ANTERIOR CERVICAL DISCECTOMY AND FUSION
This is now a common surgical procedure that is designed to relieve some of the irritation that a bulging, prolapsed or herniated disc, thickened ligament or new bone formation is causing a nerve in the neck. Before this I will have discussed other possible options. The aim is to improve the symptoms that you experience which are going into your arm. This includes the pain and pins and needles. Although there is some evidence to show that it may help neck pain, the procedure is not guaranteed to help your neck pain at all. There is also no guarantee that any numbness or weakness that you are experiencing will get better. The main aim is to stop the numbness or weakness getting worse. Of course many people do find that things do get better and it can take up to twelve months for these improvements start to become noticeable. There is an over 80% chance that you will be very happy with the result of this operation.
Before the operation
You will be contacted by the hospital and invited to come for a pre-assessment. You will have some routine blood tests and have your pulse and blood pressure checked. You may also need to have an electric tracing of your heart activity. You will need to come into hospital on the day of your surgery. When you come in the nurses will check that you are ready for your surgery and will fit stockings on your legs to reduce the risk of getting a deep vein thrombosis. I will visit you in your room and check that you are prepared to have your surgery. You will also be visited by the anaesthetist who will review all the tests that you have had and discuss the anaesthetic with you. You will be escorted down to the operating theatre. Your anaesthetic will be administered and you will then be asleep.
This involves having a general anaesthetic. You will be placed on your back. I shall tape your shoulder down to improve the chance of getting better x-rays of the neck. With the aid of an x-ray I will make a cut in the neck in line with the level that the disc has prolapsed. I will then peel the muscles apart and create a route down to the spine. I shall move the main blood vessels to one side and the gullet and wind pipe to the other. The spine will then in directly in front of me. I shall place a needle in to the disc and repeat the x-ray to confirm that we are operating at the correct level. If I am satisfied I shall start to clear the disc material from the spine. As well as taking away the disc I shall remove the ligament a the back of the disc. Sometimes disc material does prolapse out past this ligament and although the risk of damage to the nerves is slightly higher, I feel that this is balanced by the possibility of not creating enough space for the nerves. Some of the bone around where the nerve travels out of the spine is also removed to ensure that it is not trapped in its passage. Once I feel that I have removed sufficient amount of bone and that the nerves are no longer trapped I will washout the area to clear away any free bone or disc material, I will size the gap of the disc space and insert a cage to maintain the gap and the normal curvature of the cervical spine.
I will administer local anaesthetic to the area to try to reduce the amount of discomfort that you will experience. The stitches that are used dissolve over time. There may be a little plastic tube coming through the neck to ensure there is no significant collection of blood that could build up and cause pressure on the nerves and wind pipe. There will be a waterproof dressing placed over the wound and it is safe to shower with this on. You are unlikely to be placed into a collar. The whole procedure takes about one and a half hours to two hours, but you are usually off the ward for much longer because of the anaesthetic time and the time that you will spend in the recovery ward before you are awake enough to return to the ward.
The operation is designed to relieve your arm pain. Although this is a routine procedure it is important to be aware of the risks involved.
- Surgery always carries with it a risk of infection although this is rare. This may lead to a temporary increase in neck pain and an antibiotic may need to be prescribed. An increase in neck pain may occur for up to a year may be permanent. The risks of infection are approximately 1%
- Significant bleeding is very uncommon but the surgery does go very close to the main blood vessels of the neck and it is possible that these could be damaged
- Damage to nerves. Numbness, pins and needles and weakness may improve after surgery but recovery may be slow. If there are severe symptoms before surgery, there may be some ongoing numbness and weakness after the operation which if the nerve has been permanently damaged may not recover. On very rare occasions, the nerve may be damaged at the time of the operation leading to an increase in pins and needles, numbness and weakness. This happens in less than 1% of patients
- Damage to the nerves to the voice box and gullet. This is extremely rare and permanent change happens in less than 3% of cervical spinal surgery. Bruising of the nerves can result in temporary change. This can produce a hoarseness and change to the voice making it “breathy”. In rare cases this change can be permanent. Many people will experience a fullness or difficulty swallowing. In some studies up to half of people have some discomfort swallowing for up to six months. This is due to a combination of bruising to the muscles and nerves of the gullet during the surgery.
- Dural tear. A tear to the lining of the sac containing the spinal cord can cause a nasty headache. This is due to a leak of the fluid that surrounds the nerves and brain. The tear is patched during the surgery and you may have to lay flat for a while after the operation to allow it to seal over. It can cause headaches which may last for a few days but should wear off completely. It does not seem to change the final outcome of the surgery
- Ongoing neck pain. On occasions, neck pain can be the same or even a little worse after neck surgery. The main aim of spinal decompression surgery is to improve your arm pain
- Wrong level. The incision or cut that is made in your back is quite small and it would be easy to be operating at the wrong level of the spine as the bones look very similar. That is why I take multiple x-rays during the operation to be sure that I am working at the correct level.
Risks Related to Anaesthetics
Modern anaesthetics are extremely safe. However, as with all general anaesthetics, there is a very small risk of complication concerning the anaesthetic during the procedure. Any existing medical conditions will be taken into consideration.
There are a number of complications that can occur in any operation e.g. blood clots, heart attacks, and chest infections. The risk of these complications in a person of average good health is low. If you have any medical conditions or are taking any medicines it is very important that you inform the pre-assessment nurse, surgeon and the anaesthetist. Some people find that they are left with a tender or bulky scar, to prevent this I will suggest that once the wound has healed, at about two weeks, you start to massage the scar itself. You can use a cream or oil if you want.
After the Procedure.
You will then be placed back in your bed, woken up and taken to the recovery area. Here your pulse, blood pressure and breathing will be closely monitored. Once the staff are sure that you have woken up fully from the anaesthetic and that your pain is well controlled they will organise for you to transferred back to the ward. Later the same day either the physiotherapists, nurses or myself will get you out of bed and start you standing and walking. So long as you have fully recovered from the anaesthetic and your blood pressure is normal, we will encourage you to walk.
Your spine is still stable after the operation. It is absolutely fine for you to start to move around after the operation as much as is comfortable. The speed with which you get moving again is largely determined by how comfortable you are. Most people are able to leave hospital the next day. Some people are well enough to leave the same or next day. You should be self caring when you leave hospital but will obviously need help with cooking, shopping and cleaning. I tend to advise against driving for 4 weeks.. The idea is to be comfortable enough behind the wheel of a car such that you would have full confidence that you would be able to cope in an emergency. I discourage people from excessive movements of the neck for even as far as 6 weeks down the line and turning your head round to be able to see behind you when driving is discouraged for the first 4 weeks.
It is vital that you play an active part in your recovery. You may feel some discomfort but you are not harming yourself. Your exercises will help you return to normal more quickly and to feel better in yourself. It is quite safe to take painkillers to help you to do this. If arm pain recurs, you should ease off and rest until symptoms settle. Gradually increase the level of strenuous activity and lifting and generally by 2-3 months you should be back to normal.
Generally I would want you to have a minimum of two weeks off work after your surgery. Depending on how you travel to work and the duties you are required to perform will determine how long it will be before it is advisable for you to return to work. If you are able to return to work with reduced hours and on lighter duties this will be quicker than if you have to wait till you are fully fit.
If you perform any particular sports please discuss this with me so that I can advise you as to what would be safe. I will be able to give you guidance as to what would be considered safe and how to gradually increase the activites so that you are able to return to your sport in a safe manner.
THE FIRST WEEK
A local anaesthetic is injected into the wound at the time of surgery, which should help with pain relief.
You will be given painkillers as required on the ward and for you to take home if needed.
It is important to start moving and if pain is preventing you from doing this let us know and we may be able to alter you pain medication to help you to be able to become independent.
You may find that your arm pain is still very much the same as before. In some cases the nerve irritation does take a while to settle down. In addition you will have the pain of the operation. Although this is a different pain you may find that you need to take just as many pain killers as before to keep this under control. Do not expect to be completely pain free.
If you do not feel significant pain it may still be important to take the pain killers that you have been given. It is better that while you are increasing your level of activity you do not feel inhibited by increasing pain.
BED MOBILITY AND EXERCISES
You can sleep in any position you wish. Whichever position is most comfortable to allow you to sleep well is fine.
Whilst in bed, you can lie on your side or sit slightly propped up as comfort allows.
Early mobility is very important and the physiotherapists will start you walking within 24 hours of surgery, the same day if possible.
Generally if it is comfortable to do it is safe to do. Remember to build up gradually.
Discharge from hospital is normally within 1-3 days after your operation.
You will be given a sheet of exercises by the physiotherapists to continue at home. If you are comfortable you can increase these, but build up in small amounts. It is a slow recovery and is not meant to be a race.
WEEKS 2 - 6
For the first couple of weeks it is recommended that you avoid:
- Driving as your neck movements will be restricted and you will find it difficult to turn and look behind you to reverse safely. You can be a passenger.
- Sitting for a long time – for example longer than 20 minutes. The length of time that you will be able to sit and stand for will gradually get longer over this time.
- Getting into the bath until your wound is clean and dry
- Prolonged rest – you will get stiff and your muscles will get weaker
Return to Normal Activity
It is vital that you play an active part in your recovery. You may feel some discomfort but you are not harming yourself. Your exercises will help you return to normal more quickly and to feel better in yourself. It is quite safe to take painkillers to help you to do this. If arm pain recurs, you should ease off and rest until symptoms settle. Gradually increase the level of strenuous activity and lifting and generally by 3 months you should be back to normal.
- You can start back to normal activities, as you feel able to do so.
- You may want to ask someone else to do the hoovering in the early stages.
- Avoid lifting heavy furniture.
- After 12 weeks it is expected that you can lift as you normally would do but use your common sense.
Return to work
- If your job involves sitting at a desk, you may return after 2- 6 weeks, depending on how you are progressing. It is often possible to return to working from home with reduced hours as early as 2 weeks. Working from home or for reduced hours and lighter duties are ways that you may be able to return to work sooner and should be discussed with your employer
- Your ability to get to work, such as being able to drive a car, and how long you can sit for any length of time may actually determine when you can return to work.
- If your job involves heavy lifting, you may need to delay your return for 2-3 months. It is recommended that you discuss your job with the Consultant.
I will advise you when you can start to return to your normal sports after the operation. If you tell him which sports you do he will advise you accordingly.
- This may be resumed once you feel comfortable to do so
- You can try different positions to find out which is most comfortable for you.
YOU SHOULD CONTACT US IF YOU EXPERIENCE ANY OF THE FOLLOWING AFTER YOUR OPERATION:
A loss of sensation or change in your ability to move your bowels or empty your bladder.
Any significant leg pains and pins and needles.
Any redness, oozing or discharge from your wound.
Feeling unwell with a raised temperature.
Changes in your walking pattern.