I review medications that affect bleeding or bone healing, and I ask every patient who smokes to quit or at minimum stop nicotine well before and after surgery — smoking/nicotine is one of the most powerful and most modifiable risk factors for fusion failure. Patients with multiple medical problems may see anesthesia or their primary care provider for medical optimization beforehand.

How the Surgery Is Done

ACDF is performed under general anesthesia and typically takes anywhere from 30 minutes for 1 level to 2 hours for 4 levels. In broad strokes:

1. Approach. A small horizontal incision, usually 1–2 inches, is made along a natural neck crease. I work between the trachea/esophagus and the carotid sheath — a natural anatomic plane — to reach the front of the spine without cutting through muscle.
2. Discectomy. The damaged disc is removed under microscope magnification, along with any bone spurs or disc fragments compressing the nerve root or spinal cord. This is the decompression step, and it’s the part of the operation most directly responsible for relieving arm pain and numbness.
3. Interbody reconstruction. The disc space is prepared and fitted with an interbody spacer packed with bone-graft material, restoring the normal disc height and the natural curve (lordosis) of the neck.
4. Plating. A low-profile anterior plate is secured with screws into the vertebral bodies above and below, holding the segment stable while fusion occurs.
5. Closure. The incision is closed in layers, typically with absorbable sutures and skin glue — there are usually no stitches or staples to remove.

Most single- and two-level ACDF patients go home the same day or after one overnight stay for observation.

The Implants I Use, and Why

Implant selection in ACDF isn’t cosmetic — it affects fusion rates, subsidence, and how easily I can follow healing on X-ray afterward. Here is what I use and the reasoning behind each choice.

Interbody Spacer

DePuy Synthes ACIS™ with PROTI 360° Titanium-Integrated Surface

For patients: The spacer is the small implant that replaces the disc and holds the two vertebrae apart at the correct height. I use a version whose surface is coated in titanium in a way that mimics the texture of natural bone, which gives bone cells a better surface to grow onto and helps the fusion take hold. The center of the implant stays clear on X-ray, so I can still watch the fusion heal over time.

For providers: ACIS is available in a PROTI 360°-coated PEEK construct with titanium integrated across all surfaces, including the endplates, with fortified edges and no exposed corners to reduce delamination risk. The design preserves a PEEK core for radiolucency while presenting a topographically bone-like surface intended to promote osteoblastic attachment; bench testing cited by the manufacturer showed substantially higher early calcium deposition on the PROTI 360° surface versus PEEK or titanium alone. This is in-vitro data has been confirmed by myself over hundreds of cases as I have used ProTI for years. 

Anterior Plate

DePuy Synthes CODA™ Anterior Cervical Plate System

For patients: The plate is a thin titanium bridge, about the thickness of two credit cards, that screws into the bone above and below the disc space to hold everything still while it heals. Because it sits so low against the bone, most patients never feel it, and as an added bonus it doesn’t set off metal detectors!

For providers: CODA has a 1.9–2.1 mm profile and is available in one- to five-level constructs spanning C2–C7, with up to 32° of screw angulation at the plate ends — useful for navigating adjacent hardware, prior fusions, or unusual vertebral body geometry in multilevel or revision cases. The low profile is intended to reduce adjacent-level soft tissue irritation and dysphagia risk relative to bulkier legacy plate designs.

Biologic

OsseoGEN™ Cellular Bone Matrix

For patients: Bone doesn’t fuse just because an implant is present — it needs living cells and growth signals to do the work. I pack the spacer with a bone-graft material that contains all three ingredients bone needs to regenerate: a scaffold for new bone to grow on, growth factors that recruit healing cells, and living bone-forming cells themselves. This avoids the need to take a bone graft from your hip, which was standard decades ago and added a second, often more painful, surgical site.

For providers: OsseoGEN is a growth factor-enriched cellular bone matrix combining an osteoconductive allograft scaffold with osteoinductive growth factors and viable osteogenic cells, positioning it as an autograft alternative without iliac crest donor-site morbidity. It is DMSO-free, which simplifies handling by removing the rinse step required with some competing cellular allografts, and is supplied via open-bore syringe for direct placement into the interbody spacer and along the endplates.

One Treated Level: The Three ComponentsCODA PlateStabilizes the segmentACIS ProTi 360 SpacerRestores disc heightOsseoGENDrives biologic fusion

Recovery: What to Expect

Arm pain and numbness often improve quickly, sometimes within days, because they result from decompressing the nerve, which happens at surgery. Neck stiffness and soreness take longer, and any pre-existing weakness or numbness can take weeks to months to recover as the nerve heals — and occasionally doesn’t fully resolve if compression was longstanding before surgery.

Risks and Complications

ACDF is one of the safer procedures in spine surgery, but it is still surgery, and an honest conversation about risk is part of informed consent. Reported risks include:

• Dysphagia (swallowing difficulty) and hoarseness — the most common issue, related to retraction near the esophagus and recurrent laryngeal nerve; usually temporary, resolving over days to a few weeks
• Nonunion (failed fusion) — more common in smokers, multilevel constructs, and certain metabolic conditions; smoking cessation is the single biggest modifiable factor
• Adjacent segment degeneration — accelerated wear at the disc levels next to a fusion, which can (uncommonly) require future surgery years later
• Hardware-related issues — screw or plate loosening, migration, or, rarely, graft subsidence
• Bleeding, infection, and anesthesia risk — as with any surgery, though infection rates in ACDF are low given the well-vascularized anterior neck
• Nerve or spinal cord injury — rare, but the most serious potential complication of any cervical spine surgery

Published outcomes generally place symptom improvement in the 85–95% range for appropriately selected patients, with durable results reported at ten years and beyond.