GUIDE TO MINIMALLY INVASIVE ANTERIOR CERVICAL MICROSCOPIC DISCECTOMY
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.
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
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.
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
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
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.
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.
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.
at left indicates the plate and 4 screws (each pair superimposed).
Stephen Saris M.D.