Two or three cuts of about a centimeter, a camera inside the joint and fine instruments let surgeons repair torn ligaments, cartilage and unstable shoulders with less pain than open surgery. This guide covers the knee, shoulder, hip, ankle, wrist and elbow, where the randomized trials show arthroscopy helps and where they show it does not, how the operation is done, the risks, the recovery and how long to stay in Istanbul.
About This Department
Orthopedics
The disc comes out from the front. The nerve and the cord go free.
In a multicenter study of 278 patients with a squeezed spinal cord in the neck, function and quality of life improved one year after decompression in mild, moderate and severe cases alike.
3 to 5 cm
Length of the cut in a skin crease at the front of the neck
87%
Felt better at one year after ACDF with physiotherapy, against 62% with physiotherapy alone
2 to 3 days
Hospital stay in published Istanbul ACDF packages
Free
Review of your MRI before you book
Free consultation
The review costs nothing and carries no obligation. Send your neck MRI, any X-rays and a short description of your arm or hand symptoms, and our orthopedic spine team will tell you whether surgery is the right step now, how many levels are involved, and how long to plan for. A coordinator replies in your own language.
Pain shoots from the neck down one arm, the fingers tingle or go numb, a grip has weakened, or hands have become clumsy and walking unsteady, and an MRI shows a disc or bone spur pressing on a nerve root or on the spinal cord in the neck. Anterior cervical discectomy and fusion, known as ACDF, removes that disc through a small cut at the front of the neck, frees the nerve or cord, and fills the space with a spacer so the two vertebrae grow together into one. Below you will find what the operation treats, when physiotherapy should come first and when surgery should not wait, how it is done, what fusion means for the levels above and below, the risks, the recovery, how long to stay in Istanbul, and the follow-up at home.
What ACDF treats
Between each pair of neck vertebrae sits a disc, a cushion with a tough outer ring and a soft center. With age the discs dry out and flatten, the joints at the back thicken, and bone spurs grow along the edges, while in younger people a disc can bulge or rupture suddenly. Either way, the space for the nerve roots and the spinal cord narrows. When a nerve root is squeezed, the result is radiculopathy, felt as pain, tingling, numbness or weakness running down one arm in a pattern that tells the surgeon which level is involved. When the cord itself is squeezed, the result is myelopathy. It creeps in. Fingers fumble with buttons, handwriting changes, objects slip from the hand and balance falters, often with little pain at all, which is why myelopathy is missed for months. Compression of the cord can also follow a fall or a minor injury in a neck that was already narrow, and the symptoms then appear suddenly. The surgeon matches the symptoms, the examination and the MRI before recommending any operation, because worn discs show up on the scans of many people who have no symptoms at all.
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Problems treated with ACDF
Problem
Main symptoms
Usual first step
Disc herniation with radiculopathy
Arm pain, tingling, weakness in one arm
Physiotherapy and pain relief for six to twelve weeks
Bone spurs narrowing the nerve exit
Arm pain that comes and goes, worse when looking up
Physiotherapy, sometimes an injection
Cervical myelopathy
Clumsy hands, numb fingers, unsteady walking
Surgery in most moderate and severe cases
Instability or injury
Neck pain with nerve or cord symptoms
Surgery when the spine is unstable
How the arm pattern points to the level
Pain into the thumb side of the hand often comes from the disc between the fifth and sixth vertebrae, into the middle finger from the level below, and weakness of particular muscles narrows it further. The MRI confirms what the examination suggests.
Signs that need a spine specialist soon include
weakness in the arm or hand that is getting worse,
clumsy hands or trouble with buttons and writing,
a new unsteadiness when walking,
and changes in bladder control.
When surgery is the right step
Why a pinched nerve gets time first
A herniated disc often shrinks on its own over weeks as the body reabsorbs the soft material, and the inflammation around the nerve settles. Physiotherapy, posture work, pain relief and sometimes a steroid injection bridge that time.
On a phone, slide the table sideways to read every column.
Pinched nerve or squeezed cord
Feature
Radiculopathy
Myelopathy
What is compressed
A nerve root
The spinal cord
Main symptoms
Pain and tingling down one arm
Clumsy hands, unsteady walking, often little pain
Natural course
Improves in many patients within months
Tends to worsen slowly
Timing of surgery
After a trial of physiotherapy, unless weakness worsens
Soon after diagnosis in moderate and severe cases
Arm pain from a pinched nerve
Most arm pain from a pinched nerve settles without surgery. In a Swedish trial of 63 patients with cervical radiculopathy, ACDF plus physiotherapy was compared with the same physiotherapy alone, and at one year 87 percent of the surgical group rated themselves better or much better against 62 percent of the physiotherapy group, a gap that narrowed to 81 against 69 percent at two years. Neck pain improved more with surgery. Arm pain and disability scores improved in both groups, and the authors concluded that structured physiotherapy should be tried first.
A squeezed spinal cord
Myelopathy behaves differently, because a compressed cord tends to worsen over time and lost function may not fully return. Among 278 patients with cervical myelopathy treated at twelve North American centers, function, disability and quality-of-life scores all improved significantly one year after decompression, in mild, moderate and severe cases alike.
1
Examination
Reflexes, hand function, balance and gait show how much the cord is affected.
2
MRI
Shows where the cord is squeezed and whether its signal has changed.
3
Nerve tests where needed
Separate cord compression from nerve problems in the arm, such as carpal tunnel syndrome.
For a nerve, patience first. For the cord, decompression sooner.
Before surgery, plan to
stop smoking and nicotine products,
pause blood thinners as your surgeon advises,
and bring all neck MRI and X-ray images.
Signs it may be time
Arm pain or weakness that persists after six to twelve weeks of physiotherapy, weakness that is getting worse, myelopathy, or an MRI that matches the symptoms at one or two levels.
Talk to us first
Neck pain alone without arm or cord symptoms, findings on MRI that do not match the symptoms, smoking that cannot be stopped, or a medical condition that makes general anesthesia unsafe.
How ACDF is done
The approach goes through the front. A cut of three to five centimeters, usually in a natural skin crease on one side of the neck, lets the surgeon move the windpipe, esophagus and the large vessels gently aside without cutting muscle, and reach the front of the spine directly. Under a microscope, the damaged disc and any bone spurs are removed until the nerve roots and the cord are free.
Why operate from the front
The disc and most bone spurs lie in front of the cord, so the front approach reaches them directly without moving the cord. It also passes between natural layers of the neck, which is why pain afterward is usually modest.
1
Anesthesia and position
General anesthesia, lying on your back. An X-ray confirms the level.
2
Approach
A small cut in a skin crease and a natural plane between the structures of the neck.
3
Discectomy
The disc and bone spurs are removed under the microscope, freeing the nerves and cord.
4
Fusion
A spacer, or cage, filled with bone graft takes the disc's place, often held with a small plate and screws.
5
Closure
The cut is closed with dissolving stitches under the skin.
Fusion or artificial disc
For some patients with one or two affected levels and healthy joints at the back of the spine, the disc can be replaced with an artificial disc that keeps motion instead of fusing the level. Your surgeon explains which suits your neck after reviewing the MRI and X-rays.
The levels above and below
A fused level no longer moves, so the discs next to it share a little more of the load.
Not every change on a later scan causes symptoms
Wear at the next level shows up on X-rays in many patients. Only some develop new arm pain or cord symptoms, and the figures below count only those.
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New symptoms at a level next to an anterior cervical fusion
Measure
Finding in 374 patients followed for up to 21 years
Yearly rate
2.9 percent per year during the first ten years
Within ten years
25.6 percent predicted to develop new symptoms at an adjacent level
Levels most at risk
Between the fifth, sixth and seventh cervical vertebrae
Needing another operation
More than two thirds of those with new symptoms
What this means for you
Wear at the neighboring levels largely reflects the same aging that caused the first problem. Surgeons plan to include every level that is causing symptoms, and a healthy weight, good posture and regular neck exercises protect the remaining discs.
Risks and how they are managed
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Swallowing difficulty after anterior cervical surgery in 249 patients
Time after surgery
Patients with any difficulty
One month
50.2 percent
Two months
32.2 percent
Six months
17.8 percent
One year
12.5 percent
Who has more swallowing trouble
In that study, women had a higher risk at six months, and surgery on several levels raised the risk in the first two months.
Difficulty swallowing
Common at first and mild in most. Only 4.8 percent had moderate or severe symptoms at six months. Soft food and patience help most.
Hoarse voice
From stretching of the nerve to the voice box, usually temporary. Persistent hoarseness was seen in 1.3 percent at one year in the same study.
Failure to fuse
More likely in smokers and in fusions of several levels, sometimes needing a second operation.
Nerve or cord injury, leak of spinal fluid, bleeding
Rare. Monitoring of nerve signals during surgery is used for cord compression.
The recovery
First days
A sore throat, mild trouble swallowing and some neck stiffness are expected and ease within days to weeks.
Arm pain goes first, numbness and weakness follow more slowly.
Arm pain can ease as soon as you wake up. Numbness and weakness recover more slowly, over weeks to months, and a cord that was squeezed for a long time may keep some stiffness or clumsiness even after a good decompression, which is one reason surgeons do not like to wait too long with myelopathy. You walk the same evening and go home after one or two nights, with a sore throat and some neck stiffness. A soft collar is used for comfort by some surgeons. Desk work resumes in two to four weeks. Driving returns once you can turn your head freely and are off strong painkillers, and lifting, contact sports and heavy work wait until X-rays show the fusion forming, around three months, while daily walks that lengthen each week, gentle shoulder rolls and a physiotherapy program for the neck and upper back start from the first weeks. Nicotine in any form slows bone healing. Sleep on your back or side with a supportive pillow.
How long to stay in Istanbul
Plan for seven to ten days.
Published Istanbul ACDF packages list two to three days in hospital and include preoperative and blood tests, an MRI, consultations with a neurosurgeon and an anesthesiologist, language assistance, meals and transfers, while one recommends a considerably longer stay in Turkey. A wound check and a first X-ray a week after surgery allow a confident flight. Fitness to fly is confirmed at the final visit, and a neck pillow, an aisle seat and regular walks make the flight easier.
What decides the cost
The number of levels, the cage, plate and graft, nerve monitoring, nights in hospital and imaging set most of the figure.
A quote you can compare names the levels and the implants, and that figure comes only after a spine surgeon reviews your MRI, X-rays and examination findings. The review costs nothing.
Arranging the trip
Your MRI images and a short note on your symptoms, sent on WhatsApp, are all the review needs to begin, and the coordinator who replies stays in touch from the first message through the follow-up after you return. Conversations happen in English, Arabic, French, Russian, Serbian, Romanian or Spanish, and interpreters cover any other language. A family member can stay the nights with you on the companion bed. The international office books the hotel, sends the visa invitation letter ten days before travel and arranges transfers, and halal, vegetarian and diabetic menus, a prayer room and a female physician on request complete the stay.
Once you are back home
X-rays at six weeks, three months and a year show the fusion, and your images can be sent through the coordinator for the Istanbul team to review.
Swelling of the neck with difficulty breathing, worsening difficulty swallowing, fever, a leaking wound, or new weakness or numbness in the arms or legs. Each needs a doctor the same day.
ACDF FAQ
Is ACDF a major operation?
It is done under general anesthesia through a small cut at the front of the neck, and most patients go home after one or two nights.
How long does the fusion take to heal?
Bone bridges the level over about three months, and fusion is usually solid by a year.
Will I lose neck movement?
Fusing one or two levels changes neck movement very little in daily life.
Should I try physiotherapy first?
For arm pain from a pinched nerve without worsening weakness, yes. Myelopathy usually calls for earlier surgery.
Will swallowing be difficult afterward?
Often for a few weeks. In one study, half of patients noticed it at one month and 12.5 percent at one year.
Can a family member stay with me?
Yes. One relative stays overnight on the companion bed in your room, and the international office books a hotel for others traveling with you.
References
Engquist M, Löfgren H, Öberg B, et al. Surgery versus nonsurgical treatment of cervical radiculopathy. A prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine. 2013;38(20):1715-1722.
Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy. Results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013;95(18):1651-1658.
Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman HH. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am. 1999;81(4):519-528.
Bazaz R, Lee MJ, Yoo JU. Incidence of dysphagia after anterior cervical spine surgery. A prospective study. Spine. 2002;27(22):2453-2458.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Assistant Professor Şafak SAYAR, Orthopedics and Traumatology.
