Cervical Fusion FAQ’s

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 surgery. 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?

Cervical spine fusion can be performed routinely from the front of the neck or the back of the neck. The type of surgery needed depends on the type of problem the patient is having. The decision as to go from the front or the back of the neck is taken by the spine surgeon after discussion with the patient with regards to the type of problem the patient has and how it can be relieved.

How much of the disc is removed?

In the more common spine fusion in which it is done from the front of the neck, almost all of the disc is removed between the two vertebrate so as to create a good environment for spine fusion.

Why have a cervical fusion for a disc prolapse, and not just a discectomy?

There are few patients who are good candidates for cervical discectomy which is done from the back of the neck, but most of the patients are not a good candidate for such a surgery, in which case we have to go from the front of the neck to remove the disc and do what is called Cervical Fusion Surgery. When duly performed, both of the procedures can give good results in appropriate patients.

What is the risk of failure?

Rarely patients may have failure from a spine fusion surgery, which may present in the form of persisting pain in the neck or in the arms, or worsening of the symptoms. In these cases, further investigations are done, so a to find the cause of the symptoms as well as failure if there is any. If the symptoms are not relieved by conservative measures, or the symptoms are progressively worsening, these patients may need surgery, which may be a revision or may be an augmentation of the previous surgery. A decision as to what type of surgery is done is taken after discussion with the patient.

Can the metal break?

Occasionally the patient is not able to fuse over a period of time, then the metal may fatigue due to mobility at the fusion site and may fracture. Some of these patients may go on to fuse after the metal breaks, while other may need a revision surgery.

What are some of the common complications?

Common complications of a cervical spine surgery are bleeding, temporary or permanent neurological deficits, rarely infection, leak of cerebral spinal fluid, injury to the windpipe, food pipe, or the major vessels in the neck, damage to nerves/spinal cord causing deterioration of neurological symptoms, blindness, and other complications related to the anesthesia.

Will the screws need to be removed?

Implants put into cervical spine usually do not need removal unless they are causing problems, or the patient needs to undergo a revision surgery. The implants are not removed for cosmetic purposes.

Is there a chance the fusion won’t work?

There is a small chance that surgery by fusion may not help the patient. This may happen if the fusion fails or if the patient has pain due to symptoms other than what the fusion has been done for. Exacerbation needs to be re-investigated to find the cause of pain. Occasionally, the patient may start having issues at a different level after being relieved at the symptomatic level after surgery. In such a case, the patients need to be managed for a different level accordingly.

What would cause neck pain six months post cervical fusion?

Usually patients are pain free or with minimal pain at six months post cervical fusion. If the patient still has some pain, they should consult their spine surgeon. Occasionally there may be nonunion, that means the bones are not able to fuse, which may be causing the residual pain. Certain investigations like X-rays or maybe CT scan may be needed to confirm the finding. Rarely, the patient may have infection that may cause some of the symptoms and need to be investigated and treated.

How do I tell if my spine fusion has become undone?

Spine fusions usually take a very predictable course and are completely fused by three to five months. If fusion has not been successful, then the patient will have symptoms in the form of neck pain or pain going down the arms with or without tingling and numbness. The patient should follow up with their spine surgeon who will do specific investigations in the form of X-rays and CT scans to confirm their findings.

What are the benefits of the surgery?

If the symptoms of the patient are not relieved by conservative means, then a surgery is needed. Surgery can in most cases relieve the patient completely of all the symptoms including pain, tingling, and numbness. Occasionally, severe symptoms like weakness or involvement of bowel or bladder or balance may not be completely corrected even after a successful surgery.

What is the recovery process or timeline for anterior cervical discectomy and fusion?

Most of the patients are able to walk away on the day of surgery. They are able to take care of their activities of daily living within the first week. The pain improves gradually and is better by three to four weeks. Patients in desk-type jobs can be back to work in four to six weeks, and those in heavy jobs may take longer. A fusion usually takes about three to five months to heal completely.

How’s life after the surgery?

After one to two level spine fusions surgery or after total disc replacement of the cervical spine, the patient is usually back to his normal life as before the problem started in about three to five months. Many of our patients do not have any complaints after that period. A few patients may have occasional off and on pain, which is usually relieved by use of antiinflammatory medications.

If a cervical screw comes loose one month post operatively in a multilevel fusion, what is a proper protocol for treatment?

Usually patients are in their followup with their spine surgeon at one month followup, and on x-ray, the surgeon may inform him about loosening of the screw. Most of the times, if the patient has no symptoms, these patients are treated conservatively without any surgical intervention, and they go on to uncomplicated fusion over time. If the patient has symptoms that seem to be coming out of the loose screw or if there is movement of the spine because of loosening of plate or fracture, the patient may need revision surgery.

Is the surgery the right option for someone with my condition?

The answer to this question is found after a detailed discussion between the surgeon and the patient. The patient should discuss regards to different options with the surgeon and come to an informed decision. If a patient failed all forms of conservative management, is having worsening of symptom or if there is presence of weakness or bowel or bladder involvement or gait issues, then surgery may be the best answer at that time.

How are the vertebrate fused together?

Vertebrate have disc in between them, which keeps them mobile and helps in movement. If the disc is diseased and is causing symptoms, then a decision of fusion may be done, in which case physically the disc is removed, and the bone tags are repaired so as to cause union. A spacer can also be put between the two vertebrate so as to keep the gap intact while fusion happens. There are multiple form of bone or other products that can be used to maintain the space as well to promote the fusion between the two vertebrate.

What can I do to avoid surgery?

Surgery is usually not the first step for patients presenting with radiating pain, neck pain, tingling or numbness. Patients who present with rapid deterioration of neurological symptoms, like weakness, bowel or bladder involvement, or gait problems, may be a candidate for urgent or emergent surgeries. In all the other cases, patients need to be treated conservatively with medications with or without physical therapy and other modalities. Only when the patient has failed all these modalities, are they a candidate for surgical intervention.

When do I need surgery?

Surgery is needed when the patient has failed all forms of conservative management with no relief in the pain over a period of four to six weeks or more. The patient may need an earlier surgery, which may occasionally be urgent or emergent also in case they are having weakness in muscles or involvement of bowel or bladder or gait problems.

Will I have irreversible damage if I delay surgery?

If the patient has developed neurological involvement in the form of weakness, bowel or bladder involvement or gait problems, there may be a residual neurological deficit even after the surgery. Though surgery helps in removing the pressure from the compressed nerves of the spinal cord, but the recovery of nerves happens by a natural process in which body heals by itself. The presence of chronic disease may also hamper such a healing process.

What are the new treatments on the horizon?

Spine surgeons have been doing cervical and lumbar disc arthroplasty of disc replacement for many years now with very good results. Spine surgeons have also been doing minimally invasive discectomies in which case fusion may not be needed and the patient may begin its mobile segment. Some patients may be a candidate for a procedure called laminoplasty which is done from the back of the neck and in which fusion is not required. In patients of lumbar stenosis, an implant can be inserted in the back without disturbing the anatomy of the spine to increase the space for nerve roots. There are many more surgeries which are being tried on a research basis and not yet to be validated.

What is the degenerative disc disease?

Degenerative disc disease is a process of aging of the disc. The disc gradually loses its water content and becomes stiffer henceforth causing loss of flexibility and motion within the vertebra. This usually happens as a part of aging process, but it can be accelerated due to certain other conditions like chronic diseases, smoking, injury, overuse, trauma etc.

Will I need surgery? I am experiencing electric shocks?

Worsening tingling, numbness or weakness or feeling of electric shocks going down the arms or legs are serious symptoms of cervical or thoracic disc disease. These patients should be seen by a spine surgeon as soon as possible and there may be a chance that they will need surgery to be relieved from these symptoms. If these patients are not taken care of they may develop neurological deficit which may or may not be irreversible.

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