Surgical Options

Patients are initially evaluated by a physiatrist to make sure all non-surgical options including physical therapy and non-narcotic pain management are exhausted prior to considering a surgical solution. In this section, we discuss which patients should undergo surgery.

Anterior Cervical Diskectomy and Fusion

Anterior Cervical Diskectomy and Fusion (ACDF) is a surgical procedure used to treat patients with a compressed nerve or compressed spinal cord who do not improve with conservative care.

If a patient has a compressed spinal cord and exhibits any symptoms, they will most likely need to undergo surgery regardless of their response to conservative care. The reason being that conservative care will be unlikely help improve their symptoms.

In terms of surgery, the incision is made in the front of the neck, usually in a skin fold horizontally. After the incision, there is a “natural” plane towards the anterior spine making access easy and usually the reason most patients do not have a lot of postoperative pain. The mainstay of the surgical procedure is for the surgeon to remove the disc to allow access to the spinal cord and spinal nerves. Once the disc is removed, the surgeon can free up the compressed nerve or spinal cord to provide relief. Since there is no disc remaining, the surgeon usually replaces it with a spacer and secures the spacer with a plating system. The spacer can be cadaver bone, your bone, PEEK (plastic or poly-ether-ether-ketone), or titanium cage. Titanium is compatible with MRI, CAT Scan or X-Ray. The spacer is secured with a plate or similar device to add stability to the construct. The procedure described is a fusion and will cause the vertebral body or bone above and below the disc to grow together in bony union. Some patients are concerned about a fusion as they are afraid that it will cause more damage as they become older, but the data is still early. The surgical procedure is similar to an Anterior Cervical Disk Replacement (ACDR) in that both procedures remove the pressure from the nerves but unlike the ACDR, the ACDF is a fusion procedure of adjacent segments and does not allow motion. The ACDF can be done at any number of levels of the cervical spine.

View a video detailing this procedure >

Anterior Cervical Disk Replacement

Anterior Cervical Disk Replacement (ACDR) is a surgical procedure used to treat patients with a compressed nerve or spinal cord whom do not improve with conservative care.

The surgeon removes the disc and replaces it with a synthetic disc device similar to a normal disc in that it allows for motion. The surgery is similar to an Anterior Cervical Diskectomy and Fusion (ACDF) where both procedures remove the pressure from the nerves but unlike the ACDF, the ACDR preserves motion. This can be done at 1 or 2 levels but not 3 levels.  Patients may not be a disc replacement candidate if they have excessive neck pain or compression of the spinal cord. There are reports in some patients that excessive cervical motion after anterior cervical disc replacement can cause a worsening of their neck pain, even after surgery. There is still significant controversy when comparing anterior cervical fusion to disc replacement. Current studies support that there is minimal difference at 5 years of 7 years in patients who undergo a one-level fusion versus disc replacement. For those patients undergoing two-level fusion versus disc replacement, the data seems to support that outcome may be slightly better in disc replacement group. As stated earlier, disc replacement is not approved for three-level constructs; only one-level and two-level constructs. Patients presenting with only neck, and no arm pain or cord compression would most likely benefit from a cervical fusion compared to a disc replacement.  The disc replacement procedure is similar to cervical fusion in terms of length of surgery, complications, pain and overall recovery. As with cervical fusion, patients usually are discharged to home the same day as surgery and are back to most activity within a few weeks.  Most patients request or consider cervical disc replacement because there is a risk of needing further surgery once you have any surgery on the cervical spine. After cervical fusion, patients incur a 9% chance of more surgery on an adjacent level over their lifetime.

View a video detailing this proceedure >

 

What to Know After Surgery

Do I go home the same day?

Most patients that undergo a one-level or two-level surgery will go home the same day of the surgical procedure. If patients live too far away or live alone, sometimes we recommend that they stay overnight in the hospital.

Patients that undergo a three-level surgery will stay overnight and go home the next day.

Wound Care

The incision is usually 1 ½ inches long, horizontally placed in a skin fold of the neck off to the left or right.  The incision is closed with subcuticular sutures that dissolve and do not need to be removed.  We place steri-strips over the incision and then cover with a 2 x 2 in gauze pad and adhesive.  You can shower the day after surgery and every day thereafter, but the shower should be quick.  You can remove the adhesive and 2 x 2 in gauze pad on Postoperative Day Two. Leave the steri-strips on and your surgeon will remove them when you come to the office for your first visit after surgery.

Pain Medications

No History of Pain Medications

If you have not taken pain medications in the past, you will be given a small dose of medications that you should take only if you need them. Try to use Tylenol or Motrin when possible.  The sooner you stop taking narcotic pain medication, the better you will feel.

History of Pain Medications

If you have taken pain medications before surgery and on those same medications at surgery, we will work with your pain management physician to make sure we have additional medication with your surgical pain. Once you recover from your surgical pain (2 – 4 weeks), your pain management will taken over by that provider.

Driving

Unless you do not feel well, you can begin driving 48 hours after surgery. If your surgeon does not think you should drive, they will tell you before you leave the hospital.

Work

You should discuss with your surgeon prior to surgery. Depending on your occupation, some patients are back to work with days after surgery. If your job requires physical labor, it may be 6 – 12 weeks before you can go back to work.

Bathing & Showers

The day after surgery, you can shower. Try to shower as quickly as possible and do not worry if the dressing is exposed to water.  We do recommend baths or hot tubs for the first 4 weeks after surgery.

Activity

Exercise

You should not exercise any more than walking in the first 4 weeks after surgery. During your postoperative visits, you should discuss your exercise goals with your surgeon.

Sex

It is safe to start having sex in the days after surgery.

Postoperative Visits with your Surgeon

You will see your surgeon after surgery in 7 days, one month, three months and then one year. You should have X-Rays at each visit.

Common Questions

With the advent of the internet, shared communication, and cell phones, most everyone can share their story of surgery or medical care with the rest of the world. Some patients feel compelled to go online to share their medical story; in particular when something goes wrong. However, there is a downside to social media where information can be outdated, one-sided, misleading, and all together false. Here are some of the myths of cervical spine surgery that I hear from my patients in the office who are scheduling surgery.

I have neck pain. Do I need an MRI?

Most neck pain improves with non-steroidal anti-inflammatory agents (NSAIDS) such as Motrin, Aleve, Advil and Tylenol. If your pain is persistent for more than a few weeks, you should consult your primary care physician on whether you should see a specialist and obtain imaging studies. Any patient with numbness or weakness is a more urgent matter and should undergo an MRI of their cervical spine regardless of the amount of pain.

Should I Try Physical Therapy?

Any patient with persistent and worsening symptoms greater than 4 – 6 weeks is a candidate for a cervical spine evaluation. Most patients undergo an MRI to develop a diagnosis with their clinical presentation. If the patient is diagnosed with Arthritis or Cervical Degeneration without any nerve root or spinal cord compression, then they are a good candidate for an initial course of physical therapy. Most Providers will send patients to therapy for 6 – 8 weeks and only continue if they improve after the initial course. If patients worsen, they may be referred to Pain Management or a surgeon.

Should I Try an Epidural Injection?

An epidural injection will work for a pinched nerve or Cervical Radiculopathy. Most Pain Management Providers will try a selective epidural on the compressed nerve for some form of relief. They will attempt up to three injections to try and provide improvement. If there is no improvement in the presence of a compressed nerve, they may refer to a surgeon.

Can Acupuncture Help Me?

Acupuncture is extremely helpful for someone with persistent muscle spasms without nerve root compression and without myelopathy. Constant neck pain can cause the muscles of the neck and shoulders to be in continued spasm. Acupuncture is helpful in this particular situation.

Who Needs Surgery After Non-Surgical Care?

Patients who present with any sort of neurological deficit are candidates for surgery sooner than later. This includes severe weakness of their upper extremities from a pinched nerve or someone with progressive Cervical Stenosis causing cord compression. Any other patients with mild to moderate symptoms are evaluated based on any extent of any deficits, length of symptoms and overall function.

Do I need to wear a collar after cervical spine surgery?

Most patients who undergo Anterior Cervical Surgery through a 1-level, 2-level, or 3-level surgery will not be required to wear a collar. At the outset of cervical fusion surgery and as early as 10 years ago, Spine Surgeons mandated those patients wear a collar. That is not the case anymore since fusion rates are higher, greater education on post-operative care, and better fusion technology. A small number of patients who are involved in a traumatic accident with or without cervical spine surgery may be required to wear a collar for instability, but this is the minority population (< 5%).[/et_pb_accordion_item][et_pb_accordion_item title="Are you taking bone from my hip if I have a cervical fusion?" _builder_version="4.27.4" _module_preset="default" global_colors_info="{}" theme_builder_area="post_content" open="off"]The vast majority of Spine Surgeons do not take bone from your hip. As technology for the procedure improved and allograft products became more available, the need for hip bone became less important. In fact, the part of the procedure to remove hip autograft hurt more than the actual anterior cervical surgery. In my practice, I only use bone harvested from the patient using the same incision.[/et_pb_accordion_item][et_pb_accordion_item title="Do I need to stay in bed after cervical surgery?" _builder_version="4.27.4" _module_preset="default" global_colors_info="{}" theme_builder_area="post_content" open="off"]Mobility is the key. Over the past 20 years, surgical recovery has gone through an enlightening period where immobility was previously thought the gold standard has now been converted to mobility as the gold standard. I frequently tell my patients to follow the ‘20 Minute Rule” of changing position every 20 minutes as mobility loosens muscles and improves pain.[/et_pb_accordion_item][et_pb_accordion_item title="Will I keep having more surgery after my first one?" _builder_version="4.27.4" _module_preset="default" global_colors_info="{}" theme_builder_area="post_content" open="off"]This is an excellent question. The risk of needing additional surgery after your first cervical spine surgery is approximately 4% over your lifetime risk. This means that 4 patients out of 100 surgical patients will need to come back for additional surgery most likely on the level above or below the initial surgical level.[/et_pb_accordion_item][et_pb_accordion_item title="Is Cervical Disk Replacement better than Cervical Fusion?" _builder_version="4.27.4" _module_preset="default" global_colors_info="{}" theme_builder_area="post_content" open="off"]

A research study evaluating the 10-year outcome of patients undergoing single-level cervical disc replacement versus anterior cervical discectomy and fusion in New York was recently published in the Journal of Neurosurgery – Spine (April 2023).

Although Anterior Cervical Diskectomy and Fusion (ACDF) is considered the gold standard for treatment of cervical disc disease that can cause radiculopathy or myelopathy, a number of studies have been conducted to show that cervical disc replacement (CDR) may have added benefits. Some of the benefits include increased range of motion and reduced risk of adjacent segment disease after surgery in the long term.  The study highlighted here reviewed data from the New York State Database to assess each procedure and its effectiveness over 10 years.

The authors reviewed a retrospective cohort from the Statewide Planning and Research Cooperative System using diagnosis and surgical codes for adult patients who underwent either ACDFP or CDR at one level. The study included a total of 7,450 patients where 6,615 underwent ACDF and 835 underwent CDR. The analysis showed no significant differences in the incidence of revision risk between the two study groups. The CDR cohort had a higher incidence of postoperative swallowing difficulty while those patients undergoing ACDF had a longer average hospital stay.

The study did not highlight long-term success in terms of adjacent segment disease, only revision risk and immediate complications. They noted the revision risk; revision risk is simply when a patient is taken back to the operating room in the short term after the initial surgery. The database most likely did not track adjacent segment disease because it was probably not a feature of the database.

Overall, this was an excellent study to support both procedures in terms of the success and outcomes. It did not focus on the main topic of hypermobility or adjacent segment disease. My worry as a surgeon is that patients can have increased neck pain after cervical disc replacement.