Cervical Spine Surgery
Listed below is the step by step procedure of cervical spine surgery:
- What is Cervical Spine Surgery ?
- Why is Cervical Spine Surgery Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Cervical Spine Surgery
- Post Procedure
- Risks and Complications
What is Cervical Spine Surgery ?
Cervical spine surgery is conducted in the neck region to cure herniated disc or overgrown bone that exerts pressure over spinal cord or nerve roots.
Cervical spine surgery usually lasts for approximately 3 hours and the patient is required to stay in the hospital for at least one night post surgery. During their stay in the hospital, recovery of patients is closely monitored by neurosurgeons, doctors and nurses. Blood loss is minimum but it's still a good idea to make prior arrangements for blood transfusion. The pain and discomfort associated with the surgery reduces with every passing day and it takes around few months for the bones to heal.
Why is Cervical Spine Surgery Required?
Cervical spine surgery is conducted only if medications, physiotherapy sessions and other treatments fail to produce desired outcome. The surgery is necessary in case of herniated disc. It can also be done to cure cervical degenerative disc disease. The surgery is also a good option to treat symptoms associated with cervical spinal stenosis (pain, numbness, stiffness or weakness in the neck, shoulder, arm or leg) and bone spurs (osteophytes) The ultimate goal of cervical spine surgery is to reduce or relieve pressure on nerve roots or on spinal cord by removing the damaged or degenerated disc. The surgery provides immense relief to patients suffering form chronic neck pain or from other disorders that are concerned with cervical spine.
In pre-operative preparation phase, you need to visit your doctor several times to undergo some screening tests. These tests reveal the status of spine injury or any development in herniated disc to the surgeon.
You also need to let the doctor know about your past medical history and current medications. Non-steroidal anti-inflammatory drugs may be discontinued for a week or so prior to surgery.
Anti-coagulants may also be stopped for five days before the surgery. Doctor will tell you to undergo blood test to determine if there is any active infection, high blood sugar or clotting disorder of the blood. Additionally, urine test and even ECG (Heart analysis) is advised to evaluate your overall health status. If blood test shows any abnormality, then doctor will prescribe you medications accordingly so that you get better before the surgery.
Smoking, tobacco and alcohol consumption should also be completely stopped since a few weeks prior to surgery.
Also, you need to take care of your financial requirements before the surgery. If you have medical insurance, then you need to consult with the insurance agency to sort out the formalities so that they can take care of your bills while you are at the hospital.
Day Before Cervical Spine Surgery
Since, cervical spine surgery is intensive, patient will be recommended to get admitted to the hospital a day before surgery. Patient will be advised to undergo complete physical examination . Also, arrangements for blood transfusion are made day before the surgery in case if the emergency situation calls for it. Fasting for minimum eight hours prior to the surgery is mandatory.
Patient should not take lot of stress about the surgery. He/she needs to relax and not worry about the surgical procedure. Support from family members and close ones will also help patient to prepare emotionally and mentally for the surgery.
The patient is required to change into a sterilized hospital gown.
An intra-venous line is inserted into a vein in the arm or back of the wrist through which antibiotics will be administered in order to decrease chances of infection. Doctor will also check blood pressure level, pulse rate and body temperature before starting the operation. In the operating theater, anesthesiologist will be present to inject correct and precise amount of general anesthesia in your body.
Methods/Techniques of Cervical Spine Surgery
Cervical spine surgery can be approached in two different ways - anterior approach (from front of the neck) and posterior approach (from back). Some spine disorders require anterior approach while some require posterior approach. Let us understand these two approaches and get an idea about how the surgery is conducted.
Anterior Cervical Surgery Approach
In most of the cases, along with anterior cervical surgery, fusion surgery is also conducted to stabilize the cervical segment. The surgery in combination is called Anterior Cervical Discectomy and Fusion (ACDF). ACDF is generally performed to remove damaged disc to alleviate spinal cord or nerve root pressure and thereby reduce corresponding weakness, pain and numbness.
The surgery is carried out in two parts - anterior cervical discectomy and then fusion. The surgery is approached through front of the neck and the damaged disc is then taken out from between two vertebral bones. Fusion surgery is then carried out during discectomy operation to hold cervical segment in place. Fusion surgery comprises of placing implants or bone grafts in place of original disc that used to perform the function of providing strength and stability to that particular area.
General procedure of ACDF surgery comprises the following steps:
- Anterior Surgical approach
- One to two inches long incision is made; either on the right or left side of the neck.
- Underlying muscle skin is then split in synchronization with incision and the area between sternocleidomastoid muscleand the strap muscles is accessed.
- Blood vessels or flat layers of fibrous tissues which cover the spine are dissected away from the disc space.
- Disc Removal
- During the surgery, fluoroscopy is conducted to provide X-ray image of the spinal cord so that the surgeon is able to understand whether he is at the correct disc level of the spine.
- Once the correct disc space is located, the disc is removed. It is done by first cutting fibrous tissue ring which surrounds the disc and then removing the soft inner core of the disc.
- Cervical Spine Canal Decompression
- Posterior longitudinal ligament which lies between spinal cord and disc is removed so that the surgeon can gain access to spinal canal in order to remove any disc material that might have got extruded through the ligament and it may result in spinal stenosis.
- Lower portion of vertebral bone on either side which help in forming boundaries of the disc are also partially removed. This is called uncinate process. The process is usually carried out to remove bone spurs (osteophytes) and the result is relieved compression of spinal cord or nerve root.
- The process of dissection is usually carried out using an operating microscope or magnifying loupes. The instruments provide larger view of small anatomical structures and help doctor to visualize and correctly locate these anatomical structures.
- Cervical Fusion
- Once cervical discectomy is done, it is followed by anterior cervical fusion surgery. This is done in order to prevent disc space collapse and is carried out by insertion of bone graft or implant into the evacuated disc space area. The process of fusion is carried out by combining two vertebrae in a single unit. Thus, the nerve roots and spinal cord get enough room to maintain decompression. Fusion surgery also helps in preventing local deformity called as kyphosis.
- To provide additional stability across the disc space, a small plate is often joined to front portion of the spine by fitting screws into each of the vertebral bones. This also helps in promoting healing of bones which have undergone fusion process.
- Due to occurrence of cervical fusion, bone is formed in the space from where the disc had been removed and vertebral bones (both above and below located ones) unite into one solid bone.
Posterior Cervical Decompression Surgery
Some spine surgeons prefer to access spine via posterior appraoch in case of large soft disc herniations that occur on side of the spinal cord. Posterior cervical decompression surgery is also called as microdiscectomy.
The general procedure for microdiscectomy is as follows:
- Surgical approach
- A small incision; approximately one or two inches, is made in the mid-line of the back of the neck.
- The para-spinal muscles that are attached to the spinal cord are elevated off the spinal level in order to access spinal cord.
- Disc Removal
- To confirm whether the spine surgeon is operating at the correct level of spine, X-ray is taken. Through X-ray images, spine surgeon is able to clearly understand at which spine level he is operating.
- To remove some of the facet joint, a high speed burr (instrument) is used. Once the facet joint is removed, underlying nerve root is accessed.
- For better visualization, operating microscope is used. A network of veins called as plexus which lie over the disc can obstruct visualization if they bleed during the surgery.
- To cure disc herniation, the affected disc located under the nerve root will be gently moved or mobilized to the side.
Cervical spine surgery being complex, requires extensive list of post operation precautions.
After surgery it will take few months to completely heal. For the purpose of limiting neck movement and to provide support, neck bracing is often recommended by the doctor. Restricting neck movement allows the fusion of vertebrae to heal effectively. It is important that the patient takes adequate rest.
Patients are encouraged to resume slow walking as early as possible post surgery. One should gradually increase time span of walking and if you are finding it difficult to walk in initial few days post surgery, then better avoid it. Consult with your doctor from when you can start walking. Walking for 10-15 minutes daily is advisable.
Avoid lifting of heavy weights, bending over, doing overhead work and sharp or vigorous neck turns. Do not do any activity that puts stress on neck muscles. Driving, especially if you are on narcotic pain relieving medications, is also not allowed post surgery. Patient should opt for strengthening and physical therapy after three months post surgery when the bones have fused properly. These therapies commence only when the bones have fused properly. Else, doctor will wait for the bones to fuse and then ask you to start physical therapy sessions. Most of the patients do benefit from postoperative exercise program or rehabilitation program post surgery.
Time period taken for the bones to fuse completely, varies from patient to patient. It also largely depends on which technique or method has been employed for the purpose of bone fusion. If the surgeon has used the patient's own bone or instrumentation for fusion surgery, then the bones fuse quite early, say approximately 3-4 months. But, if bone graft is used , then it takes longer time around 6-9 months for the bones to fuse. Recovery time will further increase if the patient does lot of physical activity, overhead work and keeps on moving his neck randomly in any direction. With every passing day, patient will experience less discomfort. Time taken for the patient to return to normal activities will also vary. Some may take 3-6 months, while some may take a year to get healed completely.
If the patient notices any signs of infection, swelling, redness or draining at the site of surgery or incision, he/she must not delay appointment with the doctor. To treat severe pain after the surgery, doctor may prescribe you few narcotic pain relievers. Gradually, as the pain reduces, doctor will shift to non-narcotic pain relievers. Certain pain relieving medications and non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin, naproxen, ibuprofen and COX-2 inhibitors have to be avoided for few months after spine surgery.
Follow-up appointments with your doctor post spine surgery are absolutely essential to evaluate the recovery process and to check if the surgical implants or disc is functioning as desired. Doctor may tell you to undergo certain diagnostic tests like CT Scan, MRI Scan etc. to diagnose the reason for persistent severe pain post surgery. It's also important that the patient takes medications prescribed by the doctor on time.
Smoking is your greatest enemy on the road to recovery. Smoking should not be resumed post surgery because the nicotine content disturbs or interferes with bone healing process that is necessary for successful fusion. It also increases risk of complications post surgery and hence, you should quit smoking if you have been doing so in the past.
Diet is another important aspect of recovery. Patient must consume healthy and nutritious diet so that the muscle loss that has occurred during the surgery gets compensated. Include sources of proteins which are important ingredients of muscle formation in your diet. Animal protein sources contain all the essential amino acids while vegetarian sources lack some amino acids. Hence, vegetarian people have to be more precise with their diet and use correct combinations like rice with beans to get complete set of amino acids. Having balanced diet helps in healing and recovery.
Family members and dear ones should offer love and support to the patient so that he/she is able to get rid of emotional stress. The patient undergoes lots of stress during the surgery and hence, care and support from family members post surgery will prove to be of tremendous help in alleviating tension and stress.
Risks and Complications
No surgery is devoid of any risks and complications. Since, the cervical spine surgery is carried out by implementing either of anterior cervical approach or posterior cervical approach, one has to know the risks and complications associated with each of these approaches. Let us check the risks and complications associated with both the surgeries:
Anterior Cervical Discectomy Fusion (ACDF) Risks
- The most common complication and risk of anterior cervical discectomy fusion is dysphagia which can be explained in simple terms as difficulty in swallowing. The esophagus which lies straight in front of the spine needs to be retracted and mobilized during the surgical process to prevent condition of dysphagia. With proper medications and treatments, dysphagia can be resolved within few days or weeks. But, the major threat could be that dysphagia if developed may remain permanent.
- Bone graft healing may fail to fuse or unite (pseudarthrosis).
- Failure to relieve the symptoms or reason the surgery was conducted
- Damage to spinal cord or nerve root. However, this possibility is very rare.
- Bleeding may occur. It may also happen that injury occurs to major blood vessel.
- Damage could occur to trachea or esophagus.
- Speech could be disturbed due to damage or injury to laryngeal nerve that is connected to the vocal cords.
- Leakage of spinal fluid
- Chances of infection could not be completely ignored.
- Hematoma (swelling of clotted blood)
- Seroma (leakage of serum from damaged lymphatic and blood vessels)
- Damage to nerve root and spinal cord
- Damage may occur to lateral femoral cutaneous nerve which provides sensation to the front part of the thigh.
- The disc could get recurrently herniated (misplace or extrude from its original space)
- Dural leak or dural tear (condition wherein the thin covering or thin layer over the spinal cord called as dura mater is nicked by the surgeon's instrument)
- Infection may occur during the surgery, since the deep inner parts of the operated body portion are exposed to air for a long time.
- Bleeding is inevitable since it is a complex surgical procedure and the surgeon has to perform tearing and dissection of various tissue fibers.
- Continued pain in the neck region or in the graft site
More information related to Spine Surgery
- Information on Spine Surgery
- Information on Spinal Fusion Surgery
- Information on Spinal Decompression Surgery
- Information on Laser Spine Surgery
- Information on Laminectomy
- Information on Lumbar Discectomy
- Information on Lumbar Puncture
- Information on Vertebroplasty
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