Anterior Cervical Discectomy and Fusion: Non-Surgical Options
Ross Hauser, MD, Caring Medical Florida, Fort Myers, FL
Anterior Cervical Discectomy and Fusion
Many people come to Caring Medical because they have issues with cervical neck instability and cervical radicular pain that radiates into their arms and legs. These people are looking for a realistic treatment option to their Anterior Cervical Discectomy and Fusion surgery recommendation. In separate articles we discuss Cervical neck instability, and, Atlantoaxial instability, and how these conditions can send you to Anterior Cervical Discectomy and Fusion.
In this article, we will explore our non-surgical regenerative medicine options to repair and stabilize the cervical spine without surgery.
- NOTE: Many people benefit from Anterior Cervical Discectomy and Fusion, especially people who have neck injuries from sport or accident where bones are fractured or in cases of significantly advanced degenerative disease where there is truly no other way to restore arm and hand function. This article will focus on “elective surgery,” meaning that you chose to have a surgery that is not addressing an urgent health crisis. It is typically these “elective,” surgeries that bring patients to our clinic with post-surgical pain and challenges.
In this article we are going to cover research from the surgical community addressing these patient concerns:
- If you do not have surgery are you at risk for worsening degenerative disc disease?
- Is your Neck MRI showing a true picture of your problem?
- How much neck motion will I lose?
The realistic expectation of cervical fusion surgery from the neurosurgeons’ point of view:
In the Journal of Neurosurgery. Spine, (1) August 2019, neurosurgeons from some of the leading neurological surgery departments in the nation published these findings on whether or not patients were truly satisfied with their surgical outcomes following anterior cervical discectomy and fusion (ACDF).
- A total of 4148 patients (average age 54 years, 48% males) with complete 12-month North American Spine Society satisfaction data (a scoring system) were analyzed.
- Sixty-seven percent of patients answered that “surgery met their expectations”
- 20% reported that they “did not improve as much as they had hoped but they would undergo the same operation for the same results”
- The findings of the present analysis further reinforce the role of preoperative discussion with patients on setting treatment goals and realistic expectations.
Comment: We should note that:
- 67% of the patients had their expectations met. They had a realistic expectation of what the surgery could do.
- 20% of the patients did not have their expectations met but after surgery found enough satisfaction that they would do it again.
- 13% had less than desirable results.
A 2018 study reported in the Global Spine Journal (2) that “patients who undergo anterior cervical discectomy and fusion can expect improvement in their pain and disability, with 74.3% of patients reporting a positive change in health status after surgery.”
Now that we have examined the realistic expectation of surgery, let’s look at what people who have been told that they need the surgery are saying.
Surgery because your neck will get worse? Researchers suggest that for many people cervical degeneration does not evolve and progress that quickly that surgery should be considered as urgently needed
For some people, cervical neck surgery may be urgently needed. Research suggests that not everyone is in that situation.
A study in the medical journal Spine (3) sought to determine whether cervical degenerative spondylolisthesis is a rapidly degenerating problem and a high-risk threat to patients or is it a more slowly degenerating disease.
Let’s look at the patients of this study:
- 27 patients with cervical degenerative spondylolisthesis
- The average age of the patient at the start of the study period was 59.0 years old. The youngest patient was 50 and the oldest was 83 years old.
Their cervical spine problems:
- Eleven patients had cervical spondylolisthesis at C4-C5
- Nine at C3-C4
- Six at C5-C6
- One at C2-C3.
- Of the 27 patients, 11 said they had NO SYMPTOMS
- Eight had cervicalgia (diagnosis of neck pain)
- Seven had radiculopathy
- One had myelopathy (spinal cord compression)
The patient’s history of cervical degenerative anterolisthesis and retrolisthesis seemed to be stable for 2 years to nearly 8 years
How much slippage?
- At the onset of the study:
- 3 of 6 patients diagnosed with anterolisthesis had translation (slippage) of more than 2 mm
- 7 of 21 patients with retrolisthesis had translation of more than 2 mm
Upwards of 8 years later, how much worse were these patients’ problems?
- At a minimum of 24 months later (and an average of 3 years and 3 months later with a maximum range of seven years and 8 months,) the patient’s history of cervical degenerative anterolisthesis and retrolisthesis seemed to be stable during 2 years to nearly 8 years. Although those with retrolisthesis seem to have a higher propensity to increase their subluxation, none experienced dislocation or neurological injury.
The suggestion is that some people will experience a very slow degeneration of their cervical spine despite clear MRI documentation that their situation may warrant a surgical recommendation. This is usually where the problems begin, an MRI showing a need for surgery that may not be there.
Aggressive spondylolisthesis and not as aggressive degenerative spondylolisthesis – a question of cervical spine instability
A 2018 study published in the journal Spine Surgery and Related Research (4) suggested Cervical degenerative spondylolisthesis can be classified into two types. The first and more common listhesis occurred adjacent to stiffened levels, and anterior slippage was common in this type. The second and less common listhesis occurred within progressively degenerated segments, and posterior slippage was prominent. Further: “Cervical spondylolisthesis in a flexed or extended neck position possibly suggests inherent instability of the cervical spine.”
The suggestion is that the problem may not be spondylolisthesis, the problem may be instability.
“BUT I was told that if I did not have the surgery, I was at risk for becoming paralyzed”
In the many years of helping patients with neck problems, we have found that a highly motivating factor to have the surgery was fear, fear of paralysis. This is typical when we ask patients “what finalized your decision to have the cervical fusion surgery?” many respond, “I was told that I was at risk for becoming paralyzed. I cannot tell you how much that scared me. Now, looking back, maybe I rushed into the surgery and should have sought out more opinions.” In fact, some people do relate that they had two opinions, one surgeon who said surgery was not necessary and that the patient should continue conservative care therapy and one surgeon who talked about paralysis for a rapidly degenerating situation.
- “I had pain after the surgery. I went back to the doctor and explained that I thought I would get more pain relief than I did from the surgery and now I seem to have new pain. The surgeon told me that the surgery that he performed was entirely successful. He fused the two vertebrae that needed to be fused, I just need more fused now.”
Some people come in after undergoing surgery, looking for ways to get off of the pain medications that they have been using. Other patients come in after successful surgery with new problems of TMJ or difficulty swallowing or dizziness and headaches. They are looking for help with those problems.
You may be getting a surgery because of an MRI reading that may not be accurate
We cannot begin to count the number of patients that we have seen over the many years who begin their conversation with us with “My MRI says I need the surgery.” What is now concerning some doctors is that doctors may be recommending surgery based on an MRI which may not be entirely accurate.
- An MRI can show when there is an anatomical deformity that suggests surgery
- An MRI may be inconclusive that there is an anatomical deformity. These patients are being recommended to surgery anyway.
Look at this research from Yale University that was published in the Spine Journal (5)
“MRI findings play an important role in the management of patients with cervical spine conditions. For this reason, consistent descriptions of these findings are essential and physicians should be aware of the relative reliability of these findings. (Our) systematic study developed standardized grading criteria and nomenclature (a catalogue) for common clinically significant MRI findings in the cervical spine.
Even in this optimized research setting, we found significant ranges in agreement across these MRI findings. In the clinical setting, inter- and intra-rater agreements may be lower, and the range of agreements between findings may be greater. Physicians should be aware of inconsistencies inherent in the interpretation of cervical MRI findings and should be aware that some findings demonstrate lower agreement than others.”
- Simply, even in the “best-case scenario,” with the highest standards of interpretation applied, the MRI and interpretation may be wrong in presenting what is the true cause of the patient’s problems.
The MRI looks for a pinched nerve – if it finds one – a surgical recommendation can be made whether surgery is needed or not.
Anterior cervical discectomy and fusion (ACDF or sometimes anterior cervical decompression) is a cervical neck surgery that is recommended to patients that have been diagnosed with a pinched nerve in the neck that is causing pain, weakness, numbness and other symptoms of cervical radiculopathy.
- The discectomy removes a damaged disc identified as causing the patient’s problems. Once the disc is removed the fusion part of the surgery is performed.
- The fusion surgery’s goal is to successfully place a bone graft and/or an implant where the original disc was removed. The ultimate goal of the surgery is cervical stability and pain-free movement.
- The surgery can also address removing bony overgrowth or bone spurs that can pinch on the cervical neck nerves and be causing the problems of cervical radiculopathy. Typically numbness or weakness in the shoulders, arms, legs and upper neck region.
Cervical fusion – there is an option – it starts with DMX vs MRI
DMX stands for a digital motion x-ray. If you watch the two videos below you may be somewhat amazed at what the DMX can show as opposed to a convention X-ray or a conventional MRI. The DMX shows your cervical spine in motion. DMX is a tool we rely on to help us treat patients with very difficult chronic neck pain and symptoms.
As opposed to an MRI, DMX, or sometimes referred to as a cineradiography or videofluoroscopy, can show spinal and peripheral joint instability in real-time and how it impacts your quality of life. Whereas MRI is a tool that confirms you need surgery, DMX is a tool that can help confirm that you do not need surgery. The DMX gives us the tool of showing your neck in real-time motion and revealing more clues to the true nature of your problem than a static image can.
Digital motion X-Ray C1 – C2
The digital motion x-ray is explained and demonstrated below
- Digital Motion X-ray is a great tool to show instability at the C1-C2 Facet Joints
- The amount of misalignment or “overhang” between the C1-C2 demonstrates the degree of instability in the upper cervical spine.
- This is treated with Prolotherapy injections to the posterior ligaments that can cause instability.
- At 0:40 of this video, a repeat DMX is shown to demonstrate the correction of this problem.
In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine
- In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy. A discussion of the Prolotherapy treatment is below.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals a completely closed neural foramina and a partially closed neural foramina
- At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
- At 0:46 the previously completely closed neural foramina is now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina is now opening normally during motion
Caring Medical research on alternatives to Discectomy and Fusion
In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including severe pain, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations to complicated cervical neck surgeries they don’t understand.
Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.
Surgical recommendations are described in a way to the patient that seemingly makes sense as the only solution to their problems.
- The surgery will help, the patient is told, because it will cut away the cervical vertebrae bone that is pressing on the nerves
- The surgery will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again.
- The cervical disc that has been flattened or herniated is replaced with an artificial implant or bone from the pelvis.
Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage
In neck and spine surgery, doctors focus on degenerative disc disease and its treatment, anterior cervical discectomy and fusion and cervical decompression surgery to remove whole or part of the cervical vertebrae to allow space on compressed nerves and to fix the instability by fusing vertebral segments together. In the case of C1-C2 instability, these two vertebrae are fused posteriorly (behind) to limit their amount of movement. The goal is to limit pressure on the nerves.
However, it may limit motion to such an extent that patients become completely unable to move that portion of their neck. In addition, fusion operations can accelerate the degeneration of adjacent vertebrae as the motion in the neck is distributed more on these tissues.
- The cervical capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury, and whiplash-associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome.
When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
- In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain.
- In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.
Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially when due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.
Stabilizing the unstable neck – degenerative disc disease vs. degenerative ligament disease
Back to our 2014 research headed by Danielle R. Steilen-Matias, PA-C, published in The Open Orthopaedics Journal. Here we outline that the problems of the cervical neck are not always problems of degenerative disc disease but problems of degenerative ligament disease. This explains why traditional treatments focused on the discs will not be successful in the long-term.
In another of our published research studies, in the European Journal of Preventive Medicine, (7) we presented the following findings:
- Ninety-five percent of patients reported that Prolotherapy met their expectations in regard to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
- Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
- Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.
We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability.
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
If you have a question about options to Anterior Cervical Discectomy and Fusion, you can get help and information from our Caring Medical Staff.
1 Discectomy and Fusion: Insights From the Quality Outcomes Database. Neurosurgery. 2019 Aug 20;66(Supplement_1):nyz310_609. [Google Scholar]
2 Andresen AK, Paulsen RT, Busch F, Isenberg-Jørgensen A, Carreon LY, Andersen MØ. Patient-reported outcomes and patient-reported satisfaction after surgical treatment for cervical radiculopathy. Global spine journal. 2018 Oct;8(7):703-8. [Google Scholar]
3 Park MS, Moon SH, Lee HM, Kim SW, Kim TH, Suh BK, Riew KD. The natural history of degenerative spondylolisthesis of the cervical spine with 2-to 7-year follow-up. Spine. 2013 Feb 15;38(4):E205-10. [Google Scholar]
4 Aoyama R, Shiraishi T, Kato M, Yamane J, Ninomiya K, Kitamura K, Nori S, Iga T. Characteristic findings on imaging of cervical spondylolisthesis: Analysis of computed tomography and X-ray photography in 101 spondylolisthesis patients. Spine Surgery and Related Research. 2018 Jan 20;2(1):30-6. [Google Scholar]
5 Fu MC, Webb ML, Buerba RA, Neway WE, Brown JE, Trivedi M, Lischuk AW, Haims AH, Grauer JN. Comparison of agreement of cervical spine degenerative pathology findings in magnetic resonance imaging studies. The Spine Journal. 2016 Jan 1;16(1):42-8. [Google Scholar]
6 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
7 Hauser R, Steilen D, Gordin K The Biology of Prolotherapy and Its Application in Clinical Cervical Spine Instability and Chronic Neck Pain: A Retrospective Study. European Journal of Preventive Medicine. Vol. 3, No. 4, 2015, pp. 85-102. doi: 10.11648/j.ejpm.20150304.112396 [Google Scholar]