This rather common procedure is performed by most surgeons trained specifically in the field of spine surgery. It is usually offered to the patient who is suffering from a herniated disc or narrowing of the tunnel that the nerves pass through. The section regarding Cervical (neck) radiculopathy reviews this subject and should be examined by the reader. The decision to undergo this procedure should be carefully discussed with your spine surgeon. Furthermore, the ultimate responsibility for making the final decision of undergoing this surgery lies upon the patient.
First, the procedure will be discussed followed by some issues special for this procedure.; Patient is prepared by the staff prior to the procedure, seen by the anesthesiologist and is brought into the operating room. In most cases medications will be provided to relax the patient since this time is usually anxiety provoking. Patients are then anesthetized and respiratory support is provided. No memory to these events will be present after recovery from the procedure. The area of the skin is prepared to remove any bacteria, reducing risk of an infection. An incision is placed over the skin in front of the neck and the first muscle layer (Platysma) is cut and retracted. The blood vessels and the other muscles groups are pushed aside and an interval is developed between these outer structures and the trachea (windpipe). Deeper dissection leads us directly on the spine.; The offending level is identified by X-ray and the disc is removed from the specific intervertebral space; Some surgeons choose to use an operating microscope (as seen on the left) yet other may choose special magnifying glasses.; After removal of the disc, the space must be filled with bone to facilitate fusion and prevent later deformity. Refer to the section below for a discussion regarding bone grafting and their sources. The exact measurement for the space is taken and appropriate sized bone graft is placed. When appropriate, we choose to supplement the bone graft with a plate and screws. This provides added support to the construct and maintains the alignment of the bone graft. Some studies show faster and higher rate of fusion using a metallic plate. We utilize Titanium plates since it does not interfere with MRI scans should it be needed at a later time. A drain is placed in the wound to drain any blood that accumulates in the wound and the skin is carefully closed. We utilize a special technique of skin closure to achieve a more cosmetically pleasing scar. All of our sutures are buried under the skin surface and this avoids the suture tracks seen with other techniques. A more cosmetically enhanced scar is important to most of our patient since it is located in front of the neck. Sterile dressing is applied to the wound and the patient is awakened from the anesthetics. A neck brace is then applied and the patient is taken to the recovery room. After a short stay in the recovery room, patients are taken to their room and usually discharged the following day. Post operative pain is usually minimal. Most patients will complain of sore throat which resolves within a few days.
Few Basic concepts regarding this procedure are noteworthy. Some surgeons choose to perform this operation in a surgical center on an outpatient basis while others may choose to admit the patient for one to two days in the hospital. This decision should be made prior to the date of the procedure and make appropriate arrangements. Second important factor is bone grafting. After removal of the offending disc, an empty space remains in that area that is replaced by bone. This bone can be harvested from the patient’s hip area (Pelvis) or can be provided by donated bone from cadaveric specimens. The disadvantage of Autologus (patients own bone) is the moderate to sever post operative pain and the possibility of infection in the donated area. Of note is the fact that autologus bone has a slightly higher rate of fusion and better results. The advantage of cadaveric bone is that it avoids the pain that is associated with harvesting from patients own pelvis. Slightly lower fusion rates have been reported with cadaveric bone but when this bone is supported by screws and plates implanted in the area, the fusion rates and success of surgery are comparable. Currently the use of cadaveric bone vs. bone from the patient depends on patient and surgeon preferences. Even though it is still possible to transmit disease using cadaveric bone, its chances are comparable to being struck by lightening. Cadaveric bones are obtained from bone banks and undergo rigorous testing procedure before being provided for operative procedures. These issues are usually discussed prior to the procedure between the patient and surgeon.
Patients may have a concern regarding the adjacent levels which are healthy and their risk for deterioration after this operation. Indeed, there is elevated stress on the neighboring spinal segments with any fusion procedure. However, most patients will undergo a recovery period and will not be bothered by adjacent level disc disease. The surgeon must decide which level or levels to fuse and diagnose the level causing the pain and dysfunction. This could be a very difficult task and could be confusing. Your surgeon will base his decision based on his judgment and experience to arrive at a logical and reasonable surgical tactic. The ultimate goal of the surgery is to relieve the pressure over the nerves, remove the offending disc, and achieve fusion between the two spinal segments to avoid deformity and instability of the neck.
After the operation the patient will periodically follow in the office to monitor for progress and healing. The incision is carefully examined to make sure its healing progress and detect any early stage infection. X-rays are taken periodically to follow the fusion process which may take 3-6 months until completion. We will carefully look at X-rays to see the alignment of any metallic implants placed. Once fusion takes place, the metallic plates and screws have no function but they remain in place since their removal requires another surgery. Usually patients are un-aware of their existence and have no complaints regarding these implants.
Complications are infrequently seen but are discussed with patients prior to the procedure. Included here are only the most common ones and as we continue to improve medical technology and science we discover new complications as well. Fortunately, these complications are usually manageable. The most common complaint patients have is sore throat. This usually resolves on its own but can be helped with an anesthetic solution which is used to numb the throat. Other complications include but not limited to infection, bleeding, damage to nerves and vessels, injury to the tube carrying food to our stomach (Esophagus), injury to the wind pipe (trachea), nerve injury, spinal cord injury and others. However these are rare events and each one deserves a whole section of information.
In summary, the patient should have an understanding of the procedure in advance. You should trust your surgeon to do the best he can and lead you to a productive, pain free, and functional life to enjoy. Still much more information is available regarding your disease and proposed surgical procedures. Other alternative procedures are available and include procedures that approach the neck from the back. For a summary alternative procedures refer to Cervical Foraminotomy, Cervical Micro-Endoscopic Foraminotomy, and Cervical Laminectomy.
Most neck pain is due to degenerative changes that occur in the intervertebral discs of the cervical spine and the joints between each vertebra. The vast majority of patients who have neck pain will not require any type of operation. However, in some cases degenerative changes in the cervical spine can lead to a very serious condition where there is too much pressure on the spinal cord. When this condition occurs, the entire spinal cord is in danger. One surgical option is to remove the pressure on the spinal cord by opening the spinal canal from the back to make the spinal canal larger. This procedure is called a laminectomy. The purpose of this information is to help you understand:
- The anatomy of the cervical spine
- The rationale for performing a posterior laminectomy
- What you can expect from this procedure
In order to understand your symptoms and treatment options, you should start with some understanding of the general anatomy of your neck. This includes becoming familiar with the various parts that make up the neck and how these parts work together.
If spinal stenosis is the main cause of your neck pain, then the spinal canal must be made larger and any bone spurs pressing on the nerves must be removed. One way that this is done is with a complete laminectomy. Laminectomy means “remove the lamina”.
The lamina is the back side of the spinal canal and forms the roof over the spinal cord. Removing the lamina gives more room for the nerves and allows the removal of bone spurs from around the nerves. A laminectomy reduces the pressure on the spinal cord and the irritation and inflammation of the spinal nerves.
To perform a cervical spine laminectomy, an incision is made down the center of the back of the neck. The muscles are then moved to the side. The arteries and nerves in the neck are protected as well.
Once the spine is reached from the back, each vertebra is identified. Your surgeon will probably take an X-ray during surgery to make sure that the right vertebrae are being selected and the correct lamina removed. Once this is determined, the lamina of the affected vertebrae is removed. Any bone spurs that are found sticking off the back of the vertebra are removed as well. Great care is taken to not damage the spinal cord and nerve roots.
In the cervical spine, removing the lamina completely may cause problems with the stability of the facet joints between each vertebra. If the joints are damaged during the laminectomy, the spine may begin to tilt forward causing problems later. One way that spine surgeons try to prevent this problem is not to actually remove the lamina. Instead, they simply cut one side of the lamina and fold it back slightly. The other side of the lamina opens like a hinge. This makes the spinal canal larger, giving the spinal cord more room. The cut area of the lamina eventually heals to keep the spine from tilting forward.
With any surgery, there is a risk of complications. When surgery is done near the spine and spinal cord these complications (if they occur) can be very serious. Complications could involve subsequent pain and impairment and the need for additional surgery. You should discuss the complications associated with surgery with your doctor before surgery. The list of complications provided here is not intended to be a complete list of complications and is not a substitute for discussing the risks of surgery with your doctor. Only your doctor can evaluate your condition and inform you of the risks of any medical treatment he or she may recommend.
Neck fusion can be the operative choice for some disorders of the neck. Some of the reasons to fuse the neck from the back (posterior cervical fusion) include avoidance of late deformity, failed attempted fusion from the front, fusion for neck pain, fusion for fractures, and halting the progression of deformity. The ultimate goal of the operation is to fuse two or more bony segments in the neck into one single solid bone. This will limit motion in that segment only which may avoid pain, prevent deformity, and can stop dynamic compression over neural structures.
In cases of fractures or dislocations of the spine, a fusion procedure can stabilize the neck and prevent further neural compression, further injury, late deformity, while providing greater chance for recovery.
In cases which the bony elements press on the spinal cord (spinal stenosis) a laminectomy and decompression can be performed to create more space for the spinal cord. Bone is removed from the back of the spine in the neck area to create more space. By doing so, the patient is placed at risk for future deformity. The surgeon must find a balance to remove enough bone to create enough room, but avoid removing too much bone that may create late deformity of the bony elements in the neck. One way to prevent late deformity after a decompression procedure is a fusion of the bony elements which is again referred to posterior cervical fusion.
Surgeons usually use bone grafting to enhance chances for bony fusions. Bone grafting means placement of extra bone in the area to be fused. Donor bone can be obtained from the pelvis of the patient or can be obtained from a bone bank which is similar to blood banks. Bone banks provide bone harvested from cadaveric specimens and undergo rigorous testing before usage. These tests are performed to minimize the risk of disease transmission. The use of bone from a bone bank avoids a second incision and the operative risk in the area of bone harvesting from the patient; however, better fusions rates have been obtained from bone harvested from the patient (Autologus bone grafting).
Eliminating motion from an area to be fused increases the chance for fusion. Spine surgeons can utilize metallic implants to stop motion in specific areas until solid bony fusion takes place. Placement of metallic implants are referred to as Instrumentation. The addition of instrumentation to a fusion procedure adds certain risks and benefits to the proposed operation.These implants add rigidity to the fusion area and certainly enhance fusion rates; however, they increase operative risk by increasing operative time, increasing risk for infection, and increasing risk for neural injury during the operation. Most surgeons however, agree and do utilize instrumentation for fusion procedures to the back of the neck. The reason for such approach is that stabilization of the neck is very difficult with braces or external stabilizers. Even if stability is achieved by bracing or casting, they are poorly tolerated by patients to wear for 3 or more months. Two forms of instrumentations are available to stabilize the spine and optimize fusion. One type is the use of titanium plates and screws and the other is the use of stainless steel wires. Both of these techniques have been used successfully and are surgeon dependent.
As with any surgical procedure, risks, benefits, and alternatives should be discussed with your surgeon. Operative risks are unique to the condition treated and may include bleeding, infection, neural injury, hardware failure, etc. The discussion of all possible complications is beyond the scope of this web page and is best described by your own physician.