What is the future of ACDF?

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Anterior cervical discectomy and fusion is considered a "gold standard" in spine surgery, but it will likely be eclipsed by disc replacement.

Six surgeons discuss ACDF's future.

Note: Responses were lightly edited for clarity.

Question: What will ACDF and technology for the procedure be like in five to 10 years?

Joseph Ferguson, MD. MedStar Health (Washington, D.C.): We're seeing a lot of good evidence about cervical disc replacements, and I think we're going to see the evidence continue to expand as people's indications with cervical discs have expanded. With that said, ACDF is still the gold standard. The best surgery spine surgeons do in terms of outcome is probably the elective ACDF. I don't think we're ever going to shift away from it completely. But I do think you're going to start to see more disc replacements substituting it, especially for multiple levels.

Brian Gantwerker, MD. The Craniospinal Center of Los Angeles: In five to 10 years, we will see the development of better and more durable disc arthroplasty. We will always need the option of cervical fusion, without question. The indications for each operation will, I think, remain the same, and probably should remain the same. However, just like in hips and knees, arthroplasty will get better and maybe even supersede ACDF in the future, but not until we can get good long-term outcome data and implants that are even more robust than the best we have today.  

Frank Phillips, MD.  Midwest Orthopaedics at Rush (Chicago): ACDF is a well-evolved procedure with documented excellent outcomes for appropriate indications. As material science continues to advance, we will see cages that are no longer inert spacers but rather actively participate in the fusion process. This will be coupled with advanced biologics that lead to more reliable and rapid fusion or cage bone ingrowth, "welding" the spine together. This will allow patients to more rapidly resume unrestricted activities. 

As total disc replacement has evolved, surgeons are stretching the indications and claiming excellent outcomes, typically with one-day follow up and "peer reviewed" images posted on LinkedIn followed by the echo chamber adulation. Rigorous study is needed to define the place of TDR and ACDF in the spine surgeon's armamentarium.  

Vladimir Sinkov, MD. Sinkov Spine (Las Vegas): In five to 10 years there will be less ACDFs and more disc replacements being performed as the implant design, techniques and clinical data for disc replacement technology continues to evolve and improve. The remaining ACDFs will likely be done with more low-profile and zero-profile implant technology that minimizes soft tissue retraction and post-operative dysphagia.

Timur Urakov, MD. University of Miami (Fla.): ACDF is one of the oldest spinal procedures. Over the past decades it has been optimized across all steps, and it is difficult to imagine any further changes in five to 10 years. There may be further developments in implant materials and biological substitutes to further refine fusion rates. Prevalence of the procedure will decline as arthroplasty becomes a better choice for properly selected patients. Preventative care and research in regenerative medicine may also influence the outlook on ACDF over a longer term. 

Christian Zimmerman, MD. St. Alphonsus Medical Group and SAHS Neuroscience Institute (Boise, Idaho): Current methodologies of decompression and surface area-based fusion techniques will remain. A tried-and-true procedure, well-suited for singular, multilevel and adjacent level disease processes. From the Cloward Technique, the Smith-Robinson Sub axial Approach and whatever the current iteration being employed, this ACDF surgical procedure has stood the test of time.

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