Anterior Cervical Decompression and Fusion for Cervical Spondylosis with Myelopathy
Cervical laminectomy is done mainly to remove the posterior (back) part of the spinal canal to relief the pressure on the spinal cord. In most cases, it’s the most common procedure to treat spondylotic myelopathy resulting from cervical arthritis.
That is one thing, but the issue is that the large majority of abnormal anatomy that compresses the spinal cord is normally at the front of the spinal cord itself, not the back….so this means that this problem is a work-around-behind by a posterior approach cervical laminectomy.
To make matters possibly worse, cervical laminectomy may cause chronic spinal instability, and this may in turn aggravate the disease. Not to mention fibrous post-operation scarring, which can also contribute to spinal cord compression and reproduce the original symptoms/complaints after the surgery.
That’s why many surgeons prefer a frontal (anterior) decompression of the spinal cord and nerve roots, or a laminoplasty instead of laminectomy.
Contents
Benefits of frontal based cervical decompression surgery over laminectomy
- It’s a more direct approach: front problem, frontal approach. This means that the compression can be dealt direct without the need for manipulation of the spinal cord and roots.
- Stabilization of the spine by way of a fusion, will remove unncessary movements and development of further degenerative changes at the operated levels.
- Overall, patients experience less pain because front approach done by dissecting along tissue planes, not cutting through muscle as required by a posterior cervical approach.
Results of the spine surgery
Generally, most of the results of this surgery lead to significant improvement, as long as the surgery is done before irreversible spinal cord injury as happened.
At the very least, this operation can help to remove the source of spinal cord compression and injury as well minimize (if not stop) worsening of the disease.
Patients need to know that how much they can improve depends a lot on
- severity and duration of the spinal cord compression
- advanced/severe cases usually have poorer diagnosis (means more neurological symptoms such as weakness, numbess etc)
- regular physiotherapy
Anterior cervical decompression and spinal fusion procedure
Cervical decompression and spinal fusion fusion surgery is done with patient lying on their back, facing up (supine position) with the use of general anesthesia (GA). Patients would have compression boots to the lower extremities to prevent development of blood clots.
The operating spine surgeon will often use either an operating microscope or surgical loupes to provide for magnification and illumination as the operation proceeds. Although the dural sac is visualized during the decompression, the spinal cord and nerve roots are not directly seen.
The surgical procedure is done usually with this flow:
- longitudinal or transverse incision in the lower front of the neck. This underlying musculature of the neck is carefully dissected, allowing the surgeon to expose the front of the cervical spine by retracting the esophagus and trachea toward midline and the carotid artery and associated structures to the side.
- the muscles and membranes that lies over the anterior cervical spine are dissected as well, and then place retractors to protect the soft tissues of the neck
- the operational intervertebral discs are removed at the level(s) to be decompressed. In some instances it is only necessary to remove the abnormal discs, with or without small bone spurs at their margins.
- If the patient needs to decompress at more than 1 level (multiple levels), especially if large osteophytes (bone spurs) are present, the surgeon may opt to remove the vertebrae between the evacuated disc spaces.
- After the spinal cord and nerve roots have been decompressed, the removed portions needs to be reconstructed because they need to support the normal loading of the cervical spine.
That being said, generally the spinal surgeon will recommend internal fixation of the grafted parts using a titanium plate and screw device, which is then secured to the other vertebral bodies at the corpectomy. This will provide more stability as well as help with fusion plus helps with preventing the dislodgement of the bone graft.
Factors thought to increase the probability of bone graft/fusion failure include:
- Increasing numbers of levels to be fused (i.e., 2 levels is more difficult to fuse than one level)
- Smoking or other sources of nicotine intake
- Patient failure to comply with postoperative activity restrictions and/or brace wear
- Poor bone quality (e.g. from osteoporosis)
- Certain medications (e.g. predisone, anti-inflammatories, chemotherapy, rheumatoid arthritis, etc.)
- Malnutrition
The usual length of stay in the hospital for decompression and spine fusion surgery ranges from one to four days.
Potential risks and complications of ACDF surgery
While uncommon, as with all surgery there are a number of risks and potential complications that can occur as a result of a cervical decompression and fusion surgery, including:
- Hemorrhage or formation of a wound hematoma
- Damage to the carotid or vertebral artery resulting in a stroke or excessive bleeding, even death
- Damage to the recurrent laryngeal nerve resulting in hoarseness
- Damage to the superior laryngeal nerve resulting in swallowing disturbance
- Damage to the esophagus or trachea resulting in infection
- Damage to the dura, resulting in a cerebrospinal fluid leak or pocket of cerebral spinal fluid beneath the incision (pseudomeningocele)
- Mechanical complications of the graft and plate (including graft migration, breakage of the plate, screw pullout, etc.)
- Wound infection
- Development of painful pseudoarthrosis (failure of adequate fusion to occur)
- Damage to the spinal cord or nerve root(s) resulting in pain, weakness, paralysis, loss of sensation, loss of bowel or bladder function, impaired sexual function, etc.
Postoperative care for decompression/fusion surgery
Immediately after the surgery, the patient may experience
- some difficulty with swallowing
- sore throat
- throat discomfort
because of the access and manipulation of the esophagus. Most of the time, this discomfort will resolve within a couple of days, but in some patients they may have more persistence which can last for a few weeks.
That being said, generally, postoperative pains is relatively minimal, because most of the exposure is obtained by dissecting tissue, not dividing it.
Pain at the graft site (where bone graft is obtained from the hip) is more of a risk/concern if the iliac crest graft is utilized (compared to a needle stick to obtain bone marrow aspirate).
The doctor will avoid prescribing NSAIDs (non-steroidal anti-inflammatory medications) because NSAIDs may inhibit bone formation which is not good because we want bone fusion to happen. Side note: tobacco products can also inhibit bone formation. For patients who are at high risk of poor bone fusion (such as in osteoporosis or osteopenia), the surgeon may opt to add external bone stimulators.
The spine surgeon may prescribe a cervical collar for a specific period of time to
- protect the neck and general post-surgery repair work
- which will help with healing
- prevent extremes of neck range of motion and movements
The spine surgeon may refer the patient to spine physiotherapy to teach / guide on
- neck physiotherapy
- lifting techniques
- things to avoid
- gentle range of motion (allowed)
Generally, adequate healing (fusion) occurs within a three to six months. The spine surgeon may require sequential x-rays over time to document adequate healing and ensure appropriate alignment at the operative site.
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