Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion is an operation that exposes the front of the neck vertebras and the relevant pathology through purposeful dissection of the neck structures. The approach is usually on the right side. Neck muscle plasma is opened, and then using blunt dissection, the front of the spinal column is exposed. Structures including the oesophagus, trachea, and carotid artery are carefully retracted to avoid injury.

Anterior Cervical Discectomy and Fusion, performed by placing a graft in the disc space

Anterior Cervical Discectomy and Fusion

Fusion is performed at the same time by placing a graft in the disc space. The graft can be made of various materials; it can be an autologous bone (the patient's own bone, most commonly from the iliac crest) or a synthetic material (such as PEEK or titanium). In some cases, the fusion is strengthened by placing a plate on the front of the spinal column.

Post-operative image, showing two level synthetic graft and plating

Post-operative X ray image - Showing two level ACDF using synthetic graft and plating

Major risks and complications include:

  • Perforation of the pharynx or oesophagus
  • Speech problems due to vocal cord paresis
  • Arterial injury resulting in bleeding and stroke
  • Cerebrospinal fluid leakage and creation of a fistula
  • Damage to the thoracic lymphatic duct
  • Horner's syndrome
  • Venous thrombosis
  • Spinal cord or nerve root injury
  • Displacement of the graft
  • Failure of the fusion
  • Postoperative clot formation
  • Swallowing difficulties and hoarseness
  • Complex regional pain syndrome
  • Adjacent level disease
  • Wound infection

Post-operative image, used only synthetic graft without plating

Post-operative X ray image - used only synthetic graft without plating

Once the front of the spinal column is identified, the level is checked and confirmed using a portable X-ray. Then, the diseased disc space is incised using a blade, and the rest of the degenerated disc material is removed using instruments such as curettes and rongeurs. Bony osteophytes are drilled off using a high-speed drill. A posterior longitudinal ligament is opened at that level. Once this is done, the cervical spinal cord and the nerve roots at that level should be decompressed.

At the end of operation muscle (platysma) and skin are stitched back together. Good position of the graft is later confirmed on X-Ray or CT scan.

Post-operative image,showing anterior cervical discectomy and fusion at C5-C6 - using synthetic graft with plating

Post-operative X ray image - Showing ACDF at C5-C6 - using synthetic graft with plating

Cervical Disc Arthroplasty

Cervical disc arthroplasty is an alternative to fusion procedure. In arthroplasty, an artificial disc is used to preserve motion at the level of a cervical discectomy. Various cervical disc replacement models use a variety of materials.

Post-operative X-ray - showing cervical disc replacement

Post-operative X-ray - Cervical disc replacement

Cervical Laminectomy

Cervical laminectomy procedure - removal of lamina

Cervical Laminectomy-removal of lamina


Cervical laminectomy is a procedure where the cervical spinal cord and the relevant nerve roots are decompressed posteriorly, or from the back of the neck.


Cervical laminoplasty procedure, with titanium plate

Cervical Laminoplasty

Neck muscles are retracted, and the bone laminas are exposed. Laminas represent a "roof-like" structure closing off the spinal canal from behind. These bony structures are removed using a high-speed drill and other surgical instruments. As the result of this intervention, a closed spinal canal is turned into a "trough" and the cervical cord and nerve roots are decompressed.

An alternative to complete removal of cervical laminas is cervical lamina elevation, which widens the cervical spinal canal. This procedure is called laminoplasty. At the end of the intervention, the muscles and skin are stitched back together.

The major risks and complications of this intervention include:

  • Wound infection
  • Bleeding
  • Spinal cord injury
  • Nerve root injury
  • Destabilisation of the spinal column, which may result in dislocations; these can cause significant neurological harm and deficit.

Cervical Laminectomy and posterior Fusion

Cervical Laminectomy and posterior Fusion

Cervical laminoplasty operative picture following placements of plates and screws

Cervical laminoplasty following placements of plates and screws

Intra-operative picture - Cervical Laminoplasty using screws and plates

Intra-operative procedures - Cervical Laminoplasty using screws and plates

Cervical Foraminotomy

Cervical foraminotomy is performed using a microscope and high-speed drill. The procedure approaches from the back of the neck and decompresses one or more individual nerve roots. The operation aims to create a small "keyhole" opening in the bony lamina where the nerve roots are coming outside the spinal canal. This procedure is done for cervical radiculopathy, which is caused by a disc herniation or foraminal narrowing (due to ligamental and bony hypertrophy).

Cervical foraminotomy performed by using a microscope and high-speed drill

Cervical - posterior Foraminotomy


Cervical Foraminotomy

Cervical Foraminotomy

Cervical Foraminotomy - operative picture with nerve root exposed

Operative picture - Cervical Foraminotomy

Microdisectomy

Lumbar Microdiscectomy - operative procedure to access the compressed nerve root

Lumbar Microdiscectomy

Microdiscectomy is an operative procedure that utilises a relatively small incision and microscope to access the compressed nerve root. Most commonly, a nerve root is compressed by protruding degenerated disc material; in some cases, the disc fragment can separate itself from the actual intervertebral disc-this is called sequestrated disc.

In microdiscectomy, a small opening of the bone laminas is made. This typically requires the removal of a small part of the medial facet joint as well. This opening is called fenestration. It allows access to the compressed nerve root and the protruding disc material. Once adequate exposure has been completed, the protruding degenerated disc can be safely removed, and the nerve root is decompressed. The radicular nerve root pain (or sciatica) should subside immediately following the surgery. However, if numbness and weakness are present initially, these symptoms may persist.

At the end of the operation, the muscles and skin are stitched back together.

The complications of microdiscectomy include:

  • Infection, which is mostly superficial; in less than 1% of cases, the infection affects deep tissues.
  • Worsening numbness or weakness; this is mostly transient.
  • Incidental durotomy (opening of the dural sac). Possible consequences of a dural tear include contained or noncontained cerebrospinal fluid leaking, herniation of nerve roots through the opening, and injury. In some cases, a cerebrospinal fluid leak has been linked to chronic back pain; inflammation (arachnoiditis); and even bladder, bowel, and sexual dysfunction. These sequelae are often the consequence of nerve root injury.

Percutaneous Endoscopic Lumbar Discectomy

This surgical intervention uses an endoscope (a "key-hole" surgery) to access the herniated disc material. It is mostly used in small and contained disc protrusions. There is no relevant study showing any advantage of this technique in comparison to the accepted standard, microdiscectomy. The evaluation of this technique is still ongoing.

Percutaneous endoscopic microdiscectomy - surgical intervention - to access the herniated disc material - operative picture

Percutaneous endoscopic microdiscectomy

Lumbar and Thoracic Laminectomy

Laminectomy procedure - lamina and spinous process removed

Lumbar or Thoracic laminectomy is an operative procedure that aims to remove the bone structure called the lamina; the laminas close the back of the spinal canal. The incision depends on the number of laminas (or levels) that require decompression.

Following the incision at the back of the spine, the muscles are stripped off the laminas and retracted to the sides. Following this, the laminas are removed using a variety of instruments, such as a drill, up-cuts (also known as a Kerrison punch), bone-nibblers, and cutters.

Thoracic or lumbar laminectomy aims to decompress the spinal canal and relevant nerve roots by turning the canal into a "trough." In the thoracic spine, this operation seeks to decompress the spinal cord as well. At the end of the intervention, the muscles and skin are stitched back together.

Possible complications include:

  • Infection, which is mostly superficial; in less than 1% of cases, the infection affects deep tissues.
  • Worsening numbness or weakness; this is mainly transient.
  • Incidental durotomy (opening of the dural sac). Possible consequences of a dural tear include contained or noncontained cerebrospinal fluid leaking, herniation of nerve roots through the opening, and injury. In some cases, a cerebrospinal fluid leak has been linked to chronic back pain; inflammation (arachnoiditis); and even bladder, bowel, and sexual dysfunction. These sequelae are often the consequence of nerve root injury.
  • If the facet joints are extensively removed, then the spine may become destabilised and subluxation (or "slippage") may follow. Spinal instability, pending on the level of the spine affected, may lead to significant and severe neurological injury. In those cases, the stabilisation and fusion of the unstable spinal segments are necessary.

Costotransversectomy

Costotransversectomy is an operation used in the thoracic spine for degenerative disc disease (in particular with central disc protrusion), trauma, tumours of the spine, and infections such as tuberculosis.

Costotransversectomy approach - the approach to the spine from side of the lesion

Costotransversectomy approach

The approach to the spine is usually from the side of the lesion. The incision is carried on through the skin, subcutaneous fat tissue, and muscles. The aim is to expose the affected spinal vertebra and the relevant rib. The portion of the rib and the transverse process of the corresponding vertebra are removed. This intervention should provide access to the spinal pathology.

In some cases, and very much depending on the underlying pathology, this procedure may lead to spinal instability. Thus, it must be accompanied by instrumentation and fusion. At the end of the operation, the muscles and skin are stitched back together.

Costotransversectomy is an intervention that includes operation in the proximity of lung pleura. Injury to the lung pleura can lead to the accumulation of air in the pleural cavity; this condition is known as pneumothorax and will cause compression of the lung on that side. Pneumothorax is a medical emergency and must be treated urgently.

Transpedicular Approach

Costotransversectomy approach - posteolateral approach

Transpedicular approach

The transpedicular approach is also known as the posterolateral approach. It is utilised in the removal of degenerative disc material compressing the nerve root laterally and is often in tumour biopsies or resections. The transpedicular procedure requires removal of the head of the corresponding rib and the vertebral pedicle. Thus, this operation usually requires spinal instrumentation and stabilisation.

The risk of developing pneumothorax is smaller than in costotransversectomy.

Spinal Cord Stimulation

Spinal cord stimulation is sometimes used to treat conditions associated with chronic pain. These conditions include failed back syndrome, complex regional pain syndrome, intercostal neuralgia, multiple sclerosis, diabetic neuropathy, and postherpetic neuralgia. Other conditions that may benefit from a spinal cord stimulator include pain in a limb due to vascular disease and ischemia, some cases of spastic paresis, and some cases of angina pectoris.

Doctor stimulate spinal cord with electrodes

The spinal cord stimulator procedure includes placing electrodes on the spinal cord then stimulating areas of pain. The electrodes can be placed using a large needle (also known as a Tuohy needle) through the skin or in the open surgery. Different types of electrodes are used in these 2 surgical techniques. In addition to electrodes, a small electric generator needs to be implanted.

Before this can advance, it is necessary to perform a trial procedure. The trial requires placement of electrodes with an external generator over several days. The trial procedure will establish whether the treatment is effective or not in treating the pain.

The success rate of this intervention ranges from 50% to 75%.

The complications of this surgical intervention include:

  • Infection
  • Electrode migration
  • Breakage of a lead
  • Failure of the battery
  • Cerebrospinal fluid leakage
  • Nerve root pain
  • Interference with a heart pacemaker
  • Limb weakness

Fusion and Stabilisation Procedures

Spinal column and vertebral bodies stabilise with rods and screws

Many surgical interventions aim to stabilise an unstable spinal column. These procedures often include placement of rods, screws, and other constructs in the spinal column and vertebral bodies to support the number of spinal segments.

These procedures are usually performed in cases of trauma, in cases of deformities, in cases where the neoplastic (cancerous) disease leads to spinal instability, in the surgical treatments of spinal infections, and in some cases following spinal procedures for the degenerative spine when there is evident spinal instability.

In cases of spinal instrumentation, the actual operative procedure and its associated risks vary depending on the technique and the part of the spine that is to be stabilised.

A fusion procedure is not recommended following a simple decompression in patients who have no evidence of spinal instability. Fusion procedures in the treatment of degenerative low back pain without pre-existing instability is highly controversial and is not recommended.