Cervical spine surgery is generally performed on an elective basis to treat either:
Nerve/spinal cord impingement (decompression surgery)
Spinal instability (fusion surgery).
The two procedures are often combined, as a decompression may de-stabilize the spine and create the need for a fusion to add stability. Spinal instrumentation (such as a small plate) can also be used to help add stability to the spinal construct.
Cervical Spine Surgery Approaches
The cervical spine can either be approached from the front (anterior approach) or from the back (posterior approach). In general, where possible, most surgeons favor an anterior approach for most conditions.
An anterior approach results in less disruption of the normal musculature and is also easier to maintain the normal alignment of the spine. For example, many degenerative conditions of the spine cause a loss of the normal lordosis (gentle curvature of the spine); however, by opening up the front of the spine, this lordosis can be reestablished.
With that said, there are some conditions that do require a posterior approach or a combined anterior/posterior approach. The various approaches adopted by Mr Torrie are outlined below:
The standard surgical procedure for a cervical disc replacement requires an anterior approach (from the front) to the cervical spine. This surgical approach is the same as that used for an anterior cervical discectomy and fusion (ACDF) operation.
The cervical ADR surgery will typically include the following:
- An incision is made in the front of the neck.
- The affected disc is completely removed, as are any disc fragments or osteophytes (bone spurs) that are pressing on the nerve or spinal cord.
- The disc space is distracted (jacked up) to its prior, normal disc height to help decompress (relieve pressure) on the surrounding nerves.
- Restoring the original disc height is important; when a disc becomes worn out, it will typically shrink in height, which can contribute to the pinching of the nerves in the neck.
- Using X-rays or fluoroscopy as guidance, the artificial disc device is implanted into the prepared disc space.
- Postoperatively, the patient typically can go home within 24 hours with minimal activity limitations.
Potential Risks and Complications
The potential complications of an artificial disc are in general similar to an anterior cervical discectomy and fusion (ACDF) and may include:
- Blood loss
- Nerve injury or paralysis
- Failure to relieve the patient’s pain and symptoms
- Need for further surgery
- Reactions to the anesthesia
- Spinal fluid leak
- Voice change, difficulty swallowing, difficulty breathing
While these complications can be severe, they are rare occurrences.
Anterior cervical discectomy and fusion (ACDF) is a surgical procedure to treat nerve root or spinal cord compression by decompressing the spinal cord and nerve roots of the cervical spine with a discectomy in order to stabilize the corresponding vertebrae. This procedure is used when other non-surgical treatments have failed.
The neurosurgeon or orthopedic surgeon enters the space between two discs through a small incision in front (= anterior) of and at the right or left side of the neck. The disc is completely removed, as well as arthritic bone spurs. The disc material, pressing on the spinal nerve or spinal cord, is then completely removed. The intervertebral foramen, the bone channel through which the spinal nerve runs, is then enlarged with a drill giving the nerve more room to exit the spinal canal.
To prevent the vertebrae from collapsing and to increase stability, the open space is often filled with a graft. That can be a bone graft, taken from the pelvis or cadaveric bone; or an artificial implant. The slow process of the bone graft joining the vertebrae together is called “fusion”. Sometimes a titanium plate is screwed on the vertebrae or screws are used between the vertebrae to increase stability during fusion, especially when there is more than one disc involved.
The surgery requires a short stay in the clinic (1 to 3 days) and a gradual recovery between 1 and 6 weeks. However, the technology has advanced and it can be performed by ‘Endoscopic Micro Discectomy” with the patient able to continue their normal life in two days. The patient may be advised to wear a neck brace or collar (for up to 8 weeks) that serves to ensure proper spinal alignment. Wearing the brace heightens one’s awareness of posture and positioning and helps prevent movements (e.g., sudden and/or excessive bending or twisting of the neck) that may aggravate or slow down the healing process. It is especially advisable to wear a protective neck brace when traveling (e.g., by car), sleeping, showering, or any other activities in which the patient may not be able to be ensure proper spinal alignment. In addition, physical therapy and related healing modalities (e.g., massage, acupuncture) may be recommended in order to promote proper healing, as well as to strengthen the surrounding muscles that can take over the neck brace’s ‘job’ of ensuring proper spinal alignment when the patient starts (around 4 to 6 weeks after surgery) to wean off the neck brace.
The procedure is performed in the back of the neck, which means that you will be lying face down on the operating table. You will be under general anesthesia so that you will feel nothing during the procedure. The spinal surgeon will make a small 1 to 2 inch skin incision and with the help of magnification, he/she will dissect away soft tissue on the side of the compression. Precision instruments are used to carefully remove a small amount of bone which serves as the outer wall of the foramen. Once the foramen is opened, the nerve root can be seen. In cases of compression due to disc material, the nerve root is gently lifted and the disc material is removed. The wound is then closed, and the surgeon may provide you with a soft collar. A variation of this technique is a truly minimally invasive procedure where the surgeon may use an even smaller skin incision and use a tubular retractor to access your spine. Regardless of which approach, standard skin incision or with minimally invasive tubes, posterior cervical foraminotomy provides relief of nerve root compression with minimal bone removal. Symptomatic relief is seen in 85- 90% of cases. Some patients may require a short course of post-operative physical therapy. Risks of this procedure are uncommon but they include: bleeding, infection, neck stiffness, repeat disc herniation, incomplete relief of symptoms, damage to nerve root or spinal cord, or problems with anesthesia.
Cervical laminoplasty is a surgical technique that removes pressure from the spinal cord in the neck. Pressure on the spinal cord can be due to various causes including degenerative changes, arthritis, bone spurs, disc herniations, OPLL, tumors, or fractures. Frequently this spinal cord pressure, called spinal stenosis, can occur at multiple levels of the cervical spine at the same time. If this pressure is severe enough, symptoms called myelopathy can develop. Laminoplasty may be an excellent option to remove the pressure, allow the spinal cord to heal, and reverse the symptoms.
Who needs Cervical Laminoplasty?
Patients with spinal cord compression and myelopathy would likely benefit from evaluation by a spinal surgeon. Patients with myelopathy can have various symptoms including numbness, pain, or weakness in the arms or hands, difficulty using their hands, and balance problems. Occasionally, myelopathy can progress to a point where patients have extreme difficulty walking or using their hand for everyday tasks. A full physical examination including neurologic exam would then be performed. Together, the history and physical provide your surgeon important information regarding the severity of your spinal disease. Your surgeon may also order specialized tests such as X-rays, which show the bones of the spine, or an MRI scan, which shows the soft structures in the spine such as the discs or spinal cord. The MRI scan can provide very detailed information regarding the amount of compression on the nerves or spinal cord. If there is compression on the spinal cord and the patient has symptoms, the surgeon may suggest surgery to prevent further damage to the spinal cord. Fortunately, spinal cord compression and myelopathy can be treated by taking the pressure off of the spinal cord via surgery.
How is Cervical Laminoplasty Performed?
One option for removing compression from multiple levels in the neck is called a cervical laminoplasty. A laminoplasty is performed via an incision in the back of the neck which is called a posterior approach. During surgery, the patient will be lying face down on the operating table. Frequently, specialized monitoring devices are used to check the spinal cord during the surgery to ensure that there is no damage to the spinal cord during the surgery. Instead of removing the bone and other compressive structures, the bone overlying the spinal cord (the “lamina”) is partially cut on both the right and left sides. This creates a hinge on one side of the lamina and a small opening on the other side. The lamina is then moved into the “open” position by elevating the lamina on the open side. This vastly increases the space available for the spinal cord and takes the pressure off of it. The spinal cord can move away from whatever was compressing it including disc herniations or bone spurs, and the spinal fluid can then flow around the spinal cord more normally . A spacer made out of bone, metal, or plastic, is usually inserted to hold the spinal canal open. The final position resembles an open door being help open with a door stop, and many surgeons refer to this technique as an “open-door” laminoplasty. Another type of laminoplasty called a “French-door” laminoplasty is performed by creating hinges on both side of the lamina and an opening in the center of the lamina. The lamina is then opened by elevating both sides and ultimately resembles a French-style patio door.
Posterior Discectomy Advantages and Disadvantages
The principal advantage of the posterior approach is that a spine fusion does not need to be done after removing the disc.
The principal disadvantage is that the disc space cannot be jacked open with a bone graft to give more space to the nerve root as it exits the spine. Also, since the posterior approach leaves most of the disc in place, there is a small chance (3% to 5%) that a disc herniation may recur in the future.
What Occurs During Posterior Cervical Decompression?
The general procedure for the posterior cervical decompression (microdiscectomy) surgery includes the:
1. Surgical approach.
A small incision is made in the midline of the back of the neck.
The para-spinal muscles are elevated off the spinal level that is to be approached.
2. Disc removal.
An x-ray is done to confirm that the surgeon is at the correct level of the spine.
A high-speed burr is used to remove some of the facet joint, and the nerve root is then identified under the facet joint.
An operating microscope is then used for better visualization.
The disc will be directly under the nerve root, which needs to be gently mobilized (moved to the side) to free up the disc herniation.
There is usually a plexus (network) of veins over the disc that can obstruct visualization if they bleed.
Posterior Cervical Discectomy Risks and Complications
Possible risks and complications of a posterior approach for cervical discectomy include:
Nerve root damage
Spinal cord damage
Recurrent disc herniation.
In general, however, complications are rare.
For more information on cervical disc surgery please do not hesitate to get in touch with Mr Torrie through our appointments page.