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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 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 join 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 30 years of practice, and the chance of contracting such an illness is less than one in 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 plastic or metal 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.

Following this, the incision is closed. We no longer use stitches in the skin, only paper strips (Steri-strips) or a thin watery film that makes the incision waterproof. You can take a shower 48 hours after surgery. For weeks to months afterward, the incision will appear as a very thin and perhaps 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: About half of our patients go home a few hours of the microsurgery. Whether or not you do so is determined by your reaction to the general anesthesia, the requirements of your insurance company, and whether there are concerns about post-operative internal bleeding. Given the proximity of the operation to the spinal canal, we tend to be conservative and keep patients overnight. Fortunately, we have not had a problem with such bleeding in over 15 years. This decision is made between me, you, your family, and the anesthesiology staff.

You will have achiness in the throat that is 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 fusion 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 the day after the microsurgery. Driving is allowed, as are all other regular activities. Unless a complication arises, you may return to work quickly after the surgery with no restrictions whatsoever. It is safe to do so the following Monday, though the average in our practice for years has been 3 weeks.

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. 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 and inability to breathe. Again, in over 30 years of performing this procedure, I have not caused a single case of this.

BENEFITS: This is one of the most satisfying and reliable 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 have some numbness in the hand or forearm for months.

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 for over three decades. The risk of an infection is also under 1%. There is the risk of one of the screws backing out into the food pipe or the plate becoming loose. Again, in my 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 virtually never lasts 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: You are always free to contact me in the office or through my answering service. In general, either Rodd or I will see you 2 weeks 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.

Red arrow at left indicates the plate and 4 screws (each pair superimposed).

The best way to reach us is email. We discontinued our answering service years ago. Any email will appear on Rodd or my iPhone immediately, and we can usually answer in under an hour.


Mr. Casper: roddcasper@cox.net

Dr. Saris: stephensaris@comcast.net


________________
Stephen Saris M.D.

Neurosurgery Associates, Inc.
1 Davol Square,
Suite 302
Providence, Rhode Island 02903


(401) 453-3545

FAX (401) 453-3533

email: contact@neurosurgery-associates.com

Copyright 2013 Neurosurgery Associates, Inc.

Neurosurgery Associates
Neurosurgery Associates