How is cervical spine surgery done?
Anterior cervical spine surgery is surgery done from the front of the neck to relieve the compression of the spinal cord and nerves. There are two main types of anterior cervical surgery, one is called anterior cervical discectomy decompression fusion (ACDF) and the other is anterior cervical discectomy decompression fusion (ACCF).
How is ACDF surgery done? Routinely, an incision is made on the right side of the neck, and when the target location is reached, the disc tissue and the hyperplastic bony bulge (which is a small bone spur that has grown) and the posterior longitudinal ligament (which is the ligament that covers the back of the cervical spine) are removed from the diseased segment to allow sufficient decompression of the diseased area so that the nerves and spinal cord are no longer compressed, and then a suitable intervertebral fusion device is placed in the diseased segment. The orthopedic department of Peking University First Hospital generally uses an intervertebral fusion without a steel plate for anterior cervical spine surgery. If the plate is fixed, the surgery will be more traumatic, and the tracheoesophagus is in front of the plate, which may lead to esophageal fistula, and some patients may have foreign body sensation when swallowing, but using intervertebral fusion alone can reduce these risks, and our long-term follow-up confirms the effectiveness and safety of this surgery.
Diagram of the anterior cervical ACDF procedure
The ACCF procedure is performed through the same incision as the ACDF procedure, requiring the surgeon to remove the diseased cervical disc and vertebral body, restore the normal height of the cervical spine with a spacer, select the appropriate length of titanium mesh (which is filled with the previously removed fragmented bone), implant the mesh into the bone socket, and fix it with an anterior cervical titanium plate.
Diagram of anterior cervical ACCF surgery
Posterior cervical surgery is performed from the back of the neck and is generally divided into a canalplasty and a laminectomy with fixation and fusion.
In posterior cervical ACCF surgery, the spinal canal is enlarged to relieve the posterior compression of the spinal cord without destroying the posterior structure of the cervical spine, so that the compression from the front remains, but the spinal cord can be moved backward to avoid the compression from the front, thus achieving indirect decompression.
Posterior cervical spine surgery is often performed for multi-segment cervical spondylosis. If two or three segments of the cervical spine are compressed at the same time, it is riskier and takes longer to perform the surgery from the front. With posterior surgery, the patient’s nerve root function is better improved and the mobility of the cervical spine can be preserved. For patients with severe compression or even local deformity, posterior fixation and fusion surgery can be performed.
Diagram of posterior cervical spine surgery
There are also some radiofrequency ablation procedures for cervical spine for sympathetic cervical spondylosis or neurogenic cervical spondylosis. Minimally invasive surgery in the anterior cervical approach is performed by radiofrequency ablation of low-temperature plasma to ablate and retract the local cervical disc and reduce local radicular pain or sympathetic symptoms. Minimally invasive surgery in the posterior cervical approach is performed by endoscopic assisted technology for keyhole decompression, which is a small localized decompression with minimal muscle stripping. Nerve root cervical spondylosis used to be treated only by anterior surgery, but now the posterior keyhole decompression can also achieve the desired effect with little damage to normal structures.
What are the advantages and disadvantages of anterior/posterior cervical surgery?
There are seven cervical vertebrae and six cervical discs in humans, and most patients have single-segment cervical pathology. In the case of single-segment lesions, anterior cervical surgery is definitely the preferred option; there are fewer patients with double-segment and more-segment lesions, so there are relatively fewer patients who have posterior surgery.
The advantage of anterior surgery is that it is minimally invasive and the patient recovers quickly. A small incision of two to three centimeters is usually made in the front of the patient’s neck to reach the front of the vertebral body, and the incision is made along the muscle texture, causing little damage to the normal structures.
However, the risk of anterior surgery is higher than that of posterior surgery because there are some very important structures in front of the cervical spine, and in front of the cervical spine there are large blood vessels on one side and trachea and esophagus on the other. So anterior cervical spine surgery, once there are complications is very serious. Of course, with the improvement of surgical techniques, the risk of such complications is getting lower and lower, which is the reason why anterior cervical spine surgery is now so popular.
Posterior cervical surgery is less risky than anterior cervical surgery because posterior surgery is done completely outside the spinal cord and does not directly touch the spinal cord, so there is no pressure on the spinal cord and no further damage is caused.
However, the decompression of the posterior surgery is indirect, and as mentioned earlier, the pressure on the front of the spinal cord is not completely relieved, and the symptoms are mainly relieved by moving the spinal cord backward after the posterior decompression. This depends on the overall physiological curvature of the cervical spine. If the physiological curvature of the cervical spine is good (the anterior convexity angle is relatively normal), the spinal cord has more room to move backward, and the effect will be better; if the curvature of the cervical spine is not good (the cervical spine has become straight, or there is a local posterior convexity deformity), it may not be possible to do posterior surgery.
All cervical spine surgery is a standard surgical procedure, and as long as the diagnosis is clear, the results of doing surgery are better and the success rate is higher.
What are the contraindications to surgical treatment?
The first is that the patient’s body cannot accept surgery, for example, if the patient has more medical comorbidities, a new cerebral infarction, a heart attack within a short period of time, unstable angina, plaque in the neck blood vessels, narrowing of the blood vessels in the neck, insufficient blood supply to the brain, etc., then these medical comorbidities need to be corrected before the next step of treatment can be performed.
How long does the surgery take?
Single segment surgery in the anterior cervical spine takes less than one hour, with each additional segment increasing the surgery time by about half an hour, and posterior cervical spine surgery takes two hours.
The anterior cervical spine surgery usually takes 3 to 5 days in the hospital, while the posterior cervical spine surgery takes 5 to 7 days.