Fusion Surgeries of Lower Cervical Spine

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• Can the hardware used in the surgery cause complications?

  While complications from hardware are rare, they can include hardware breakage, movement, or irritation. Regular follow-ups help monitor for any such issues.

• When do I need fusion?

  Most of the patients in whom cervical disk herniation is causing worsening problems or patients who have no relief with conventional conservative measures need cervical spine surgery. Most of the patients need fusion when they need the discectomy to be done from the anterior neck, but a few patients may be eligible for discectomy from the back, and these patients may not need fusion. In some of the patients who need surgery from the anterior neck may be a good candidate for artificial cervical displacement and may not need fusion surgery.

• What are the chances for success?

  Well-performed surgeries on cervical disk have good results in majority of cases. Rate od success can be jeopardized if the patient has involvement of multiple levels, in the presence of chronic diseases, smoking etc.

• What are my risks?

  The risk of surgery include bleeding, infection, failure of fusion or failure of implant requiring another surgery, incomplete resolution of symptoms, neck or back pain, nerve damage leading to reversible or irreversible weakness in either extremity, involvement of bowel or bladder or weakness in lower extremity, hoarseness of voice. Patients may also have difficulty in swallowing or eating with sore throat for a few days.

• What are the risk of general anesthesia?

  Risk of anesthesia may include nausea, vomiting, dry mouth, Sore throat or hoarseness, difficult recovery. There are rare but severe risks like involvement of brain in the form of stroke or hemorrhage, cardiac arrhythmias, paralysis or even death.

• When will I be back to my normal activities, especially driving?

  Patients who undergo cervical spine surgery, can do basic activities of daily living as soon as possible. They will have to take pain medications in their early post-op period. These pain medications will cause some sedation, but patients can able to take care of activities of daily living as early as two to three days after the surgery. Regarding driving, patient can get back to driving once they are free of narcotic pain medications and are able to turn their neck side to side comfortably. This may take up to two to three weeks after the surgery or longer depending on the severity of the problem as well as the complexity of the surgery. You should consult your doctor regarding this.

• What type of surgery is recommended for cervical disc and why?

  Every patient is different, and surgeries are decided according to the patient problem, as well as the patient themselves. Patient can undergo a minimal invasive discectomy or a fusion or a disc replacement, depending on the multiple factors. The final decision is usually made in consultation with the surgeon.

• How long will the surgery take?

  A usual cervical spine surgery takes up to one and a half to two hours for completion. Apart from the surgical time, some more time is needed regarding the pre-operative preparation including anesthesia as well as post-operative recovery and moving out of the patient from the operating room to the recovery room.

• What if during my surgery you encounter a different spine issue than what you expected?

  Usually we discuss all the options before the surgery with the patient and their relatives, regarding the possibility of findings and mode of management. If there is something unexpected, we will usually discuss this with the patient’s relative, and discuss regarding their options of treatment and go accordingly with the wishes of the patient’s relative.

• How long is the hospital stay?

  Most of the patients of cervical spine surgery, are discharged the next day of the surgery. There is a recent trend in which healthy patients can be discharged the same day after the surgery. It’s unusual for routine cervical spine surgery patient to stay more than one or two days in the hospital.

• Which pain medications will I be sent home with? What are the possible side-effects of these prescriptions?

• Most of the patients with cervical spine surgery, will be sent with some narcotic pain medication to take care of their pain. These medications do have their multiple side-effects, which may be constipation, nausea, vomiting, impaired judgement, drowsiness, headache. Though patients who are treated with narcotic pain medication for acute pain, mostly do not lead to addiction, but these medications do have addiction potential.

  What limitations will I have after surgery and for how long?

• Patients with cervical spine surgery do have restrictions with regards to activity, as well as the amount of work that they can do. These restrictions are usually relaxed as the patient progresses into the healing phase. Bone healing usually takes about three months, and that is a time at which the patient is usually allowed gradually progressive unrestricted activity, depending on how well he has recovered with the movement, as well as strength as well as recovery in the symptoms.

• How often will I see you after my surgery?

  Patients are usually followed at two weeks, six weeks, three months, six months, and a year after surgery.

• What symptoms should warrant a call to your office?

  If the patient develops problems like chest pain, breathing problems, sudden neurological deterioration, or any other emergency they should call 911, or go to the emergency room directly. Patients who develop worsening pain at the surgery site, discharge from the wound, fever; they should call in the office.

• What symptoms would warrant immediate medical attention?

  Patients who develop chest pain, shortness of breath, worsening neurological deficit in either extremity, pain that is not controlled with medication, and is rapidly worsening, especially if associated with tingling or numbness or loss of control of bowel or bladder or balance, or presence of weakness, or symptoms that warrants immediate attention, should call 911, or visit the emergency room of the hospital.

• How long should I wait to bathe?

  Patients are usually asked to avoid bathing, until the incision heals, which may take two to three weeks. Patient can take shower after 72 hours of surgery with an impervious dressing in place. The dressing can be changes if the wound is visibly soaked. Patients are asked not to rub the area of surgery for about two to three weeks. They can gently dab it dry with a towel.

• How long will I be out of work?

  Patients with low demand work and desk job, can be back to work as soon as three to six weeks after the surgery depending on patient pain control as well as recovery. Patients who are in heavy lifting or control of heavy machinery or handyman job, may take three to four months, or even more to get back to work depending on their recovery from the surgery.

• When can I resume normal light household chores?

  Patients are encouraged to do the activities of daily living within two to three days of surgery. At the same time, patients are encouraged not to overdo things. Patients can get involved with gradually increasing normal household chores within two to three weeks of surgery.

• What expectation do you have for my recovery?

  Patients usually stop using pain medications within a week of surgery. They start beginning the range of motion of their neck within two to three weeks, and they are symptom-free with regard to their tingling/numbness in their arms within two to five days after the surgery. Patients are able to get back to normal household activity and activities of daily living in two to three weeks. Patients can return back to desk-type job within four to six weeks, and patients requiring heavy work may take about three to four months before returning back to their jobs.

• How soon after the surgery can I start physical therapy?

  Patients are not required to start their physical therapy till two weeks after the surgery. After two weeks of surgery, physician reexamination will help in deciding if the patient requires physical therapy or not. Many of the patients do not require physical therapy after the surgery.

• Does smoking cause spine problems?

  Smoking has proven to cause spine problems, including neck and lower back. At the same time, smoking is detrimental for patients who require spine surgery, especially fusion surgeries. It has been shown that smoking delays spine fusion, as well as lead to higher incidence of nonunion and possible need for revision surgeries.

• Should I have an MRI for my pain?

  Most of the patients with cervical disk disease and subsequent pain can be treated with conservative means and do not require MRI. Patients who fail conservative measures, as well as patients who develop worsening neurological deficit or weakness or involvement of bowel or bladder or gait may require MRI. Patients usually need to see a physician before an MRI can be done.

• If I have a fusion, why do I need rods and screws in my spine?

  In any case of fusion, we need to fix the bones to each other by the use of metal implants which may include rods, plates or screws to keep the bones in place until the body helps heal the spine and fuse the two segments.

• Do the rods, plates, or screws need to be removed?

  Once Fusion has healed, the rods, plates, and screws are usually harmless and do not need to be removed after the surgery unless they are causing any problem. In rare instances, patients may develop problems because of these metal implants, or problems, management of which is hampered by the presence of metal, may need removal of implants.

• Why do I need to get a MRI, CT scan or x-ray before I have surgery?

  Patients with spine problem need to undergo special investigations to confirm the diagnosis. The initial form of imaging is an x-ray, which shows bones only. After the x-ray is done, and if patient needs, then an MRI is performed, which help to know the anatomy about the spinal cord and spinal nerves and to understand as to where the problem lies. Occasionally physician may ask patient to undergo CAT scan in which a bony anatomy is better delineated. Certain patients, especially who have contraindication to MRI, may need to undergo a CAT scan. Occasionally a dye can be put along the spinal cord and a CAT scan can be done. This procedure is called CT myelography.

• Do I have to wear a brace or collar after neck surgery?

  Most of the patient do not need to wear a brace or collar after the surgery. Even if a neck collar or a back brace is needed, it may be discarded soon depending on the recovery of the patient.

• After surgery, how long will my pain last?

  Depending on the complexity of the surgery, most of the patients will have pain in the surgical site for five to seven days. This pain is gradually improving, and patients are asked to take pain medications for the same. Even after a week, there is some residual pain which takes four to six weeks to completely resolve.

• Is there a chance of paralysis after surgery?

  There is a rare chance of injury to the nerve roots as well as spinal cord while doing a spine surgery. With advancement and use of magnification and refined instruments, the risk of causing nerve damage and paralysis are rare.

• Could I need further surgery?

  Occasionally patients may need further surgeries. These surgeries may be required due to failure of the fusion or failure of the initial procedure or failure of the implants. Occasionally after many years, some patients may develop degenerative disease on the nearby areas. These patients, if symptomatic enough, may need surgical intervention.

• What if I get an infection?

  If the patient has a superficial infection, few days of antibiotics will help heal these infections. Occasionally patient may develop deep infection. In these patients may need IV antibiotics for a longer period. If despite all efforts or in patients with rapid deterioration due to infection, surgery may be needed to help clean off the infection.

• What type of anesthesia is needed for cervical spine surgery?

  General anesthesia is a preferred mode of anesthesia for cervical spine surgery. In this anesthesia, a tube is placed through the windpipe of the patient to control the respiration while the patient is operated upon.

• Which patient needs cervical laminectomy?

  Occasionally patients will have pressure on the spinal cord from the back. These patients need the pressure to be relieved from the back and in such cases, cervical laminectomy needs to be performed. Most of the time, the cervical laminectomy is also accompanied by placement of screws and rod to make the spine stable and fuse in an appropriate position.

• Will removing my bone make my neck unstable?

  Minimal invasive surgery do not remove enough bone to make the neck unstable. If a fusion surgery is performed, then removal of disc as well as bone may lead to instability and these patients usually need placement of a support in the form of a cage with plate and screws.

• What is the chance of bone growing back?

  Most healthy patients have more than 90th percent chance of bone growing back leading to good result with fusion. This healing of bone can be suboptimal in patients with systemic diseases like diabetes, or in patients who continue to smoke after the surgery.

• How much of the bone is removed during cervical spine surgery?

  While doing fusion surgeries, the adjoining areas of the two vertebrae are cleaned, so that a healing process can be activated. In minimal invasive surgery, a small amount of bone is removed so as to make a window to reach the nerve root and the disc, to remove the discectomy. The amount of bone removed is not enough to cause any instability because of the loss of bone in itself.

• Is it possible to undergo a surgery if you have an infection?

  Surgery, if indicated, can be done in a patient who has had infection in the past. The surgeon must be cognizant about such a history and will take due diligence to avoid having an infection in the surgical site. These include use of correct and appropriate antibiotics before and after surgery, and keeping the patient informed as well as regular follow up, so as to diagnose an infection if it happens and treat it accordingly. These patients are at a higher risk of getting infected, especially if the infection was in the same surgical site where they have been operated.

• If I have Spondylolisthesis, will it be reduced?

  Spondylolisthesis or slipping of one vertebra over the other are usually taken care by the surgery if it fails to give relief with conservative means. It is not necessary to get them 100% reduced, but the most important part is to relieve the neural elements of all the pressure, which is caused either by the bony vertebrate or the disc and prepare the vertebrae for fusion. In case of lumbar spine, spondylolisthesis need not to be reduced fully 100%, especially if the patient has a high grade listhesis, it is not desirable to reduce it completely. An important part of surgery is to clean the pressure of the spinal and nerve roots and prepare a healthy environment for bones to fuse.

• Do I have to give up smoking?

  For patients undergoing fusion surgery, it is highly desirable that they quit smoking. Smoking is detrimental for bone healing and hence the fusion. Smokers are at a higher risk of nonunion, that means non healing of the fusion mass, and these patients may need revision surgery. If the patient is not able to quit smoking, it is at least highly desirable for them to quit for three months. Use of the nicotine patch in place of smoking has the same detrimental effect as smoking itself.

• Can I play normal sport after I have healed?

  Patients with one or two level cervical spine fusion are allowed to get back to sports after they are completely healed, recovered and rehabilitated from the surgery. Patients who have undergone more than two level fusion or surgery on upper cervical spine are not recommended to go back to contact sports. In circumstances when the patient undergo minimal invasive discectomy procedures and no fusion is done, these patients are allowed to go back to sports when they are fully healed and rehabilitated.

• Will I be able, at any point, to feel the screws?

• The screws, plates, and rods put into the spine, either from the front or the back, are placed very deep, and it is highly unusual for the patients to feel the metal through their skin. The metal is covered with multiple layers of thick tissue, and thus the metal is usually not amiable to be felt even with deep pressure over the skin.

• What and when should I notify the doctor after surgery?

  Patients are asked to followup regularly with the spine surgeon after a certain period of time. In the interim, patients may need to contact their surgeon if there are unusual changes to their postoperative recovery, which include discharge from the wound, worsening of pain, which is not relieved with pain medications, worsening of neurological deficits, occurrence of new neurological deficit, occurrence or worsening of tingling and numbness, involvement of bowel or bladder. If the patient suffers chest pain, shortness of breath, any stroke-like symptoms, or paralysis, sudden onset of severe pain or in the calves or in the belly, these patients should contact the emergency room or call 911 as soon as possible.

• How is the life after ACDF surgery? Do you recommend for a 26 year old?

  Life after a single or two level cervical disc fusion is usually as normal as it was before the surgery. Occasionally, these patients may have some limitation of movement and occasional neck pain. Regarding its recommendation for a 26 year old, it depends on the presentation as well as findings on examination and investigations like x-ray, MRI, and CT. The surgeon should try to keep the disc intact as much possible as it can be, but if the patient has failed all conservative means, and there are no other options, then these patients may undergo anterior cervical discectomy and fusion.

• What are the some indications for cervical spine surgery?

  A patient with neck pain with tingling, numbness, with or without weakness, but with peripheral pain going down the arms who have failed all conservative means are usual patients for surgery. All such patients should be tried with conservative means except if there is neurological deficit or worsening neurological involvement, severely worsening pain, involvement of bowel or bladder, or balance. These patients may need urgent or emergent surgery to halt the neurological deficit or progression and help in recovery.

• What effect does a fusion on the rest of my cervical spine?

  Cervical spine fusion at one level decreases the mobility of the cervical spine by approximately 10%. Under usual circumstances this is not of much consequence. There may be a subtle increased mobility on the adjoining levels to compensate. There also may be decreased mobility because of stiffness of the muscles around it, but this can be regained over time naturally, with or without physical therapy.

• Will the surgery lessen my mobility?

  Spine surgery, especially fusion, will decrease the mobility of the spine depending on the level it has been done to. Surgeries like disc replacement tend to cause decreased worsening of mobility as compared to fusion surgeries due to its quality of preserving the joint mobility.

• What is cervical fusion?

  Cervical fusion is a surgery in which two adjoining spine vertebrae are prepared to undergo fusion by removal of the intervening disc and preparation of the bone ends so as to decrease the mobility of that segment. The surgery is usually performed to stabilize the segment as a part of removing the pressure over the neural elements.

• What are the different ways spine fusion can be done?

  Spine fusion can be performed through an anterior approach (Anterior Cervical Discectomy and Fusion or ACDF) or a posterior approach (Posterior Cervical Fusion or PCF). The choice depends on the location of the problem and surgeon’s expertise.

• What are the advantages of the anterior approach to cervical fusion?

  The anterior approach provides direct visualization and access to the intervertebral disc, allows for effective decompression of nerve roots, and enables placement of graft and fusion hardware with minimal muscle disruption.

• What are the advantages of the posterior approach to cervical fusion?

  The posterior approach allows for wider exposure of the spinal canal, better visualization of multiple levels of pathology, and can address bilateral symptoms. It provides good structural support through direct instrumentation.

• What is the role of bone grafts in cervical fusion?

  Bone grafts serve as biological scaffolding to promote fusion between vertebrae. They can be sourced from autograft (patient’s own bone), allograft (donor bone), or synthetic materials, and help restore disc height and spinal alignment.

• What are the benefits of using a disc replacement instead of fusion?

  Disc replacement preserves more natural motion at the treated level compared to fusion, which may reduce stress on adjacent segments. This can potentially slow the development of degeneration at neighboring discs.

• Is there a minimally invasive option for cervical spine surgery?

  Yes, minimally invasive cervical fusion techniques use smaller incisions and specialized instruments to access the spine. Benefits include reduced muscle trauma, less blood loss, shorter hospital stays, and faster recovery compared to traditional open surgery.

• What is cervical spondylolisthesis?

  Cervical spondylolisthesis is a condition where one cervical vertebra slips forward or backward relative to the adjacent vertebra, often due to degenerative changes or instability. This can lead to nerve compression and pain.

• Can physical therapy alone treat cervical spine problems?

  Physical therapy is beneficial for many cervical conditions, but if there is significant nerve compression, structural instability, or failed conservative treatment, surgery may be necessary for optimal outcomes.

• What is the cost of cervical fusion surgery?

  The cost of cervical fusion surgery varies based on the complexity, number of levels, hospital, and surgeon. Most insurance plans cover medically necessary procedures. Patients should consult with their insurance provider and surgeon’s office for specific cost information.

• What is the recovery timeline after cervical fusion?

  Recovery varies by individual and surgical complexity. Most patients return to light activities within 2-4 weeks, resume work within 4-8 weeks, and achieve full recovery within 3-6 months as the fusion solidifies.

• Are there any long-term restrictions after cervical fusion?

  After fusion, patients are generally advised to avoid excessive neck twisting, avoid carrying heavy weights, and limit contact sports. Most patients can resume normal daily activities, desk work, and light exercise without major restrictions.

• Can cervical fusion be performed at multiple levels?

  Yes, cervical fusion can be performed at multiple levels (two-level, three-level, or more) depending on the extent of degenerative disease or instability. Multi-level fusion addresses pathology at several vertebral segments.

• What is adjacent segment degeneration?

  Adjacent segment degeneration is accelerated wear and tear that can develop in the discs or joints adjacent to a fused segment over time. This may result from altered biomechanics, but most patients remain asymptomatic.

• Is cervical fusion a permanent solution?

  Cervical fusion is generally considered a permanent solution for the treated segment. Once bone fusion is achieved, the vertebrae remain fused. However, lifestyle modifications and proper posture help maximize long-term success.

• What should patients do to optimize fusion success?

  To optimize fusion success, patients should follow post-operative precautions, attend physical therapy, quit smoking, maintain good posture, avoid heavy lifting, achieve a healthy weight, and adhere to follow-up appointments for monitoring.

• What is the difference between anterior and posterior cervical fusion?

  Anterior fusion approaches the spine from the front, ideal for ventral pathology with direct disc access. Posterior fusion approaches from the back, better for dorsal pathology or multiple levels. Surgeon expertise and specific pathology determine the choice.

• How long does it take for bone fusion to achieve solidity?

  Bone fusion typically requires 3-6 months to achieve initial solidity, with complete bony fusion occurring over 12-18 months. X-rays and CT scans are used to monitor fusion progress at follow-up appointments.

• Are there any activity restrictions during the first few months after surgery?

  Yes, during the first 3-6 months, patients should avoid heavy lifting (over 5-10 pounds), vigorous exercise, repetitive neck movements, and high-impact activities. Progressive return to normal activities is guided by the surgeon.

• How successful is cervical fusion surgery for pain relief?

  Cervical fusion surgery has high success rates for pain relief, with most patients experiencing significant improvement in neck pain and arm symptoms. Success rates vary between 80-90% depending on patient selection and surgical technique.

• What is the role of bracing after cervical fusion?

  Yes, patients can return to work after cervical fusion. The timeline depends on job demands – desk workers may return within 4-6 weeks, while those with physically demanding jobs may need 8-12 weeks.

• What should you do if you experience persistent pain after surgery?

  Report persistent pain to your surgeon immediately. This may indicate complications or inadequate fusion that require investigation and possible revision surgery.

• Proper posture is crucial both before and after surgery. It reduces strain on the spine, supports the fusion, improves healing, and prevents long-term complications.

• Is it normal to have some numbness or tingling after cervical fusion?

  Some numbness or tingling can occur temporarily after surgery due to nerve irritation during the procedure. Most often this resolves within weeks to months. Contact your surgeon if it persists.

• What is the difference between ACDF and PCDF?

  ACDF (Anterior Cervical Discectomy Fusion) accesses the spine from the front, while PCDF (Posterior Cervical Discectomy Fusion) accesses from the back. Choice depends on pathology location.

• What are the key differences between minimally invasive and open cervical fusion surgery?

  Minimally invasive cervical fusion uses smaller incisions and specialized instruments, resulting in less muscle damage, reduced blood loss, and faster recovery compared to open surgery. However, open surgery allows for better visualization and may be preferred for complex cases. The choice depends on the patient’s condition and surgeon expertise.