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.
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
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.
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
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
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.
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
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
technology in the form of their Titanium ABC Plate and screw system
and the "Atlantis Translational Plate" from Medtronic
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 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
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
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
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 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
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
The PRESTIGE® Cervical "Disc" is not indicated for patients with any
of the following conditions:
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
- Local inflammation
- Segmental instability
- Morbid obesity
- 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
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.
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
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
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.
(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