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CERVICAL NERVE ROOT AND/OR SPINAL CORD INJURY DUE TO HERNIATED DISC
AND/OR DEGENERATIVE (OSTEO) ARTHRITIS - PART 2

(A Patient Information Service)

Among the neurological conditions of the cervical spine for which neurosurgical intervention is indicated are those, which do not respond to attempts of conservative treatment. In those cases where a vigorous attempt at conservative treatment has failed, or where the neurological problem has worsened despite conservative treatment or the neurological (or structural spine) problem is so far advanced that further delay will result in serious, permanent neurological deficit, then operative intervention may become the appropriate therapy. The alternatives of any form of manipulation of the neck are seriously contraindicated in patients with neurological involvement already present.

There are, primarily, two surgical avenues to the spinal canal. The older of the two operations is a LAMINECTOMY (removal of part or all of the "lamina" which is the roof of the spinal canal). This technique is excellent for decompressing the spinal canal, particularly when multiple levels of the canal are involved in the disease process that is producing symptoms (Figure 7). For patients who have a tumour in or pressing upon the spinal cord, this has usually been the preferred method to approach and surgically treat these problems. This "traditional" approach is referred to as a "Laminectomy". It is accomplished through a midline incision in the back of the neck. In some cases the operation requires only a unilateral (one sided) approach. That operation is termed a "Hemi-Laminectomy", meaning that the lamina is removed on one side of the vertebra. In the older form of a full Laminectomy operation, the muscles that lie alongside the bone of the spine (paravertebral muscles) must be stripped from the bone (lamina) on both sides (right and left). In the event that this is indicated, the details will be discussed with you.

Minimally Invasive Spine Surgery

We now have an elegant alternative to type of Laminectomy referred to in the above paragraph. Minimally Invasive techniques are now an available option for Cervical Spine surgery in selected patients. This includes conditions such as some Spinal Cord tumours, herniated cervical discs that are laterally (off to one side of the spinal canal or in the neural foramen) positioned or pathologically hypertrophic (enlarged) Cervical Facet joints that are producing significant compression of the underlying nerve root.

One of the significant advantages of Minimally Invasive Spine Surgery is the ability to remove the overlying lamina of the spine without stripping the paravertebral muscles from the spinal bone as was required in the older form of Microsurgical Laminectomy or Laminotomy (limited opening of the lamina). In those instances the operation required a midline incision with resultant stripping of the paravertebral muscles from the bone of the spine on either one or both sides of the spine. The Minimally Invasive Microendoscopic operations are done through a very small vertically oriented incision made just off the midline on the side of the pathology. Instead of stripping muscle from bone, the muscle fibres are separated by the special instrumentation (dilators) designed for these procedures. The operation is conducted through a small tube inserted over these dilators. Tubes of various sizes are available depending on the amount of room that is required to conduct the operation. The smaller tubes are 14 and 16 millimeters in diameter. It is through tubes of this size that a herniated disc that is in a far lateral position of the spinal canal or in the neural foramen can be treated in selected patients. For Spinal Cord tumours, larger tubes such as those of 26 and 28 millimeters are required. One of the major advances in Minimally Invasive technique is the ability to conduct a bilateral (both sides) Decompressive Laminectomy through a unilateral (one sided) approach thus avoiding the need to strip the paraspinal muscles from bone.

Among the disadvantages of this operation done for a herniated disc is that it only permits the surgeon to remove the fragments of disc that are herniated and does not allow for the removal of the degenerative disc remaining in the disc space. The potential consequence to this is the added risk for a "recurrent herniated disc". The operation does allow the surgeon to decompress (relieve pressure) the nerve root at the operative level(s). However, in the event that the pressure is caused by bone spurs lying in front (anterior) of the nerve root or spinal cord, this operation does not permit the removal of the bone spurs themselves either from the area of pressure on the nerve roots or from the more central area of the spinal canal if they are pressing upon the spinal cord. In the event that the major compression of the nerve root is related to a markedly overgrown (hypertrophic) facet joint (which lies just behind the nerve root), then the Minimally Invasive Microendoscopic procedure would be an excellent choice.

Anterior Cervical Operations

An alternative operation, called an Anterior Cervical Discectomy and Fusion, which was developed over 50 years ago, permits access to the spinal canal from the front (anterior) and thus allows direct visualization of the majority of pathological anatomical structures that require surgical attention such as the disc, bone spurs, anterior and posterior longitudinal ligaments, front of the spinal cord and the nerve roots. Access is usually afforded through a relatively short skin incision is placed in the front of the neck, off the midline towards one side (usually the left). (Figures 8 and 9). This operation has been progressively refined to a point where it is a microsurgical procedure utilizing the same elegant Neurosurgical operating microscope and instruments that are utilized in the Minimally Invasive Microendoscopic procedure.

In the majority of patients, the neurological symptoms and signs from herniated cervical disc and/or bone spurs and calcified ligament result from disease that is anatomically in FRONT of the spinal cord. This operative approach allows the surgeon direct access to the disease process without manipulating the spinal cord. This means that the herniated disc material can be directly visualized and removed eliminating the chance for recurrent herniated disc problems from this level. In a similar way, bone spurs arising from the vertebral bodies and/or the calcified Posterior Longitudinal Ligament (the ligament that runs vertically along the back of the vertebral body and frequently is part of the pathological process that compresses the spinal cord) can be entirely removed. It is important to recognize that the Laminectomy approach described elsewhere is not able to address any of these issues directly. That operation only allows the spinal cord to shift backwards away from the spur and/or calcified Posterior Longitudinal Ligament. Unless the actual disease process is dealt with directly, the degenerative process will progress over the subsequent years resulting in a far more complicated clinical problem than was previously encountered.

The primary indications for these operations involve problems of the nervous system. Patient candidates usually already have some form of neurological injury (numbness or sensory impairment, weakness of particular muscles, etc.) These patients usually have some degree of pain, which frequently is quite severe. In some patients the primary indication relates to the significant degree of spinal cord and/or nerve root compression that results from bone spurs and/or pathologically calcified ligaments (Posterior Longitudinal Ligament) adjacent to the spinal cord and/or herniated disc material. The mere presence of bone spurs and/or "bulging" discs in the absence of significant neurological deficit and/or spinal cord compression does not constitute an indication for surgery in our practice.

This operation has proven itself to be highly reliable for relieving pain associated with nerve root compression (which usually diminishes rapidly). Neurological recovery after operation may take a little more time although most patients enjoy early and complete resolution of their deficits. Our experience over the years has shown that many patients note immediate resolution of their motor (muscle weakness) deficits upon awakening from the anaesthetic. Sensory impairments may take a little longer to reverse. As a general rule: Whatever neurological deficit remains one year after operation is likely to be permanent. Nevertheless, despite a technically successful decompression operation it is possible for patients to fail to improve neurologically or even to become worse. Fortunately nerve root and/or spinal cord injury (which could result in increased pain/weakness/numbness or paralysis of extremities and bowel or bladder function) consequent to surgical treatment is exceptionally rare. Each and every operation is associated with some general risks together with some specific risks. These specific risks are related primarily to the disease process and the avenue of approach.

This operation can be carried out in several different ways. Some few remaining surgeons prefer to avoid the "fusion" process (the part of the operation where a piece of bone or other "grafting material" is inserted between the vertebrae where the disc was removed) and suggest that their patients may "fuse" (healing process that results in 2 vertebrae uniting) anyway at a later date without having a "Bone graft" placed between the vertebrae, as is usually done in the Anterior Cervical Fusion.

In evaluating these claims, your surgeon relies on accumulated experience and understanding of the disease process. In this medical controversy, we require the placement of a "graft" (which acts as a "spacer") to re-establish the critical (intervertebral) distance between adjacent vertebrae in a more anatomically correct position and alignment. While there is a small chance that this graft will not "fuse" or the "spacer" will crumble or dislodge itself, these unusual complications rarely result in any problems requiring further surgery. Objective evidence of early bone formation (healed bone from one vertebra to the next) at the operative level is generally seen on routine follow up post-operative x-ray within six weeks to three months after operation. This issue is discussed in more detail in the following paragraphs.

The vertebrae are normally separated by the disc. As degenerative disc disease progresses the vertebrae come closer together. Among the several consequences that result, one is that the canal of bone through which the nerve roots pass becomes narrower. This bone passage (neural foramen) is frequently further compromised by bone spurs. When a nerve is injured, it will swell. If it swells inside a bone canal that is already narrowed, it will suffer further compromise of its blood supply and therefore further injury. The most beneficial surgical treatment results in the successful removal of the disease process that is pressing upon the nerve. Unfortunately the nerve root swelling does not immediately resolve. In placing the intervertebral "spacer", the surgeon is better able to reconstitute the more normal distance between the vertebral bodies and thus a more anatomically correct opening for the nerve root (which seems to need this room now more than ever).

Of the several fusion techniques available, the "Smith-Robinson" technique is the most frequently carried out. In this operation a "wafer" or "wedge" of bone (or other "grafting" material) is placed within the disc space that has been cleansed of all disc material. Another, although much less frequently used, method is the "Cloward" technique. It involves placing a bone dowel between the vertebrae.

There are now several choices regarding the technical method of "grafting" that results in the "fusion" process. Modern technology has permitted far more reliable materials.

The "older" and infrequently used techniques involved the use of Autologous (a patient's own bone) bone grafts. These were usually taken through a small incision below the "bikini line" from the pelvis bone (iliac crest) which does not weaken the pelvis nor interfere with its function. However all patients report significant discomfort from this incision. Frequently they notice that this donor site is more painful than the operative site in the neck. The pain usually diminishes rapidly and within a couple of days is rarely a problem. On very rare occasion there may be a need to take bone from the fibula (the smaller bone on the outside of the lower leg) or from a rib. Your surgeon will discuss the alternatives with you in the unlikely event that they become alternatives that may be indicated in your unique situation.

Another possibility involves the use of "bone bank" bone. There are some significant advantages to this including the absence of a separate incision as is done in harvesting the patient's own bone. On a comparative basis to the autologous bone, bone bank bone may take a little longer to demonstrate the progression towards fusion and may have a slightly higher incidence to failure of fusion (generally considered to be around 2%).

Nowadays, we rarely use any of these types of bone grafts. However, we generally DO USE THE PATIENT'S OWN BONE TO FILL THE SPACERS THAT ARE DISCUSSED BELOW. In these cases the "bone" that we use is harvested from the parts of the vertebra (such as "bone spurs") that we routinely remove at the time of the Anterior Cervical operation. As part of these operations, it is routinely required to drill away a part (the amount varies depending on the extent of the "disease" process) from the vertebra in order to gain access to the pathological condition for which the operation is being done. It is this "autologous" bone that is saved and used to fill the devices that are implanted.

Advanced Materials for Spine Surgery

Some newer materials that can be used as a substitute for these bone grafts include devices and materials that were once considered "space age". In our practice, bio-absorbable synthetic devices have almost entirely replaced bone as a grafting material. In this case the grafting material is used as a scaffold until the patient's own bone replaces it.

We are pleased to also offer the very latest in BIOABSORBABLE CERVICAL SPINE reconstruction SPACERS for those patients requiring an Anterior Cervical Spine Fusion operation. These bioabsorbable "spacers" replace the disc that has been removed. This device maintains the critical distance between each vertebra in order to sustain the "window" (foramen) through which each nerve root exits the spinal canal. These "spacers" have a hollow center that is filled with the patient's own bone that is saved when we remove the patient’s bone spurs at the time of operation.

In our practice, we also use Bone Morphogenic Protein ("BMP") as a bone growth accelerant in the reconstruction portion of an "Anterior Cervical Fusion" as well as in the more extensive "Anterior Corpectomy" operations. We mix the BMP with the patient's own bone (that is saved when we remove the patient's Bone Spurs at the time of operation) to fill the hollow center of the intervertebral "spacer" (or the reconstruction Titanium Cage) that is used to maintain the critical distance between the vertebral bodies ("intervertebral distance") after the disc (or vertebral body) has been removed.

Bone Morphogenic Protein 2 (which is symbolized as BMP2) belongs to a super-family called "transforming growth factor beta" (TGF-beta) and is a protein that induces the formation of bone and cartilage. "RhBMP-2" is the symbol for "recombinant human bone morphogenetic protein". RhBMP-2 has long been recognized for its remarkable potential as a bone graft substitute. In fact, BMPs are the only known proteins capable of inducing new bone formation. The first commercially available BMP ever to exhibit clinically proven osteoinductivity is the INFUSE® Bone Graft (distributed by Medtronic Sofamor-Danek Memphis, Tennessee.)

The use of BMP has considerable advantage in assisting the patient to grow bone faster resulting in earlier and stronger bone union (fusion) and structural stability which is one of the important goals of the operation. The "spacer" will actually be replaced by the patient's own bone after which it disappears through a natural autolytic/hydrolysis process (which turns it into water.) This process is usually complete by 18 months.

In all of our cases of Anterior Cervical fusion, we reinforce the "spacers" with an "Anterior Internal Fixation" device called an Anterior Cervical Spine Plate. The "plate" is designed to reinforce the cervical spine reconstruction (spacer placement), stabilize the repair and maintain the alignment and position of the operated vertebral levels as well as to assist in "load bearing" of the head and neck during the healing phase. The length of the device used in any particular patient depends on the number of disc spaces and vertebrae requiring surgical correction.

There are several choices of materials and devices available to accomplish these goals. We consistently monitor the development of these devices and materials and offer those which, in our professional opinion, offer the optimum advantage for the technical requirements of these procedures. In all of these cases, the plate is "fixed" to the front (anterior) surface of the operated vertebra by specially designed screws that are compatible with the plate system.

Among the most advanced materials is the BIOABSORBABLE ANTERIOR FIXATION PLATE and SCREWS which are now available from several different surgical equipment manufacturers including Inion and Medtronic. These plates and screws are currently ONLY available for one or two level operations since their strength is not adequate for more extensive procedures beyond 2 cervical disk spaces. Nevertheless, they do offer the advantage (for the appropriate patient) for the plate and screw to "disappear" in 18 months through an autolytic/hydrolysis process without having a permanent implant. By that time the bone fusion is expected to have occurred. This plate/screw system is reliable and effective although it is not as robust as the titanium option discussed below. The advantage of the bio-absorbable system is that a "foreign body" (such as the titanium plate which is permanent) is no longer required as a permanent implant. Patients who are to have a one or two level Anterior Cervical Fusion operation now have a choice and may wish to consider discussing this with their surgeon. It is important to recognize that these bioabsorbable alternatives can be used, instead of a Titanium Plate and Screw system, where "strength" is not a major issue such as would be required for a) short, heavy-set necks; b) patients with significant osteopenia or osteoporosis; c) patients who smoke; d) patients in whom extensive resection of one or more vertebrae is required.

For more complex and extensive operations (3 or more levels, "Corpectomy" procedures or where "strength" requirements are an issue), it is important to stabilize the spine with a stronger "internal fixation" device. This is a "permanent" TITANIUM PLATE placed on the front (anterior) aspect of the cervical spine. As mentioned above, the plate is held in position with special fixation screws placed into the cervical vertebrae. We utilize the latest in Aesculap, Inc. (http://www.aesculap.com) technology in the form of their Titanium ABC Plate and screw system and the "Atlantis Translational Plate" from Medtronic Sofamor-Danek (www.medtronic.com) Both of these "plates" are "load sharing" which means that they assist in stabilizing the segments of the spine operated upon but the spine, itself, is the primary weight bearing and stabilizing entity. This "stress" upon bone is the greatest stimulus to new bone formation. A major goal of these operations is the permanent "fusion" of the vertebrae operated upon. "Fusion" means that these cervical spine segments have been permanently united by this bone growth.

The plate and screws are fastened in place AFTER the grafting material (bio-absorbable spacer[s]/bone spacer[s]/titanium cage) are in position. Generally speaking, these devices are permanent and do not usually require later surgical removal.

Cervical Spine "CORPECTOMY"

Cervical Spine operations constitute a significant part of our practice. We specialize in the reconstruction of the cervical spine for complex and extensive problems such as high grade spinal stenosis resulting from calcified posterior longitudinal ligament/large bone spurs/bone tumors/instability. There are critically important cervical spine disease processes that require the complete removal of one or more of the cervical vertebral bodies. This operation, called an "Anterior Corpectomy" permits considerably more direct access to the front of the Spinal Cord compared to the limited exposure offered through the disc space as discussed above in the section relating to Anterior Cervical Fusion. This more extensive Anterior Corpectomy procedure is used when the disease process is beyond the capability offered by an Anterior Cervical Fusion approach (which limits access to a relatively narrow region through the disc space) such as in patients requiring the removal of a more extensively Calcified Posterior Longitudinal Ligament that is compressing the Spinal Cord over a considerable distance and is located directly behind the vertebral body. Other conditions that require the use of an Anterior Corpectomy procedure include fracture, infected, dislocated or compressed vertebral bodies as well as tumors of the vertebra or some spinal cord tumors.

Once the vertebra and disease processes have been removed we must reconstruct the vertebral column with highly advanced and specially engineered devices such as with Medtronic's ( www.medtronic.com) TITANIUM "PYRAMESH" CAGE SYSTEM. We use the patient's own bone harvested from the vertebral bone that we remove in order to fill the cage. Rarely is there any requirement to obtain bone from any other area of the patient nor do we generally need cadaver bone. The remarkable development of Bone Morphogenic Protein (please see the previous explanation) has resulted in earlier, more extensive and stronger bone growth through the cage.

In almost all cases where one or more vertebral bodies must be removed and reconstructed using a titanium cage (or long bone graft), an anterior internal fixation device is used as well. In cases where there is instability of the spine these devices have been invaluable in helping to reestablish stability.

There are similar (Non-absorbable) devices that can be used for internal stabilization utilizing posterior (back of the spine) procedures. They will be discussed on an individual basis when appropriate. Similarly, there are times when "external" stabilization devices may be required such as in the use of a "Halo" fixation system. This is rarely required for the patient with a herniated disc or degenerative arthritis problem. The use of this device is usually for very complex spine reconstruction cases. Cervical collars are not usually required or recommended for one or two level disc operations. In those patients where a major cervical spine reconstruction has been undertaken (such as in cases of Anterior Corpectomy), or where there are technical surgical problems, or in patients with osteoporosis, a rigid collar may be needed for several months to restrict motion until early bone formation is detected by x-ray examination.

Cervical Motion Preservation - The "Artificial Disc"

Cervical Spine motion preservation is the theoretical concept underlying the development of "Cervical Spine Replacement Discs". These devices are, in fact, definitely not "disc" material, but rather are surgical implants made of one or several durable materials such as advanced polymers and/or metallurgical materials.

At the present time, the "best" (or "Gold Standard" treatment) form of surgical therapy for degenerative cervical arthritis (spurs/calcified posterior longitudinal ligament) and/or herniated disc that either alone or in combination result in significant spinal cord or nerve root compression, comprises some form of anterior cervical spine operation for removal of the offending pathology followed by an immobilization (fusion) of the diseased joint(s). One of the theoretical disadvantages of this "fusion" is the transference of "motion" and the forces of that motion to the immediately adjacent joints which may result in an acceleration of progressive degenerative changes (bone spurs) at those adjacent joints. Recent neurosurgical and orthopedic professional publications have paid considerable attention to this issue. While the actual risk, in our considerable experience, is exceptionally low, there is some truth to the concept. The "artificial discs" have been designed to, hopefully, reduce the risk for the progression of spondylosis at the adjacent levels by preserving cervical spine motion.

One of the early studies of long term follow-up for "Artificial Disc Implantation" was initially reported at the American Association of Neurological Surgeons Annual Meeting held in San Francisco on 26 April 2006. The report was based upon a European Multi-center Study that was tabulated in Leuven, Belgium and consisted of 67 patients, some of whom have been monitored for up to 9 years. The authors identified several unanticipated consequences of the "artificial disc" that was used in this study (the "Bryan" - type device.) Whereas it was hoped that progression of spondylosis at the adjacent cervical levels would be markedly reduced, if not aborted entirely, in actual fact there was progression of the spondylosis at the adjacent level(s) in 20 of 38 patients (52.6%). It appears that the study participants, as well as the device designers and manufacturers, have underestimated the likelihood of significant progression of spondylosis at the operated level as well as impressive progression of paravertebral calcification (calcification in the "lateral longitudinal ligaments" and the "uncovertebral joints" that are positioned on either side of each vertebra) in 22.4% of these patients. In fact, once one understands the pathological anatomy coupled with the "preservation of motion", it should be clear that there will be "progression" of the disease process since it is the result of "motion". Therefore if a patient already has degenerative arthritis at the "adjacent level(s)", one would expect the natural progression of that disease whether or not motion is "preserved" at the operated level. In a similar way, if there is any arthritis remaining at the operated level (such as posterior spurs or hypertrophic uncovertebral joints) then the "preservation of motion" will undoubtedly result in progression of that disease. This "progression" is a direct consequence to the continuation of motion at that joint.

There are certain important issues that these systems can theoretically address. In our opinion these devices will probably be best used for patients who are undergoing an Anterior Cervical Discectomy for a Herniated Intervertebral Disc and DO NOT HAVE significant bone spurs at that operative level. For other patients, the "preservation" of motion at the operated disc space may actually result in more extensive and more rapid deterioration at the operated joint as well as the adjacent joint space.

Needless to say, this is a developing field of neurosurgical interest that is under considerable scrutiny by surgeons, manufacturers as well as patients. We continue to monitor these developments and will report our findings as we determine to be appropriate. For additional information, please consult that information on our website or contact our office.

The First Cervical Arthroplasty Device to Receive FDA Approval

The PRESTIGE® Cervical "Disc" was approved by the FDA for safety and effectiveness in July 2007. While many factors contribute to the longevity of an "artificial disc", the PRESTIGE® Cervical "Disc" has undergone significant evaluation to verify the safety and adequate durability of the device. The design has undergone over 10 years of testing. It is available in a variety of sizes that allow surgeons to closely match a patient's anatomy.

The PRESTIGE® Cervical "Disc" (a stainless steel two-piece ball-and-trough artificial joint) is designed to replace a diseased or damaged disc and maintain joint motion in patients with Radiculopathy and Myelopathy related to Degenerative Disc Disease (DDD) and/or Herniated Intervertebral Disc (HNP) in the C3-C7 levels of the Cervical Spine. This represents an alternative to the more traditional Anterior Cervical Fusion (ACF) surgery. Each of two-piece stainless steel components are secured to the Vertebral Bodies via a flange and screw locking mechanism. A round "ball" located on the superior (upper) component sits within an elongated cavity, or "trough" located on the inferior (lower) component to create a unique ball-and-trough articulation. The PRESTIGE® Cervical "Disc" was designed to allow for the "normal" motions of a natural intervertebral disc: flexion, extension, side bending and rotation.

These patients usually experience neck and/or arm pain; weakness; tingling and/or numbness. The indications for surgical intervention dictate that the patient experience symptoms and neurological signs of Spinal Cord and/or Nerve root compression from any of the following, either alone or in combination: Bone Spurs (Spondylosis); Herniated Disc; calcified Posterior Longitudinal Ligament; at the anatomical level(s) compatible with the demonstrated Neurological Deficit(s).

The PRESTIGE® Cervical "Disc" is not indicated for patients with any of the following conditions:

  • Infection
  • Local inflammation
  • Segmental instability
  • Morbid obesity
  • Pregnancy
  • Mental illness or incompetency
  • Suspected or documented metal allergy or intolerance
  • Rapid joint disease, bone absorption, osteopenia or osteoporosis
  • A known hereditary or acquired bone friability or calcification problem
  • Remaining general skeletal growth (pediatric)
  • Severe osteomalacia, or metabolic bone disease
  • Disease or surgical problem that would preclude the potential benefit of spinal implant surgery, such as tumors or congenital abnormalities, local operating site fracture, elevated sedimentation rate, or marked left shift in the WBC differential count
  • Inadequate tissue coverage over the operative site
  • Any condition not described in the indications
  • Unwillingness to cooperate with postoperative instructions

The PRESTIGE® Cervical "Disc": Potential Benefits

Your doctor may recommend surgery if non-surgical treatment fails or when the extent of Spinal Cord and/or Nerve Root compression due to the demonstrated structural/anatomical problem(s) is considered to be quite significant.

Traditionally, an Anterior Cervical Fusion (ACF) has been the "gold standard" for surgically treating DDD/HNP in the Cervical Spine. Using "Spacers" (or "bone" grafts) and instrumentation such as metal plates and screws, this procedure "fuses" (creates a bond between) two or more adjacent vertebrae, ideally stabilizing the segment and providing relief of the Spinal Cord/Nerve root compression. Countless tens of thousands of patients have achieved excellent results with ACF; however, a potential disadvantage associated with any Spinal Fusion is the loss of motion and flexibility in the treated vertebral segment. The PRESTIGE® Cervical "Disc" offers these patients an alternative to ACF. However, this particular device CAN ONLY BE USED FOR A SINGLE LEVEL in the Cervical Spine.

Operative Risks to Anterior Cervical Spine Operations

Any time an operation is carried out there is an element of risk to life. Fortunately for all of us, modern anesthetic techniques have reduced these risks to a tiny fraction. It is our philosophy that surgical treatment should not be undertaken unless and until there are very specific medical indications. The anesthesiologist will discuss the matters relating to the anesthetic and will be pleased to answer any questions that you may have relating to anesthesia.

In the event that you are to undergo an Anterior Cervical procedure such as a fusion, arthroplasty or corpectomy, you should be aware of the risks related to this surgery. It is comforting to know that the complication rates and failure rates are extremely low.

Any anatomical structures that are in the operative area are at some potential risk to injury. Blood vessels supplying blood to brain (carotid and vertebral arteries), if injured, could result in a severe stroke or hemorrhage. The esophagus (gullet) could be inadvertently injured, causing a leak of food. This would require further surgery for repair. The nerve supplying the vocal cords (called the RECURRENT LARYNGEAL NERVE) runs a course adjacent to the operative area and is at some risk (less than 2%) to injury. This could result in diminished loudness to the voice. In the rare instance where this occurs, it is usually temporary and recovery would be anticipated within 3 weeks to 3 months. Injuries to the trachea (windpipe) are extremely rare. This operation is carried out directly over the spinal cord, which is protected by a very tough covering (the DURA MATER). Despite the fact that the operation is carried out using a neurosurgical microscope, an inadvertent injury to the DURA MATER, SPINAL CORD or nerves could occur. Cerebrospinal fluid (CSF) bathes the spinal cord. If an injury to the Dura Mater occurs, it would probably be recognized and repaired immediately. However, if this persists or occurs post-operatively resulting in a "leak" of cerebrospinal fluid (CSF), this could necessitate a subsequent operation to repair this tear. Cerebrospinal fluid leakage, hemorrhage and infection are very rare complications.

In those patients where surgical implants have been used, (Stainless Steel Arthroplasty/Titanium Pyramesh Cage/ Titanium Plate & Screws, bioabsorbable spacers, plate & screws/ "artificial discs" or bone grafts) it is possible that these materials could structurally fail or be dislodged. This could lead to substantial Cervical Spine instability and/or Spinal Cord and Nerve Root compression probably necessitating another operation. Fortunately these are exceptionally rare occurrences.

Swallowing may also be uncomfortable in the early postoperative hours or days. Foods such as gelatin, custard, yogurt and ice cream may be easier to swallow in the early postoperative period. We recommend avoiding items such as toast, crisp bacon, lumps of firm food, etc. This swallowing difficulty in the early post-operative period is usually the result of some local tissue swelling in the operative site. Rarely is this ever a serious problem or one that is due to a blood clot. Sore throat and swallowing usually improve within a few days. Other potential complications associated with any type of surgery include: Allergic reaction to the implant material; Local and/or systemic infection and Pain.

Post-operative care

(Please consult our website and/or our Post-operative Cervical Spine Instruction sheet for further information.)

Immediately after the operation is completed, the patient is transferred to the Recovery Room where the usual length of stay here is about 1 hour. Following this, patients are returned to their hospital room and can receive their family and friends. Most patients are mobilized out of bed within 4 hours after operation. Early ambulation is important for a smooth, rapid recovery.

Many patients can be discharged from hospital on the same day of surgery while others may remain overnight. Rarely do patients require longer stay in hospital.

The sutures in the neck (and donor site, in the unusual event that this is used) incision usually are "hidden" and do not need to be removed. In this case there will also be a series of special paper strips ("steri-strips") overlying the incision. These are used to "remind" the wound edges to stay together. Do not remove these "steri-strips" until your surgeon has inspected the incision(s) which usually occurs between 10 and 14 days post-operatively. Patients who return to their out-of-state (or country) homes will be given specific instructions regarding management of the incision and methods for follow-up. Anterior Cervical operated patients may shower on the 4th post-operative day. Minimally Invasive operated patients may shower the same day of surgery.

Ambulation outside the house is the major form of activity, beginning with short distances and progressively increasing the pace and distance. We recommend that you walk with someone. For most adults we suggest walking 1 mile/day at a point 1 month postoperatively and 2 to 4 miles/day at a point 2 months postoperatively. Avoid any activities involving bending, lifting, pushing, pulling, or stooping. Lifting should be restricted to that which you can lift easily with one arm. DO NOT LIFT WITH TWO ARMS. Sedentary (desk bound) work activities are usually well tolerated, although your neck will be "stiff" until tissues are healed. Despite the "fusion", most patients ultimately notice a normal range of motion of the neck. The remaining "unfused" joints at other levels seem to accommodate to the difference.

Patients undergoing Cervical Arthroplasty are encouraged to move their neck in any way that is comfortable. DO NOT FORCE EXTREME RANGES OF MOTION.

It is important for ALL POST-OPERATIVE ANTERIROR CERVICAL patients to AVOID pushing their heads firmly backwards when lying in bed. In order to change positions while lying in bed, please only do so when lying on your side.

Please do not hesitate to let us know if you have any questions or comments. Anatomical diagrams and models are available to assist you in understanding the anatomy of the area involved.


DISCLAIMER: Every effort has been made by the author (s) to provide accurate and up-to-date information. However, the medical knowledge base is dynamic and errors can occur. By using the information contained herein, the viewer willingly assumes all risks in connection with such use. Neither the author nor Neurosurgical Consultants, p.a. shall be held responsible for errors, omissions in information herein nor liable for any special, consequential, or exemplary damages resulting, in whole or in part, from any viewer(s)' use of or reliance upon, this material.

CLINICAL DISCLAIMER: Clinical information is provided for educational purposes and not as a medical or professional service. Person(s) who are not medical professionals should have clinical information reviewed and interpreted or applied only by the appropriate health professional(s).

OFF-LABEL DRUG USE: The off-label use of FDA-approved drugs is not regulated, but it is entirely legal in the United States as well as many other countries. The FDA does not regulate the practice of medicine. This means that once the FDA approves a treatment, licensed physicians can prescribe it for any purpose they consider medically appropriate. Off-label use can vary greatly from one doctor to another, and depends on the doctor's preferences, knowledge, and past patient experiences. The medical literature reports clinical trials, including those that are not part of the FDA approval process. This is the main source of off-label use information, but treatment guidelines may also offer options that include off-label use. Treatment guidelines are based on information from medical literature, including clinical trials, and explain recommended ways of treating a particular illness. Lack of information on off-label drug use and outcomes may put patients at a higher risk for medication errors and unwanted drug reactions.


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This page last edited on 2/20

All content ©2016 by Neurosurgical Consultants, P.A.
Author, Martin L. Lazar, MD, FACS
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