Anterior Cervical Surgery Versus Posterior Cervical Surgery
Sometimes, it is a difficult question for the patient and even for the surgeon to decide if the patient needs surgery from the front or the back of the neck. There are multiple factors that help in the decision making of the approach to the neck.
The location of the pathology has a considerable effect on the decision making of the approach. If the pathology is located in the front of the neck then going from the front may be a better option and vise versa.
Also, the number of levels involved as well as the time of disease process on its natural history timeline helps in understanding and deciding the approach. Patients who have wear and tear over multiple segments can be better treated from the back of the neck.
The contour or the posture of the neck also is important. The patients who have lost their normal contour are not a good candidate from the surgery from the back of the neck. These patients are at a high risk of further worsening of the contour if surgery is done from the back. Surgery from the front of the neck can help regain the posture back to normal or near normal.
Patients who have significant neck pain are a candidate for fusion surgery, which can be done either from the front or the back of the neck. Patients who do not have significant neck pain can be a good candidate for non-fusion surgery, which includes laminoplasty for cervical spondylotic myelopathy or foraminotomy for nerve root pain or radiculopathy. Both of these surgeries are done from the back of the neck.
What is the difference between surgery from the front or the back of the neck?
The results from a surgery done either from the front or the back of the neck not only depends on the approach but also depends on the type of pathology and its expected results. The approaches do differ in recovery as well as complications.
Patients who undergo surgery from front recover faster as compared to one who gets surgery from the back of the neck. The wound healing may be delayed with the higher incidence of infection in surgeries, which are performed from the back of the neck. Patients may have neck pain or loss of neck contour after surgery from the back of the neck.
Occasionally, the patient may need support on the neck from both sides and may have to undergo surgeries from the back as well as the front of the neck. A thorough discussion between the patient and the physician about the disease process, the anatomy of the neck, symptoms, and expectations is helpful in making a decision regarding the type of surgery as well the approach being from the front or the back of the neck.
Decision Making: Anterior Cervical Vs Posterior Cervical Surgery
As in most other situations the decision making between an approach from the front or the back is not straightforward and there are multiple variables in play.
It is not just the surgical approach being from the front of the neck or from the back of the neck that decides the result of the surgery. Surgical results also depend on the disease process as well as its presentation, severity, associated symptoms, natural history of the disease and expected results.
In a usual most common presentation of cervical radiculopathy that is pain with tingling or numbness going down into one arm, the approach depends on the condition of the disc.
If the disc is in good condition then a minimal invasive posterior non-fusion approach can give good results with minimal long term effects. This approach includes relieving the pressure from the nerve root, which is being compressed by the disk material and the process is called microdiscectomy and foraminotomy.
If the disc is degenerated and the patient has no neck pain then they can be a good candidate for Total Disc replacement arthroplasty. In this surgery, the natural diseased disc is replaced by an artificial disc. This allows us to restore normal functionality of the disc and at the same time taking care of the disease process.
If the patient has neck pain also and has a diseased disc, then a procedure from the front involving removal of the disk followed by fusion surgery may be more beneficial. The surgery involves replacing the disk with the cage and graft material, supplemented with a plate. This allows us to take care of the pathology and the disk to fuse. The surgery is called Anterior Discectomy and Fusion (ACDF).
Patients with radiculopathy can usually be treated with either of the above mentioned surgery.
Some patients may present with myelopathy, which means weakness of the arms and/or legs with issues with balance, dexterity and/or bowel and bladder function. These patients can be treated either from the front or the back depending on the number of levels involved, contour of the neck, presentation etc.
Overall patients with bad neck contour are preferably operated from the front while those with good contour can be treated from either side. Patients with one or two level involvement can be treated with Disc replacement arthroplasty from the front. All attempts are made to do a surgery from the front, so as to restore the anatomy as well as allow decompression of the nerve roots and the spinal cord.
Patients with weakness associated neck pain are preferably treated with fusion surgery rather than non fusion surgery like disc replacement or laminoplasty.
Patients with weakness, multilevel involvements and good neck contour are better treated from the back. If they do not have neck pain, avoiding fusion by doing a motion sparing surgery called Laminoplasty can give good results.
If the patient has weakness, neck pain along with multilevel involvement then fusion with an approach from the back of the neck will give better results. This surgery involves removing the back of the vertebra and fusing them with screws and rods at multiple levels. The surgery is called Laminectomy and Posterior Cervical Fusion.
Patients who present early in the course and have not responded to conservative means respond very well to surgical treatment.
Patients who are late in the course of disease and already have weakness with or without involvement of bowel, bladder or gait, balance may have incomplete recovery from the surgery.
Surgery in such patients is directed towards stopping further progression of the disease and further neurological deficit by optimizing the condition of the spinal cord and nerve root. Recovery is expected, though not complete and is not guaranteed.