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PATIENT GUIDE TO MINIMALLY INVASIVE ANTERIOR CERVICAL MICROSCOPIC
DISCECTOMY
 Neck
operations called anterior cervical diskectomies and fusions
are very common surgical procedures. They are generally safe, effective,
and expected to return you to normal activity within a few weeks
of surgery. Bear in mind as you read this that the operation has
changed for the better over the past few years. It is now a one
hour, outpatient procedure that is usually curative, and very safe.
Below is a guide to the procedure that I hope you will find helpful.
PREPARATION
FOR SURGERY: There is no special preparation for this
operation. You should eat or drink nothing after midnight before
the day of the surgery. If you take medications in the morning,
please take them as you normally would with a sip of water. There
is no special skin cleansing or preparation of any kind that need
be done.
THE
PROCEDURE: Once you enter the Operating Room, you will
be given an intravenous medication. This will put you deeply asleep,
and you will remember nothing of what occurs afterwards. The procedure
takes approximately an hour, after which I will immediately contact
your friends or family. From the time you are wheeled back to surgery
to the time I come out to speak with your friends or family is about
two and a quarter hours.
The procedure starts with a small incision slightly shorter than
a toothpick to the right of your Adam's apple. The incision
is almost always on the right side, regardless of which
arm or which side of the neck hurts. I attempt to put the incision
in a skin crease, so that 6-12 months after surgery it is often
not visible. Approximately two inches deep into the neck is the
front of the disk. Yours has been disrupted, and it is standard
practice to remove it entirely. The operating microscope is used
to perform all dissection near the nerves because that allows the
operation to be done very safely in a minimally invasive manner.
The next portion of the procedure is called the fusion. The discs
in the body are named for the bones they are between. For example,
there are seven bones in the neck, and if your disc rupture is between
the number six and number seven bones, it is called a "C6-7"
disc. The goal of the fusion is to make the C6 and C7 bones into
one bone. This is done by taking a piece of bone from our tissue
bank and sliding it between the two after the disk has been removed.
Over many months the bones will heal together as one. Many people
worry that taking a piece of bone from someone else presents the
risk of getting either hepatitis or AIDS. Although this is possible,
I have not heard of a single such case in over 25 years of practice,
and the chance of contracting such an illness is less than one in
many tens of thousands. Your body's own bone cells will soon begin
to replace this bone from the tissue bank. Many people also worry
that the fusion will decrease your ability to move your neck. There
will be no change in your neck motion that you can
notice. Most of this motion comes from the top three segments of
the neck, and your operation is far from there.
After the fusion,
I usually perform what is called a plating. It involves
putting a plate made out of either plastic or metal over the area
of the disk removal. This plate is extremely small, and is about
the size of a postage stamp. Two screws will go into the bone above,
and two below, to keep it in position. These plates have become
extremely popular in recent years for a number of reasons. The main
one is that they eliminate the need for a collar after the surgery.
In addition, they allow a very rapid return to work. This is usually
in a few weeks regardless of what kind of profession you engage
in. In addition, many people think that the percentage of people
who go on to have a solid fusion is significantly increased. The
plastic plate is what we usually use. It is a well-engineered
device that is extremely strong during the healing phase after your
procedure. Then, over a year or two, it disappears. We will occasionally
use the titanium metal plate if two levels need to be fused.
Following this,
the incision is closed. We no longer use stitches in the skin, only
paper strips (Steri-strips). For weeks to months after the surgery,
the incision will appear as a very thin and purple line. In some
people, it is more prominent than others. In general, between six
months and a year after the surgery, it will be difficult to see
the incision at all.
AFTER THE SURGERY: In general, you will go home immediately
after the surgery after a few hours in the recovery room. You will
have achiness in the throat that is likely due to the breathing
tube that was placed during the procedure. When you get home, difficulty
swallowing bothers many people. This is because the food pipe
(esophagus) has been pushed to the side so that the diskectomy and
the rest of the procedure can be performed. You will likely feel
as if food does not move well down your throat, though it does eventually
make it down into your stomach. Although very unpleasant, this should
ease up very quickly over a few days, and should be gone by two
weeks after the surgery. The dressing can come off the day after
the surgery. Try to leave the paper strips on your skin for 2 weeks,
as the longer they are on, the less noticeable your scar will be.
Eventually they will fall off. ]
On occasion, pressure on the voicebox (larynx and recurrent laryngeal
nerve) can produce hoarseness that can on occasion be very
bothersome. This almost invariably resolves in 2 weeks, but can
take up to 3 months.
In the weeks after the surgery, people commonly complain of annoying
pain in the low, back part of the neck and between the shoulder
blades. This symptom is related to the fusion that is slowly becoming
more solid. It can last several weeks, but is extremely rare after
that period of time.
In regard to activity, there are almost no restrictions. Apart from
contact sports, you may do most anything. Driving is allowed, as
are all other regular activities. Unless a complication arises,
you may return to work a few weeks after the surgery with no restriction
whatsoever.
RISKS OF OUTPATIENT SURGERY: : During my years of surgical
training in the 1980s, the standard of care was to remain in the
hospital for several days after this operation. However, as anesthesia
has improved, and as the operation has become less invasive under
the microscope, many surgeons have begun performing this as an outpatient.
We have performed one and two level procedures in this manner for
several years without a single, major mishap at home on the night
of the surgery. However, like any medical decision, there are benefits
and risks.
The benefit
is the simple advantage of being in your own home and bed to recover
from the microsurgery. Any painkiller you might receive via an intravenous
in the hospital, you can take as easily by mouth at home. We have
become increasingly concerned about hospital-acquired infections.
There is a particularly dangerous strain called "MERSA"
that is resistant to many of our best antibiotics and potentially
fatal. Outpatient surgery minimizes your exposure to such infections.
The main risk is internal bleeding or swelling after the
operation. In the cervical spine after a microdiskectomy, this could
result not only in weakness or paralysis of the arms and legs, but
closure of the airway with difficulty breathing and death. Again,
in over 25 years of performing this procedure, I have not caused
or heard of a single case of this.
It is your option
to remain in the hospital or return home. I recommend returning
home, and waiting until at least 11pm before going to sleep. If
there are any problems, call an ambulance or come immediately to
the emergency room. If you are more comfortable remaining in the
hospital overnight, let our staff know and we will arrange this
for you.
BENEFITS:
This is one of the most satisfying operations that I perform. Many
people have severe arm pain before the procedure, and the full expectation
is that this will be gone immediately after the surgery in the Recovery
Room. Not everyone improves that quickly, but most people do. The
strength will generally return quickly in a matter of a few weeks.
Numbness is the least predictable in regard to recovery, and you
may always have some numbness in the hand or forearm.
COMPLICATIONS: An ACDF is a very safe procedure. In the medical
literature, the risk of a serious complication such as a spinal
cord injury with partial or complete paralysis of the arms
and legs is under one half of 1%. I have performed over 1,000
of these procedures, and only one individual developed weakness
in the arms and legs after the surgery. Fortunately, he made an
almost complete recovery. The risk of an infection
is also under 1%. With the titanium plate, there is the risk of
one of the screws backing out into
the food pipe or the plate becoming loose. Again, in my over 20
years of neurosurgical practice that has only occurred two times.
In both patients, I needed to do another operation to correct the
situation; both patients did well. The chance of the bone not fusing
is in the range of 4%. The risk of hoarseness
is approximately 5%. This can be very annoying, but I have not had
a patient with hoarseness that lasted more than 3 months. There
are some specialists that believe that a fusion causes increased
stress at the spinal levels above and
below. This might lead to another herniated disk, or excessive
bone spur formation. I have not found this to be a problem in my
patients.
AFTER THE SURGERY: Following your surgery, as mentioned above,
you will likely go home immediately afterward. You are always free
to contact me in the office or through my answering service. In
general, either Rodd or I will see you a week after the surgery.
I will then see you about 6 weeks after the surgery, often after
a neck X-ray to see how the fusion is taking. The X-ray will be
similar to the picture at left.
________________
Stephen Saris M.D.
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