Multiple chronic pain case
Melbourne Victoria Australia

TREATMENT OPTIONS: NECK (CERVICAL) Anterior Cervical Discectomy Anterior Cervical Discectomy with Fusion Foraminotomy Corpectomy Laminoplasty Recovery

Anterior Cervical Discectomy What is it? Pain in the neck and extremities, among other symptoms, may occur when an intervertebral disc herniates – when the annulus fibrosus (tough, outer ring) of the disc tears and the nucleus pulposus (soft jelly-like center) squeezes out and places pressure on neural structures, such as nerve roots or the spinal cord. Bony outgrowths, called bone spurs or osteophytes, which form when the joints of the spine calcify, may also cause these symptoms. Anterior cervical discectomy is an operation that involves relieving the pressure placed on nerve roots and/or the spinal cord by a herniated disc or bone spurs – a condition referred to as neural compression. Through a small incision made near the front of the neck (i.e., the anterior cervical spine), the surgeon removes disc material and/or a portion of the bone around the nerve roots and/or spinal cord to relieve these compressed neural structures and to give them additional space. Discectomy involves removing all or part of an intervertebral disc. The term discectomy is derived from the Latin words discus (flat, circular object or plate) and -ectomy (removal).

Why is it done? Pressure placed on neural structures, such as nerve roots or the spinal cord, by a herniated disc or bone spur may irritate these neural structures and cause: pain in the neck and/or arms; and lack of coordination, numbness or weakness in the arms, forearms or fingers. Pressure placed on the spinal cord as it passes through the neck (cervical spine) can be serious since most the nerves for rest of the body (e.g., arms, chest, abdomen, legs) have to pass through the neck from the brain. Patients who suffer from these symptoms are potential candidates for this operation.

The Operation An understanding of what an anterior cervical discectomy involves will help you to approach your operation and recovery with confidence.

Incision: The operation is performed with you lying on your back. A small incision is made to one side of the front of your neck.

Exposure: After pulling aside the soft tissue – fat and muscle, your surgeon exposes the source of the neural compression.

Removal: Disc material – and, in some cases, a portion of the bone – around the nerve roots and/or spinal cord is then removed to relieve the compressed neural structures and to give them additional space.

Closure: The operation is completed when your surgeon closes and dresses the incision.

Recovery: Your surgeon will have a specific post-operative recovery/exercise plan to help you return to normal life as soon as possible. The amount of time that you have to stay in the hospital will depend on this treatment plan. You will normally be up and walking in the hospital by the end of the first day after the surgery.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Anterior Cervical Discectomy with Fusion What is it? Pain in the neck and extremities, among other symptoms, may occur when an intervertebral disc herniates - when the annulus fibrosus (tough, outer ring) of the disc tears and the nucleus pulposus (soft, jelly-like center) squeezes out and places pressure on neural structures, such as nerve roots or the spinal cord. Bony outgrowths, called bone spurs or osteophytes, which form when the joints of the spine calcify, may also cause these symptoms. Anterior cervical discectomy with fusion is an operation that involves relieving the pressure placed on nerve roots and/or the spinal cord by a herniated disc or bone spurs - a condition referred to as nerve root compression. Through a small incision made near the front of the neck (i.e., the anterior cervical spine), the surgeon: Removes the intervertebral disc to access the compressed neural structures Relieves the pressure by removing the source of the compression Places a bone graft between the adjacent vertebrae, and In some cases, implants a small metal plate to stabilize the spine while it heals. Discectomy involves removing all or part of an intervertebral disc. The term discectomy is derived from the Latin words discus (flat, circular object or plate) and -ectomy (removal). Spinal fusion involves placing bone graft between two or more opposing vertebrae to promote bone growth between the vertebral bodies.

Why is it done? Pressure placed on neural structures, such as nerve roots or the spinal cord, by a herniated disc or bone spur may irritate these neural structures and cause: pain in the neck and/or arms; and lack of coordination, numbness or weakness in the arms, forearms or fingers. Pressure placed on the spinal cord as it passes through the neck (cervical spine) can be serious since most the nerves for rest of the body (e.g., arms, chest, abdomen, legs) have to pass through the neck from the brain. Patients who suffer from these symptoms are potential candidates for this operation.

The Operation: An understanding of what an anterior cervical discectomy with fusion involves will help you to approach your operation and recovery with confidence.

Incision: The operation is performed with you lying on your back. A small incision is made to one side of the front of your neck.

Exposure: After pulling aside the soft tissue - fat and muscle, your surgeon exposes the disc between the vertebrae.

Removal: The intervertebral disc - and, in some cases, a portion of the bone around the nerve roots and/or spinal cord - is then removed to relieve the compressed neural structures and to give them additional space.

Material Placement: Through a separate incision, a small section of bone is obtained from your iliac crest (i.e., your hip) for use as a bone graft. The bone graft is placed in the disc space, where it helps the adjacent vertebrae to fuse.

Stabilization: A metal plate may be implanted on the front of the cervical spine to increase the stability of the spine immediately after the operation. Surgeons use these implants to decrease the amount of time that you have to wear a cervical collar after surgery and to increase your chances of developing a solid fusion.

Closure: The operation is completed when your surgeon closes and dresses the incision.

Recovery: Your surgeon will have a specific post-operative recovery/exercise plan to help you return to normal life as soon as possible. The amount of time that you have to stay in the hospital will depend on this treatment plan. You will normally be up and walking in the hospital by the end of the first day after the surgery.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Foraminotomy Cervical foraminotomy is an operation to enlarge the space where a spinal nerve root exits the cervical spinal canal to relieve the symptoms of a "pinched nerve."

Indications for Operation: Compression of the cervical nerve roots can cause neck pain, stiffness, and pain radiating into the shoulder, arm, and hand, as well as numbness, tingling and/or weakness in the arm and hand. Protruding or ruptured discs, bone spurs, and thickened ligaments or joints can all cause narrowing of the space where the nerve exits the spinal canal and cause the above symptoms. Patients who do not improve with conservative treatment may be candidates for the operation. What happens afterward? Some pain at the operative site is expected, but generally resolves over time and can be controlled with oral pain medicines. Some patients can be discharged the same day of surgery, but most patients will require 24-48 hours in the hospital. Most patients will notice immediate improvement in some or all of their symptoms, however some symptoms may improve only gradually. A positive attitude, reasonable expectations, and compliance with the doctor's recommendations all contribute to a satisfactory outcome. A cervical collar (brace) is rarely necessary. Most patients can return to their regular activities within several weeks.

The Operation

Incision: A small incision is made in the middle of the neck after localizing the area of interest with an x-ray.

Decompression: The muscles on the side of the spine involved are dissected and a retractor is placed. (Sometimes an endoscope and tubular retractor or microscope are used). Bone from the posterior arch of the spine and joint over the nerve are removed using special cutting instruments and/or a drill. Thickened ligament, bone spurs and/or bulging discs are removed to decompress the exiting nerve, which is checked with a probe to insure adequate space around the nerve root.

Closure: The muscles and tissues are closed in layers with absorbable sutures. The skin may be closed with absorbable sutures and steri-strips, or surgical staples, which are removed when the wound is well healed.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Corpectomy Cervical corpectomy is an operation to remove a portion of the vertebra and adjacent intervertebral discs for decompression of the cervical spinal cord and spinal nerves. A bone graft with or without a metal plate and screws is used to reconstruct the spine and provide stability. Indication for operation In some patients, the cervical spinal canal can be narrowed by bone spurs arising from the back of the vertebral body or the ligament behind the vertebral bodies. In this situation it may be necessary to remove one or more vertebral body and the discs above and below to adequately decompress the spinal cord and/or nerve roots because the area of compression cannot be addressed by an anterior cervical discectomy alone. What happens afterward? Most patients experience only mild discomfort at the operative site, which is generally well controlled with oral pain medicines. A mild sore throat is not uncommon and is usually short lived. Most patients are discharged from the hospital in 24-48 hours. Patients may notice immediate improvement in some or all of their symptoms, however, some symptoms may improve only gradually. A successful outcome will depend on your compliance with the health care provider's recommendations, and a realistic expectation for meeting the goals of surgery (which depend on one's condition preoperatively). Since cigarette smoking dramatically impairs bone healing, smoking cessation will significantly improve the likelihood for a successful fusion.

The Operation

Incision: The patient is positioned on their back. If using the patient's own bone, an incision is made over the hip to harvest bone from the iliac crest. For the corpectomy, a small incision is made on either side of the neck. (A longer "up and down" incision may be required for multiple corpectomies).

Decompression: The cervical spine is widely exposed by separating the spaces between the normal tissues. The discs above and below the vertebrae involved are removed. The middle portion of the vertebrae is removed (some of which is saved for use in the fusion) using special cutting instruments and drills to decompress the underlying spinal cord and nerve roots.

Reconstruction: A strut of bone is placed to span the bony defect and provide support to the front of the spine. The bone is incorporated (fused) into the remaining vertebrae over time. Bone from the bone bank (allograft) may be substituted for the patient's own bone. A metal plate and screws are often used to provide extra support and facilitate the fusion process.

Closure: Absorbable sutures and sometimes skin staples are used to close the incisions. A cervical collar may or may not be required for use after surgery. The doctor will follow the fusion with periodic x-ray exams after the operation.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Laminoplasty What is it? For patients with painfully restricted spinal canals in their necks, this procedure immediately relieves pressure by creating more space for the spinal cord and roots. The technique is often referred to as an "open door laminoplasty," because the back of the vertebrae is made to swing open like a door.

The Operation Incision: An incision is made on the back of the neck. A groove is cut down one side of the cervical vertebrae creating a hinge. The other side of the vertebrae is cut all the way through. The tips of the spinous processes are removed to create room for the bones to pull open like a door. The back of each vertebrae is bent open like a door on its hinge, taking pressure off the spinal cord and nerve roots. Small wedges made of bone are placed in the opened space of the door. End of Operation: The door of the vertebrae swings shut, and the wedges stop it from closing all the way. The spinal cord and the nerve roots rest comfortably behind the door.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

Recovery As you prepare yourself mentally to undergo spinal surgery, you also need to prepare yourself for the recovery period that will follow your operation. While the surgery entails work on the part of the surgeon, after that, the brunt of the work is in your hands. To ensure a smooth and healthy recovery, it is important that, as a patient, you closely follow the set of instructions that your surgical team gives you. Hospital Recovery After the operation, you will be brought to the recovery room or intensive care unit (ICU) for observation. When you wake up from the anesthesia, you may be slightly disoriented, and not know where you are. The nurses and doctors around you will tell you where you are, and remind you that you have undergone surgery. As the effects of the anesthesia wear off, you will feel very tired, and, at this point, will be encouraged to rest. Members of your surgical team may ask you to respond to some simple commands, such as "Wiggle your fingers and toes" and "Take deep breaths." When you awaken, you will be lying on your back, which may seem surprising, if you have had surgery through an incision in the back; however, lying on your back is not harmful to the surgical area. Prior to the surgery, an intravenous (IV) tube will be inserted into your arm to provide your body with fluids during your hospital stay. The administration of these fluids will make you feel swollen for the first few days after the operation. When you awake from the anesthesia, you may feel the urge to urinate. So, in addition to the IV, a catheter tube (also commonly called a Foley Catheter) will be placed into your bladder to drain urine from your system. The catheter serves two purposes: (1) it permits the doctors and nurses to monitor how much urine your body is producing, and (2) it eliminates the need for you to get up and go to the bathroom. Once you are able to get up and move around, the catheter will be removed, and you can then use the bathroom normally. During your hospital stay, you will get additional instructions from your nurses and other members of your surgical teams regarding your diet and activity. Proper nutrition is an important factor in your recovery. Your surgeon may restrict what you drink and eat, or place you on a special diet, depending on the surgical approach that was used during the operation. Calories and food intake are an important part of recovery. Some patients find that their physician orders are less restrictive than the diet they follow at home. After the surgery, you will continue to receive intravenous fluids until you are able to tolerate regular liquids, which typically involves gradually transitioning you from sips of clear fluids to full liquids (including JELL-O® gelatin). From there, you will be given small amounts of solid food until you are ready to return to a regular diet. With respect to physical activity, in most cases, your surgeon will want for you to get out of bed on the first or second day after your surgery. Nurses and physical therapists will assist you with this activity until you feel comfortable enough to get up and move around on your own.

Home Recovery Before you are discharged from the hospital, your doctor and other members of the hospital staff will give you additional self-care instructions for you to follow at home - a list of "dos and don'ts," which you will be asked to follow for the first 6 to 8 weeks of your home recovery. So, if you are unsure of any of these instructions, ask for clarification. Following these instructions is crucial to your recovery. Nowadays, surgery involves one or more incisions depending on the surgical approach used to perform the operation. Therefore, when you are discharged home you may still have a surgical dressing on your incision(s). Either a nurse will visit your home to change the dressing or a caregiver, such as one of your family members, will be taught to do it for you. It is important that the dressing be changed daily and kept dry. If any signs of infection are observed while changing the dressing, call your doctor. These signs include: Fever - a body temperature greater than 101°F (38°C) Drainage from the incision(s) Opening of the incision(s), and Redness or warmth around the incision(s). In addition, call your doctor if you experience chills, nausea/vomiting, or suffer any type of trauma (e.g., a fall, automobile accident). During this recovery period, you will also be instructed to keep your incision(s) clean, making sure only to use soap and water to cleanse the area. In general, you should not shower until your doctor has permitted you to do so. In addition to caring for your incision(s), you will also be encouraged to: Drink plenty of fluids Maintain a healthy diet (high in protein) Walk or do deep-breathing exercises, and Gradually increase your physical activity. Activities to avoid include any heavy lifting, climbing (including stairs), bending, or twisting. You should also avoid the use of skin lotion in the area of the incision(s); you need to keep this area dry until it has had the opportunity to heal well.

Follow up with your doctor on a regular basis during this post-operative period, and make sure to call your doctor if you have any concerns or questions.

As you read this, please keep in mind that all treatment and outcome results are specific to the individual patient. Results may vary. Complications, such as infection, blood loss, and bowel or bladder problems are some of the potential adverse risks of spinal surgery. Please consult your physician for a complete list of indications, warnings, precautions, adverse events, clinical results, and other important medical information.

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