Mr James Langdon

BSc (Hons) MB BS MRCS (Eng) FRCS (Orth) Consultant Orthopaedic Spinal Surgeon

Anterior cervical discectomy and fusion or disc replacement

What is the difference between a cervical disc replacement and a cervical fusion?

The aim of both of these operations is to relieve you of your arm, and occasionally leg symptoms. They are generally not designed to treat neck pain.

Both types of surgery require a discectomy. This is the removal of the damaged disc to allow the decompression of the nerves and spinal cord to give you relief from your symptoms. After the discectomy has been performed there is a choice between using either a disc replacement or a fusion device to reconstruct your cervical spine.

In a cervical disc replacement the disc is replaced with an artificial disc. The artificial disc is designed to allow preservation of neck movement at that level.

In a cervical fusion the disc is replaced with an artificial spacer called a ‘cage’. The cage is designed to stabilise the vertebrae on either side of it, allowing fusion between the 2 levels to occur. A cervical fusion is not intended to allow any movement at the operated level.

Which is type of operation is best for me?

If you have significant wear and tear in your neck and the natural movement has already been lost, if there is structural instability in your neck, or if the spinal cord has been damaged by being severely compressed then you should have a fusion. If you have a cervical disc prolapse, then you have a choice. It is important to remember that when treating a cervical disc prolapse both operations are good operations.

The problem with fusing a disc is that the movement from that disc is transferred to the discs above and below. In theory, this can result in an increased rate of disc degeneration in these adjacent discs. Cervical disc replacements are now being increasingly used to treat cervical disc prolapses.

Unfortunately, a cervical disc replacement does not guarantee that you will have no further neck problems in the future, and it does certainly not prevent further wear and tear in the adjacent level discs. Currently, there is no convincing data that a cervical disc replacement is any better than a fusion in the long term. However, most spinal surgeons would aim to preserve motion and function where possible. If a disc replacement does not work, then it can always be converted into a fusion.

Before you come into hospital

If you take anti-inflammatory tablets then you must stop taking them 7 days before your surgery.

How do we do an anterior cervical discectomy?

A cervical discectomy is done under a general anaesthetic. The operation takes about 1 ½ – 2 hours. Once asleep the patient is placed on their back on the operating table. X-ray is used to identify the correct area of the neck.

A small incision is made in the front of the neck, just to the right of the Adam’s apple. The incision is normally about 3 cms long, usually within an existing skin crease. In order to expose the front of the spine the neck structures need to be carefully retracted out of the way. Once the correct level has been confirmed the disc is removed. This is done with the aid of an operating microscope. The microscope provides magnification as well as an excellent light source. The use of a microscope allows makes the operation safer In addition to removing the disc, bony overgrowths secondary to wear and tear may also have to be removed to allow a satisfactory decompression of the nerves and the spinal cord.

Following the discectomy and decompression the cervical spine has to be reconstructed using either a fusion cage or a cervical disc replacement.

The wound will be closed with a fine, dissolvable suture, and covered with a dressing.

What are the risks of anterior cervical spine surgery?

Infection - The risk of infection is less than 1%. All patients receive a dose of intravenous antibiotics when they are going off to sleep. If you develop an infection it is most likely to be a superficial wound infection that will resolve with a short course of oral antibiotics. Occasionally patients develop a deep infection. This is much more serious and may require a prolonged course of intravenous antibiotics or additional surgery.

Bleeding – You will loose minimal blood during the operation.

DVT – Developing blood clots in the legs (deep vein thrombosis – DVT) is a risk of any surgery.  We minimize this risk by using thrombo-embolic deterrent stockings (TEDS) and mechanical pumps. These pumps squeeze your lower legs, helping the blood to circulate. They are put on when you go to sleep and stay on until you start to mobilise. We encourage early mobilisation as this also helps to prevent DVTs.

Spinal cord injury - Any surgery on your neck carries the risk of paralysing you. Fortunately, this is incredibly rare. However, if you were to become paralysed during a cervical spine operation you could loose all arm, leg, bowel, bladder and sexual function.

Nerve injury – During this operation there is a 1% risk of physical nerve damage. This can lead to loss of nerve function with persisting pain, weakness, and numbness in the territory of that nerve. This may be permanent.

Difficulty swallowing – Following anterior neck surgery it is usual to have some discomfort on swallowing for a few days.

Hoarse voice – Following anterior neck surgery, most patients feel a bit hoarse for a few days. Occasionally the nerve to the vocal cords – the recurrent laryngeal nerve – is damaged during the operation. This may result in a permanent change to your voice.

Posterior neck pain – It is not uncommon for patients to experience some discomfort in the back of their neck for a few days following surgery.

Persisting symptoms – It is always possible for symptoms to persist, despite a technically successful operation. This usually reflects the degree of pre-operative nerve damage. These operations are very successful in relieving pain, but it is not uncommon for some persisting weakness or numbness, especially when the symptoms have been there for a long time before the operation.

Recurrent symptoms – Unfortunately there is no guarantee that you will not experience a return of your symptoms. This can be due to the formation of scar tissue, or further degenerative processes in your neck.

What can I expect following my operation?

Following your operation you should start trying to move your neck as soon as you feel able. To begin with this may be a little bit uncomfortable. The aim is to do small amounts of neck movement on a regular basis. You will be seen by the physiotherapists whilst in hospital, and they will give you some simple exercises to do. For the first 2 weeks you should not do any exercise that hurts.

You will be in hospital for 2 or 3 nights. By the time you are discharged home you will have been safely mobilising around the ward and able to manage the stairs. Once you get home you should not plan to anything more than gentle pottering around for the first 2-weeks. If you need to use a computer, then you should only do so for short periods of time.

Following the operation you will have a waterproof dressing over your wound. Ideally this should be kept dry. If you get it wet, then it should be dabbed dry. If the dressing starts to come off, then it should be changed. You should keep your wound covered and dry for 10 days. The nursing staff will explain to you how to look after your wound before you go home.

When you are sitting, you should aim to sit up straight and not have your neck too supported by pillows and this will lead to you bending your neck forwards. When in bed do not use too many pillows.

You will be seen back in the clinic a few weeks after your operation. You will normally be referred on for further physiotherapy at this stage. After 2-weeks you can slightly increase your activity levels, and start doing a bit more walking. However, you should avoid prolonged activity, lengthy trips, housework and looking after others for the first 6-weeks following your operation. You should also avoid bending and heavy lifting.

Driving - For the first few weeks following your operation you should not drive. As you feel more comfortable you can start to undertake short journeys yourself. Initially you should do this with someone else in the car with you. There is no restriction with the DVLA, though there will be with your insurance company. You will need to be able to undertake an emergency stop, and be in complete control of your car at all times without being distracted by pain. If this is not the case then your insurance will NOT be valid. Unless you can look over your shoulder, you are not considered safe to drive.

Flying – You should not fly for 2-weeks following your surgery. You should not undertake any long haul flights for 6-weeks.

Sports – You should not plan to return to any sports for 3-months following your operation.

Returning to work - When you can return to work depends on what it is that you do, and may be anything between 2 and 12 weeks. This will be discussed with you before your operation. Where possible days spent working from home can be helpful as part of your return to work. Your return to work should be gradual, and you should increase what you do over a period of time.

Follow-up

You will be seen back in the clinic a few weeks after your operation. An appointment will be made for you before you are discharged.