Surgical Treatment Options
The goal of surgery for cervical spondylotic myelopathy (CSM) is to open the space for the spinal cord. This involves removing the parts of bone or soft tissue that are pressing on the cord.
Your surgeon will consider many options regarding treatment for cervical myelopathy, including your overall health, and will discuss the advantages and disadvantages of surgical interventions.
People who have progressive neurologic changes (such as weakness, numbness, or falling) with signs of severe spinal cord compression or spinal cord swelling are candidates for surgery. Patients with severe or disabling pain may also be helped with surgery.
People who experience better surgical outcomes often have these characteristics:
- The symptom of an electrical sensation that runs down the back and into the limbs
- Younger age
- Shorter duration of symptoms
- Single rather than multiple areas of involvement
- Larger areas available for the cord
There are many successful surgical techniques for treating CSM. The goal of surgery is to open the space for the spinal cord, or "decompress" the spinal canal. The decompression is performed either from the front of your neck (anterior) or the back (posterior). Each approach has its advantages and disadvantages (see table below) and these should be discussed with your surgeon. Neither surgical approach is ideal for every patient.
An anterior surgical approach involves operating from the front of the neck through a 1- to 2-inch incision along the neck crease. Neck surgery from the front involves removing the disks (diskectomy) or the bones (corpectomy) that are pressing on the spinal cord. The bones are then fused back together with a bone graft.
Anterior cervical diskectomy and fusion. During this procedure, your surgeon removes the problem disk. The area left over is stretched, so that the height is similar to what it was prior to the disk wearing out. A bone graft is placed in the space where the disk was removed.
Anterior cervical corpectomy and fusion. This procedure is similar to diskectomy, except that the vertebra is removed and replaced by bone graft material.
In some cases, both disk and bone may be pressing on the spinal cord. A combination of diskectomy and corpectomy may be performed.
Removing a disk or vertebra requires stabilizing the spine through fusion. Spinal fusion is essentially a "welding" process. The basic idea is to fuse together spinal bones (vertebrae) so that they heal into a single, solid bone.
Fusion will take away some spinal flexibility. The degree of limitation depends upon how many spine segments or "levels" are involved.
In addition to fusion, metal plates and screws are commonly used to help keep the bones in place.
Animation courtesy Visual Health Solutions, Inc.
Bone graft. Bone graft material is used to fill in the space left after the disk is removed. It is also placed along the sides of the vertebrae to assist the fusion. A bone graft is primarily used to stimulate bone healing. It increases bone production and helps the vertebrae heal together into a solid bone.
A bone graft can be obtained from the patient's hip. This type of graft is called an autograft. Harvesting a bone graft requires an additional incision during the operation. It lengthens surgery and can cause increased pain after the operation.
Although autografts are considered the gold-standard and provide a high union rate, disadvantages include prolonged pain at the donor site for some people, as well as fracture and infection.
One alternative to harvesting a bone graft is an allograft, which is cadaver bone. An allograft is typically acquired through a bone bank.
The use of allograft has grown because it avoids the risk of pain at the donor site. Several artificial bone graft materials have also been developed. There are risks and benefits for all types of bone grafts, and your surgeon will discuss these with you.
The posterior approach involves an incision along the midline of the back of the neck. Surgery may include laminectomy or laminoplasty. These procedures are often also accompanied by spinal fusion.
Laminectomy. This procedure involves removing the bony arch (lamina), any bone spurs, and ligaments that are compressing the spinal cord. Laminectomy relieves pressure on the spinal cord by providing extra space for it to drift backward.
Laminectomy ensures complete decompression of the spinal cord, but makes the bones less stable. This requires fusion with a bone graft and possibly screws and rods.
Posterior laminectomy is ideal for people with very small spinal canals, enlarged or swollen soft tissues at the back of the spine, and problems in more than four spine segments or levels. These approaches cannot be used in patients with kyphotic (bent forward) spines, since the cord will not shift backwards.
Laminoplasty. An alternative to laminectomy is a procedure that hinges the lamina open, without complete removal of the bone. Laminoplasty can expand the spinal canal and also allows your surgeon to address adjacent spine segments (levels) that are mildly affected.
Laminoplasty preserves 30 to 50% of motion at the involved levels. This is more than laminectomy or anterior surgery. Because pain is often related to motion, laminoplasty is not intended for patients with neck pain. This is because motion still occurs after the procedure.
Laminoplasty does not ensure that the spinal canal will be completely open for the spinal cord. Another disadvantage is that in some cases, the lamina that is hinged open can inadvertantly close.
Select patients will require combined anterior and posterior approaches to ensure the best outcome, such as patients with:
- Fixed or severe kyphosis (abnormal cervical spine curvature)
- Severe osteoporosis which weakens the bone
- Multiple levels of involvement requiring supplemental stabilization
As with any surgery, there are accompanying risks. Possible complications can be related to the approach, healing, the graft, and long-term changes. Your doctor will discuss potential risks with you when discussing consent for the surgery.
Elderly patients have higher rates of complications from surgery. So do overweight patients, diabetics, smokers, and patients with multiple medical problems.
The potential risks for cervical spine surgery include;
- Injury to the nerves
- Injury to the spinal cord
- Reactions to anesthesia
- Need for additional surgery in the future
- Failure to relieve symptoms
- Tear of the sac covering the nerves (dural tear)
Anterior Cervical Spine Surgery Risks
The potential risks specific to anterior cervical spine surgery include:
- Misplaced, broken, or loosened plates and screws
- Soreness or difficulty with swallowing
- Voice changes
- Difficulty breathing
- Injury to the esophagus
- Degeneration of disk levels above or below the surgery level
- Fibrous union
The potential risks specific to anterior cervical diskectomy and fusion include:
- Graft related complications, including hip pain (if an autograft is used), dislodgement, fracture, or severe settling
- Nonunion of vertebral body fusion
Posterior Cervical Spine Surgery Risks
The potential risks for posterior cervical spine surgery include:
- Degeneration of disk levels above or below surgery level
- Injury to the vertebral artery
- Stretch on the nerves from the spinal cord drifting backwards
After surgery, it is typical to spend one or two days in the hospital, although it really depends on how you respond to the surgery and how many disk levels were involved.
Spinal fusion may take six to 12 months for the bone to become solid. Because of this, your surgeon will provide specific restrictions for some time period after your surgery (wearing a collar, lifting restrictions, for example).
You will be able to walk and eat on the first day. It is normal to have difficulty swallowing solid foods for a few weeks, or have some hoarseness following anterior cervical surgery.
You may need to wear a soft or a rigid color at first. How long you should wear it will depend on the type of surgery you had. Your surgeon will likely encourage you to begin walking as soon as possible.
Depending on the extent of your surgery and number of spine levels fused, you may notice some neck stiffness or loss of motion. Also, as nerves begin to awaken following surgery, you may experience different nerve symptoms or feelings. This is normal and will often continue to improve for one to two years after surgery.
If nerve symptoms and pain progressively worsen, or you have any wound problems, you should contact your surgeon.
Usually by four to six weeks, you can gradually begin to do range of motion and strengthening exercises. Your doctor may prescribe physical therapy during the recovery period to help you regain full function.
Return to Work
Most people are able to return to a desk job within a few days to a few weeks after surgery. They may be able to go back to all daily activities by three to four months, depending on the procedure.
Typical discharge instructions after surgery are below. Your surgeon will provide you with specific instructions according to the procedure you have had.
- Time spent walking or sitting in chairs is unlimited.
- Incisions should be checked for signs and symptoms of infection: drainage, fever >101.5 degrees, flu-like symptoms, increased redness/ tenderness/ swelling at the surgical site.
- Staples/ sutures can be removed at the follow-up visit in the office around two weeks after surgery.
- Do not take anti-inflammatory medication for six weeks following surgery.
- Do not lift anything greater than 10-15 lbs.
- Do not drive a car until cleared by physician.
The primary goal of surgery for CSM, regardless of approach, is to stabilize the spine and prevent neurologic problems from getting worse. The goal is not necessarily to restore normal function. A secondary goal is potentially improving the associated neck pain, motor (weakness), sensory (numbness/tingling), and gait (walking) disturbances.
Final outcomes from the surgery vary. Typically, one-third of patients improve, one-third stay the same, and one-third continue to worsen over time, with respect to their pre-surgical symptoms.
People with CSM are recommended for surgery to make sure that their symptoms do not get worse. In most cases, the symptoms they have going into the operating room are what they will have afterwards. Your surgeon will discuss this with you and provide some information on what the likelihood is of improvement in your situation.
The American Academy of Orthopaedic Surgeons
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