Neck Surgery – Cervical Spinal Surgery
Deciding to go ahead with surgery on the cervical spine is no small decision. There are many risks associated with these procedures, which include the general risks of surgery and the specific risks involved in treating cervical spinal problems for neck pain relief. It is important to talk over the options with your physician prior to making a decision. It may be that conservative therapy is all that is needed and that the problem causing the neck pain will correct itself over time. The majority of patients with a herniated disc find that ten weeks or so of conservative treatment allows the disc to repair itself and removes the necessity for invasive surgery. Most physicians will adopt a wait and see strategy, along with appropriate medication, physical therapy, and intervention, for six months or so prior to recommending an invasive surgical procedure for a patient with neck pain.
When Neck Surgery is Necessary
Some conditions may require more immediate action, such as an acute disc herniation that is causing severe myelopathy, radicular pain, and potential permanent damage to the spinal nerves or spinal cord. The use of x-rays, MRI and CT scans, selective nerve root blocks and other diagnostic tools will alert the surgeon to the possibility of relief from neck pain being achieved through specific procedures. If, for example, a patient has severe stenosis of the cervical spine at many levels, then a simple foraminotomy is unlikely to achieve the decompression that is required to alleviate the associated pain and nerve compression. In this case a procedure such as a corpectomy may be more appropriate as it provides the surgeon with the opportunity to decompress several levels of the cervical spine in one operation.
The Surgical Approach
Surgeons will also be required to make a judgement regarding the approach of the surgical procedure. Some will be carried out using an anterior approach (from the front of the neck), and some from the posterior (back) of the neck. This depends on the type of procedure and the structures that are to be removed. In a laminectomy, for example, a posterior approach is used to access the lamina that covers the back of the spinal canal. Signs of a disc herniation at the front of the spinal column, however, necessitates an anterior approach, so as to allow optimal access to remove the disc fragments and possible osteophyte growth.
Even in a procedure that is always conducted from either the posterior or the anterior of the cervical spine there is still some room for debate over the approach being made from the left or right side of the neck. In operations such as a corpectomy with fusion,, or without fusion, most surgeons approach from the right hand side as it is technically easier for a right-handed surgeon. However, the left-hand side approach can minimize risk to the laryngeal nerve, whilst increasing the risk of injuring the thoracic duct. Surgeons will likely make use of x-rays, fluoroscopes, and endoscopes during surgical procedures to give them better visual access and appreciation of the structures in their operating field.
Understanding and Minimizing the Risks of Neck Surgery
Physicians will aim to ensure that the patient understands the risks associated with their cervical spinal surgery and has the opportunity to ask questions and clarify any confusing issues. There will be frank discussion about the use of medications, both prescribed and alternative, prior to surgery. This is because several medications can alter the viscosity of the blood and may cause complications during a procedure by increasing blood loss or altering blood pressure. The use of NSAIDs may not be appropriate just prior to, and after, surgical procedures where fusion is involved, such as an anterior cervical discectomy with fusion, a laminectomy with fusion, or a corpectomy with fusion. These procedures may not achieve a successful fusion of the graft if patients continue to use certain medications.
Additionally, ensuring that the patient ceases smoking prior to spinal surgery is very important as this can substantially affect the recovery from, and success of, a spinal operation. Drinking alcohol is also advised against prior to surgery as it can affect immune responses, blood viscosity, and inflammatory actions in the body. Making sure that the guidelines for pre- and post-operative care are fully understood and implemented means that the patient’s recovery can be optimized. Some procedures, such as a microlaminoforaminotomy are minimally invasive and have short recovery periods, whereas others may take a significant time to bounce back from, such as an extensive laminectomy. Taking care to observe any signs of infection after surgery, such as weeping from the incision, redness, tenderness, swelling, fever and headache, is vital in addressing this issue quickly. If a dural tear occurs during surgery it can be quickly repaired, if it goes unnoticed then it may lead to an infection of the spinal fluid and, potentially, meningitis. Preventative antibiotics may be recommended by some surgeons.
The use of a cervical collar varies enormously between different cervical spinal surgeries. A soft cervical collar at least is usually worn for a few days after most surgeries, and then the patient is often advised to only wear it on certain occasions, such as when in the car, to avoid allowing the muscles in the neck to atrophy. A foraminotomy, laminotomy, or laminoplasty, may not necessitate the patient’s use of a collar at all if the surgery is minimal. Other operations require that a hard cervical collar or halo brace is worn for several weeks after surgery. An extensive corpectomy, for example, may necessitate the wearing of a halo brace or hard cervical collar to limit the movement of the neck whilst a successful fusion occurs. The requirement to wear these collars can interfere with personal hygiene routines, with clothing choices, and with daily activities and it is important to talk over any concerns before surgery regarding these limitations.
Advances in Surgical Technique
Neurosurgeons and orthopaedic surgeons are constantly reviewing, assessing, and updating their knowledge and experience of surgical techniques. There have been numerous advances in surgical tools, approaches, techniques, and risk reduction in recent years. A major development is the implementation of minimal access microendoscopic procedures such as minimal access discectomy, and microlaminoforaminotomy. These techniques allow the surgeon to reduce the operation time, minimize trauma to areas surrounding the operation site, facilitate swifter recovery from the surgery, and reduce infection rates, blood loss, and general complications. The microendoscopic procedures are not appropriate for all patients however, with some limited to just one cervical spinal level. In cases of severe degenerative disc disease a laminectomy with fusion may be more applicable, or a laminoplasty if there is evidence of pre-operative kyphosis (curvature) of the spine.
Whichever treatment strategy is offered to the patient, it is important that they are fully aware of the consequences of that therapy and the availability of both adjunct treatments, and alternatives. By taking control of their health a patient is much more likely to achieve a satisfactory outcome, with neck pain, radicular pain, weakness, paraesthesias, and numbness alleviated, reduced, or eradicated altogether. Cervical spinal surgery is just one of the options to consider and is supported by appropriate neck pain relief medications, physical therapy, acupuncture and acupressure, and the use of devices to relieve neck pain.
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