Minimal Invasive Cervical Spine Surgery FAQ’s

A few patients are a good candidate for minimally invasive cervical discectomy. These surgeries are done from the back of the neck and through a small bony window, a part of disk is removed. These patients may avoid fusion surgeries and surgeries from the front of the neck.

A few patients with cervical disk disease may be a candidate for minimal invasive spine surgery. These patients essentially present with radiculopathy in the form of pain, tingling or numbness in one extremity and do not have neck pain. The physical examination, as well as radiological finding in the form of X Rays and MRI, helps a physician understand if the patient is a good candidate for minimal invasive spine 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Physical therapy may be required after minimal invasive spine surgery to optimize the recovery as well as rehabilitation from the problem as well as the surgery. Physical Therapy helps in pain control as well as stretching and strengthening of the muscles.

MISS done in carefully selected patients can give very good results. In certain patients, MISS is not the right choice, and offering these patients the MISS may lead to incomplete resolution of symptoms from a residual disease or worsening of the problem.

Minimal invasive spine surgery has been there for many years now and has well proven its effects. In selected patients, minimal invasive spine surgery can give very good results, and has been well proven by multiple research studies.

MIS surgery should only be performed in carefully selected patients who want to show good results. If these surgeries are performed in patients who are not good candidate for MIS surgeries, the result can be detrimental and even disastrous.

MISS is a well-established technique and most of the insurance cover MISS surgeries.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.