Cervical Spine
You have probably been referred to see a neurosurgeon because
of pain in your neck or shoulder, or perhaps tingling or
numbness in your arms. You may also have experienced some
weakness when using your arms or hands.
You may be wondering if there is a chance that everything
will return to normal or whether the surgery that may have been
talked about is very risky. These questions and concerns can be
addressed by your neurosurgeon, who is a physician trained in
the surgical treatment of disorders of the nervous system.
He or she will ask a number of questions and then perform a
neurological examination. Following a review of any x-rays or
other diagnostic tests you may have brought with you, additional
tests may be ordered if further information is needed. Finally,
he or she will propose a course of treatment which may or may
not involve surgery.
The decisions regarding your care should be reached after
discussions between you, your family and your neurosurgeon. This
booklet will help educate you about the issues involved in your
care.
Understanding the Problem
Your neck is part of a long flexible column extending through
most of your body often referred to as the spinal column, or
backbone. The neck region of the spinal column (the cervical
spine) consists of seven bones (vertebrae) shaped
like building blocks, which are separated from one another by
shock absorbing pads (intervertebral discs) (Fig. 1a).
Fig. 1a. Normal cervical anatomy showing relationship between
spinal cord, nerve roots and cervical disc.
These discs allow the spine to move freely and act as shock
absorbers during activity. Attached to the back of each
vertebral body is an arch of bone that forms a continuous hollow
longitudinal space much like a tube that runs the whole length
of your back. This space is the spinal canal, through which runs
the spinal cord and nerve bundles (Fig. 1b). The spinal
cord is surrounded by fluid (cerebrospinal fluid) and three
layers of protective membrane: the dura, the pia and the
arachnoid.
Fig. 1b. Cross-section of cervical vertebra showing relationship
between cervical spinal cord, nerve root and cervical disc.
At each vertebral level a pair of spinal nerves exit through
small openings called foramina (one to the left and one to the
right). These nerves serve the muscles, skin and tissues
of the body and thus provide sensation and movement to all parts
of the body. The delicate spinal cord and nerves are further
supported by strong muscles and ligaments that are attached to
the vertebrae.
Cervical Disc Disease
With age, injury, poor posture or diseases such as arthritis
there can be damage to the bone or joints of the cervical spine.
The cervical discs may become worn out and abnormal growths
(bone spurs) may form as a result of repetitive movement of the
disc. (Fig. 2a) Sudden movement or injury such as whiplash may
cause the disc to slip or herniate. The herniated disc or bone
spurs may narrow the spinal canal through which the spinal cord
runs or the small openings (foramina) through which spinal
nerves exit (Fig. 2b).
Fig. 2a. Cervical disc - osteophyte
Fig. 2b. Cervical disc (soft) - herniation
What problems might you experience?
Pressure on a nerve by a herniated (slipped) disc or a
bone spur may irritate the nerve resulting in pain in the neck
and arm, incoordination, or numbness or weakness in the arm,
forearm or fingers. Pressure on the spinal cord in the neck
(cervical) region can be a very serious problem because
virtually all of the nerves to the rest of the body have to pass
through the neck to reach their final destination (arms, chest,
abdomen, legs); therefore, the function of many important organs
is potentially at risk.
Initially, the symptoms of cervical disc disease may be
limited to neck pain and later arm pain; weakness or numbness
may also occur along with difficulty walking or incoordination
of the legs. Further progression may lead to severe impairment
or even paralysis.
Diagnosis
Your doctor will document your symptoms and find out the
extent to which these symptoms affect your life. The physical
examination will include an assessment of sensation, strength
and reflexes in various parts of your body to help pinpoint
which nerves or what parts of your spinal cord are affected.
Your doctor may then order studies to confirm the diagnosis
and determine more precisely the nature and extent of the
disease process. These studies may include:
Treatment
Cervical disc disease does not always mean that you require
surgery. In fact, many of your symptoms can be relieved by
nonsurgical management.
Your doctor may prescribe medications to reduce the pain or
inflammation and allow time for healing to occur. Bed rest,
reduction of physical activity or a cervical collar may also be
prescribed. The collar provides support for the spine, reduces
mobility and may reduce the pain and irritation.
To further relieve the pressure on the nerves in your neck
your doctor may prescribe a cervical traction device (Fig. 3).
This device is attached to your head and pulls up on it using a
pulley system and weights. It is usually applied a few times a
day and can be used while sitting or lying in bed.
Fig. 3. Cervical traction device for non-surgical treatment of
cervical disc disease.
What kind of surgery may be helpful?
There are several operations that may be used to treat
cervical disc disease. The selection of which operation and the
determination of when to perform the operation depend on many
factors, which obviously differ for each patient and doctor
combination. However, some general factors include the kind of
disc disease you have (herniated disc or bone spurs), whether
there is pressure on the spinal cord or spinal nerve, the
presence of one or more areas of disease within the cervical
spine, and if the spine is dislocated in addition to pressure on
the cord or nerves.
Other factors are determined by your age, how long you have
had the disease, other medical problems, previous operations on
the neck, and so on.
The particular combination of these and other factors will
determine the choice of surgical treatment.
Anterior Cervical Disectomy
This operation is performed on the neck to relieve pressure
on one or more nerve roots, or on the spinal cord. The procedure
is performed from the front, or anterior, approach.
Discectomy means to remove the disc (Fig. 4a).
Fig. 4a. Incision for anterior cervical disc surgery.
Surgery for anterior cervical discectomy is performed with
the patient under general anesthesia lying on his or her
back. The surgeon may place a traction device to pull on the
neck. During the course of the operation x-rays may be obtained
to assist the surgeon in the surgery.
The surgeon will make an incision in the front of your neck;
if only one disc is to be removed it will typically be a small
horizontal incision in the crease of the skin. If the operation
is to be more extensive, the incision may be oblique (slanted)
or longer.
The soft tissues within the neck are separated to allow the
surgeon to reach the front of the spine, following which the
intervertebral disc and bone spurs are removed (Fig. 4b). An
operating microscope may be used to better display the area
while part of the disc is removed with forceps. Other
instruments such as a drill or bone-cutting instruments may be
used to enlarge the disc space. This will help the surgeon to
relieve any pressure on the nerve or spinal cord due to bone
spurs or the ruptured (herniated) disc.
Fib. 4b. Procedure for removal of cervical disc.
Sometimes the space between the vertebrae is refilled with a
small piece of bone (fusion). The bone may be yours (for
example, from your hip bone) or it may be taken from a bone
bank. In time, the vertebrae may fuse, or join together. In
addition to the piece of bone, some surgeons may place a metal
plate at the fusion site to strengthen it.
The neck incision is closed in several layers. Skin suture
material may need to be removed or the surgeon may use absorbing
sutures and strips of tape which you can later remove by
yourself.
Historically and statistically, there are few surgical risks
with anterior cervical discectomy; however, some risk is
unavoidable and the unexpected may occur resulting in
complications.
Although every precaution will be taken to avoid
complications, common risks possible with surgery are:
infection, excessive bleeding (hemorrhage) and an adverse
reaction to anesthesia. Other risks possible with anterior
cervical discectomy include: stroke; injury to the recurrent
laryngeal nerve, which causes hoarseness and may or may not be
permanent; and injury to the involved nerve root(s) or the
spinal cord, both of which can cause varying types and degrees
of paralysis.
The process of informed consent is designed to make you
familiar and comfortable with the reasonable expectations and
foreseeable risks. Your surgeon and anesthesiologist will
discuss these with you and assist you in your decision-making.
Cervical Corpectomy
This operation is an extension of the discectomy procedure.
Also using an anterior approach, the surgeon removes a part of
the vertebral body to relieve pressure on the spinal cord (Fig.
4c). One or more vertebral bodies may be removed including the
adjoining discs. The incision is generally longer. The space
between the vertebrae is filled using a piece of bone (fusion)
and maybe a metal plate. Because more bone is removed, the
recovery process for the fusion to heal and the neck to become
stable again is usually longer than with anterior cervical
discectomy.
Fig. 4c. Cervical corpectomy (removal of portion of cervical
vertebral body)
Cervical Laminectomy and Discectomy
This operation is performed through a vertical incision in
the back of the neck, generally in the middle. Through this
opening the surgeon will use an instrument (a retractor) to pull
aside the strong muscles of the neck and expose the arch of bone
(lamina) that forms the spinal canal. A drill and bone cutting
instruments are used to remove the bone around the spinal cord
(laminotomy) (Fig. 4d 1) or the bone around the nerve opening
(foraminotomy) (Fig. 4d 2). Once the nerve is located, it is
moved gently aside and an incision is made on the outside
covering of the disc through which the disc material is then
removed.
Fig. 4d 1. Cervical laminotomy/laminectomy for cervical disc
disease.
Fig. 4d 2. Surgery for cervical discervical foraminotomy and
discectormy.
Recovery After Surgery
Following surgery, you will be taken to the recovery room for
a short while and then spend a few days in a hospital room. When
you awake you may have a collar or brace around your neck or a
drainage tube coming out of your neck. Typically, the drainage
tube is removed in a day or two.
If you had an anterior cervical discectomy or corpectomy,
your throat may be slightly sore. If a piece of bone was taken
from your hip, the area of incision is usually sore. Your
physician will give you appropriate medication to address these
problems. Fortunately, most of them are temporary.
Intravenous (I.V.) fluids will be ordered during the early
recovery period.
Discharge from the Hospital
Your length of stay in the hospital will be determined by
your progress and by your home situation. When you are ready to
leave the hospital you will be provided with instructions
regarding your brace, care of your incision(s) and physical
activity.
Generally, you will wear a brace for a few weeks, but this is
variable and it may be much longer. Usually you have to keep it
on continuously, but your doctor may allow you to take it off
for short periods. It is unlikely that you will be allowed to
drive, lift heavy objects or engage in contact sports or
vigorous physical activity for a while. Keep your incision clean
and dry and report any signs of drainage or inflammation
promptly to your doctor.
Unless instructed otherwise, you may take a shower after
surgery. This should be done with a dressing in place to protect
the incision.
Practice good posture and body mechanics even during routine
daily tasks. It is normal to have some pain, especially in the
incision area; pain in the neck or arms is also not unusual, and
is caused by inflammation of the previously compressed nerve. It
will slowly lessen as the nerve heals. Medication may also help.
Discomfort is normal while you gradually return to normal
activity, but pain is a signal to stop what you are doing or
proceed more slowly.
Follow-up
Your doctor will see you in the office after surgery and
examine your incision. He may remove skin sutures and will
evaluate nerve and muscle function. X-rays may be ordered to
check on the fusion of the bone graft. Physical therapy may be
recommended.
Numbness or tingling sensations are often the last symptoms
to leave. Your doctor will help determine when you can return to
work and with what limitations.
Driving a motor vehicle will be possible once your doctor
determines that you have recovered full coordination and are
experiencing minimal pain and that your neck is stable.
The Role of the Neurosurgeon
If you are perceiving problems in your cervical spine caused
by pressure on the nerves, a neurosurgeon is the appropriate
medical professional to direct your treatment. Although his or
her primary concerns will be diagnosis, interpretation of test
results (when necessary) and surgery, you will most likely have
other medical professionals involved in your treatment as well,
such as anesthesiologists, physical therapists and other
specialists.
Neurological surgery is the medical specialty concerned with
the diagnosis and treatment of disorders of the nervous system,
the brain or the spinal cord. Neurosurgeons treat patients with
injuries to the head, spinal cord or nerves; patients with a
stroke or in danger of a stroke due to clogged arteries in the
neck; patients with tumors or malformations of the brain or
spinal cord; as well as patients with back or neck pain
associated with a slipped disc.
Neurosurgeons undergo six to eight years of rigorous training
following medical school. After successfully completing this
training, two years of medical practice and a written
examination, neurosurgeons can become Board Certified.
Glossary
Anesthesiologist: Physician who administers
pain-killing medications during surgery.
Anterior (Front): Refers to the direction from which
the surgeon removes the cervical disc.
Cervical Spine: The seven vertebrae in the upper part
of the neck.
CT Scan (computed tomography scan): A diagnostic
imaging technique in which a computer reads x-rays to create a
three-dimensional map of soft tissue or bone.
Degeneration: Deterioration or worsening of a
structure or condition.
Disc: A small mass of elastic, gristle-like tissue
located between each vertebra in the spinal column which acts as
a "shock absorber" for the spinal bones. The disc is composed of
an outer, tough covering and a softer, gelatinous material
within.
Fusion: The surgical joining of vertebrae.
Herniated Disc: Condition in which gelatinous disc
material slips or bulges out of position and puts painful
pressure on surrounding nerves.
Laminectomy: Surgical removal of the rear part of a
vertebra in order to gain access to the spinal cord or nerve
roots, to remove tumors, to treat injuries to the spine, or to
relieve pressure on a nerve.
Ligament: Fibrous connective tissue linking bones at a
joint.
MRI (magnetic resonance imaging): Diagnostic test that
produces three-dimensional images of body structures using
powerful magnets and computer technology rather than x-rays.
Myelogram: An x-ray examination in which injected dye
outlines the spinal cord and associated nerve roots to
illustrate spinal tumors and other conditions affecting the
nerves and spinal cord.
Nerves: Fibers that conduct impulses (messages) from
the brain and spinal cord to the muscles and glands, or from
sensory organs to the brain and spinal cord.
Spinal Cord: Bundle of nerve fibers enclosed in the
vertebral column.
Spinal Stenosis: Narrowing of the vertebral column,
resulting in pressure on the vertebral column or pressure on the
spinal cord or nerve roots arising from the spinal cord.
Vertebrae: The 33 individual bones composing the
backbone or spine.
X-ray: Application of electromagnetic radiation to
produce a film or picture of a bone or soft tissue area of the
body.
