Anterior Cervical Discectomy and Fusion and Non-Surgical Options
Ross Hauser, MD
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 for 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. We also discuss other elective cervical surgery options.
The information that we present here on our website is, what we believe, to be very comprehensive. Why do we present such comprehensive information? Because of the discoveries and observations of treatment methods we have seen in now almost three decades of helping people with the problems of cervical instability and upper cervical instability. We try to make our information comprehensive because the challenges and health concerns that these people face are themselves very comprehensive and complex. Their health journeys, maybe like you health journey, have been very complex and the many diagnostic tests, while compressive, have not provided insight.
The host of symptoms that cervical instability causes is immense. Everything from symptoms in the leg to whole body neuropathy to diffuse body pain can come from cervical instability in the neck. At our center, 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.
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 accidents where bones are fractured or in cases of significantly advanced degenerative disease or degenerative cervical myelopathy 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?
- I have all these symptoms . . .I was told to have cervical fusion surgery.
- The realistic expectation of cervical fusion surgery from the neurosurgeons’ point of view.
- A follow up to this research on 1 and 2 level cervical fusions.
- Multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF).
- Indicators for substantial neurological recovery following elective ACDF
- Possible Anterior Cervical Discectomy and Fusion complications compared to other neck surgeries.
- Possible pulmonary complications following elective anterior cervical discectomy and fusion.
- 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.
- The patient’s history of cervical degenerative anterolisthesis and retrolisthesis seemed to be stable for 2 years to nearly 8 years.
- Aggressive spondylolisthesis and not as aggressive degenerative spondylolisthesis – a question of cervical spine instability.
- “BUT I was told that if I did not have the cervical fusion surgery, I was at risk for becoming paralyzed.”
- You may be getting cervical fusion surgery because of an MRI reading that may not be accurate.
- The MRI looks for a pinched nerve – if it finds one – a cervical fusion surgical recommendation can be made whether surgery is needed or not.
- Surgeons caution against including asymptomatic levels in an anterior cervical fusion surgery.
- “Even patients with severe imaging abnormalities at the time of the index (first fusion) operation are likely to be managed nonoperatively at long-term follow-up.”
- A comparison between physical therapy and anterior cervical decompression and fusion.
- After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.
- People have very successful fusion surgeries – Some do not – some have very successful second fusion surgeries, some do not. A story of C3-C7 fusion and C1-C2 instability.
- Four-level and Five-level anterior cervical discectomy and fusion.
- Airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.
- Swallowing difficulties after cervical fusion.
- Pseudoarthrosis after cervical fusion.
- The complication of obesity in Anterior Cervical Discectomy and Fusion
- Caring Medical research on alternatives to Discectomy and Fusion.
- Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage.
- Stabilizing the unstable neck – degenerative disc disease vs. degenerative ligament disease.
I have all these symptoms . . .I was told to have cervical fusion surgery
These is the type of communication we receive from people exploring options to ACDF.
I have cervical myelopathy at C5-C6 and osteophytes. I have had two opinions from neurosurgeons and both recommend ACDF due to spinal cord compression. I have no pain but symptoms of sudden loss of taste and smell, Tinnitus, numbness and tingling in mouth, cognitive issues, constant throat clearing, voice issues, swallowing problems, ear fullness and pain, hearing issues, headaches, sense of off balance. I have not been offered any alternative treatments other than surgery. I have seen three ENTs, an allergist, a speech pathologist and primary care, to rule out allergies, ear problems, etc. Nothing has helped any of these issues and they don’t know the cause.
I have no equilibrium. Not vertigo. Just unbalanced and can’t walk a straight line.
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 on patients with 1-2-3 level fusions, reported in the Global Spine Journal (2) : “When analyzed for patient satisfaction we found that 65.9% of the patients were satisfied, 28.2% were uncertain, and 5.9% were dissatisfied with the surgical result at 1-year follow-up.”
A follow up to this research on 1 and 2 level cervical fusions
There is less of a reoperation rate when the patient has one or two level fusion. Many patients we see have more than two levels fused. This would appear to be good news. A July 2021 study from the University of Tennessee published in the Archives of orthopaedic and trauma surgery (3) assessed the 2 year rate of reoperation and determine patient-reported outcomes after elective one- and two-level anterior cervical discectomy and fusion.
Here are the learning points:
- A retrospective chart review was performed on 116 consecutive one- and two-level primary ACDF for adult degenerative disease with structural allograft and anterior plating in one surgeon’s practice.
- Patient-reported pain, disability and functional scores were assessed preoperatively and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and 2 years
Results: One hundred and four patients were identified with a final reoperation rate of 2.9% at a mean final follow-up 2 years. No reoperations occurred within 90 days. After 1 year, three patients required reoperation.
A follow up on 1-2-3-4 level cervical fusion at 5 years
An April 2022 study in The spine journal (4) comes to us from the Department of Orthopedics and Rehabilitation, Yale School of Medicine and the Carle Neuroscience Institute. What this study sought to provide information on was patient outcomes after three- and four-level cases, which the authors noted, had significantly less data than the outcomes of one to two level cervical fusions.
- Overall, 97,081 patients undergoing ACDF were identified, of which:
- one-level cases were 42,382 (43.7%),
- two-level cases were 24,055 (24.8%),
- three-level cases were 28,293 (29.1%), and
- four-level cases were 2,361 (2.4%).
Outcome measures: Number of patients who had Ninety-day adverse events and number of patients who needed reoperation within five years.
- Of the 97,081 cases identified, patient characteristics and complication rates differed between the groups defined by levels treated.
- Analyses revealed statistically different rates of 90-day any, serious, and minor adverse event rates between the groups, but the differences were all less than 2.5%.
- Readmission rates were statistically different by 2.9%, dysphagia by 3.2%, and prolonged length of hospital stay by 6.3%.
- Three-level ACDF cases were not found to have greater 90-day adverse outcomes than two-level cases.
- Four-level ACDF cases were found to have significantly greater odds ratios of readmission, dysphagia, and prolonged length of stay (relative to one-level cases) but not other 90-day adverse events.
Reoperation rates at five years:
- One level -13%
- Two levels 13.5%
- Three levels 15%
- Four-level cases 22.1%
Conclusions: While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. While these outcomes were found to be acceptable, they should help guide hospital planning and patient counseling.
Return to work after cervical fusion
A November 2018 paper in the journal Neurosurgical focus (26) tried to offer a way to better predict which patients would return to work to work at 3 months after cervical spine surgery.
In this paper the authors found that among previously employed and working patients, 89.3% returned to work compared to 52.3% among those who were employed but not working (e.g., were on a leave) at the time of surgery. They found that patients who were less likely to return to work were older more than 56 – 65 years old, were employed but not working; were employed part time; had a heavy-intensity or medium-intensity occupation compared to a sedentary occupation type; had workers’ compensation; had a higher Neck Disability Index score at baseline.
An August 2022 paper in the journal Cureus (27) determined the rate of return to work and contributing factors after a one- and two-level anterior cervical discectomy and fusion (ACDF).
- In this study, 68 patients were examined at three, six, and nine months after anterior cervical discectomy and fusion and the rate of return to work and contributing factors.
- The results of this study demonstrated that
- 77.9% had returned to work after three months,
- 82.4% had returned to work after six months and
- the same 82.4% of workers had returned to work after nine months.
- At nine months, the 82.4% of the patients had returned to work, 19.6% returned to part-time work, and 80.4% had returned to their previous work. Conversely, 17.6% of the patients had not returned to work after nine months. These patients who did not return to work were seen to be older, had longer absence from work before surgery, and less employer support.
A May 2022 paper in the Global spine journal (28) found that the majority of nonretired patients undergoing surgery for degenerative cervical myelopathy had returned to work 12 months after surgery; active preoperative employment and anterior surgical approach were associated with better return to work averages before surgery.
Indicators for substantial neurological recovery following elective ACDF
A May 2022 paper from doctors at the Mayo Clinic, Walter Reed National Military Medical Center, and Thomas Jefferson University, published in the medical journal Clinical spine surgery (20) examined the indicators for substantial neurological recovery following elective ACDF.
The researchers noted: “While neck and arm pain reliably improve following anterior cervical discectomy and fusion (ACDF), the frequency and magnitude of motor recovery following ACDF remain unclear.”
In this study a review of 618 patients who underwent 1-4-level ACDF were created. Patients were subdivided into 2 groups based upon the presence or absence of significant preoperative weakness.
- Significant preoperative upper extremity weakness was present in 27 patients (4.4%). Postoperatively, 19 of the affected patients (70.3%) experienced complete strength recovery, and 5 patients (18.5%) experienced an improvement in muscle strength to a motor grade.
- The rate of motor recovery postoperatively was 85.7% in the triceps, 83.3% in the finger flexors, 83.3% in the hand intrinsics, 50.0% in the biceps, and 25.0% in the deltoids.
- Risk factors for failure to experience significant motor improvement were the presence of myelomalacia (spinal cord softening) and the performance of more than 2 levels of ACDF
- Patients with substantial preoperative upper extremity weakness can expect high rates of motor recovery following ACDF, though patients with deltoid weakness, myelomalacia, and more than 2 levels of ACDF are less likely to experience significant motor improvement.
Multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF)
A March 2022 paper from the Department of Orthopaedics and Rehabilitation, Yale School of Medicine and published in the North American Spine Society journal (16) compared multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical fusion (PCF). While posterior procedures may be technically easier for four-level pathology, there are advantages and disadvantages to both approaches that make it of interest to compare outcomes.
- A total of 3,714 patients 1:1 matched for four-level ACDF and posterior cervical fusion (PCF) performed for degenerative pathologies were followed.
- Posterior cervical fusion (PCF) was found to have significantly greater odds ratios for any serious and minor adverse events, as well as for length of stay more than three days.
- However, PCF had nearly three times lower odds of dysphagia compared to ACDF.
- At five years, four-level ACDF cases were found to have significantly higher reoperation rates compared to four-level PCF cases (26.3% vs 18.3%).
The researchers concluded: “In evaluating four-level cervical cases, compared to anterior approach cases, posterior approach procedures were associated with approximately double the odds of any, serious, and minor adverse events, but around one third the rate of dysphagia and two thirds the rate of five-year reoperations. While the pathology may dictate surgical approach, this data suggests that the choice between four-level anterior versus posterior approach becomes a balance of risks/benefit considerations.”
Anterior cervical decompression fusion vs. posterior laminoplasty
A December 2022 paper in the Journal of neurological surgery (24) compared anterior cervical decompression fusion and posterior laminoplasty. The authors suggest: “Although anterior or posterior surgery for cervical spondylotic myelopathy (CSM) has been extensively studied, the choice of anterior or posterior approach in 4-segment cervical spondylotic myelopathy remains poorly studied and controversial.” In this study the researchers compared the clinical and radiographic outcomes of 4-segment cervical spondylotic myelopathy by posterior laminoplasty (LAMP) and anterior cervical decompression fusion (ACDF).
- There were 47 patients in the anterior cervical decompression fusion (ACDF) group.
- There were 79 patients in the posterior laminoplasty (LAMP) group.
- Patients in the ACDF group had a significantly longer surgical time and lower estimated blood loss and length of hospital stay than those in the posterior laminoplasty (LAMP) group.
- While there were no significant difference in many pain, function and disability scores in patients proceeding the surgical procedures, certain disability and pain scores in the ACDF group were significantly lower than those in the LAMP group at final follow-up.
- Results indicated that ACDF can improve cervical lordosis better than posterior laminoplasty (LAMP) and patients may have a better improvement of cervical lordosis may have better prognosis.
While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases.
An April 2022 paper from the Yale School of Medicine published in the Spine journal (20) explores surgical outcomes in patients getting three or four level fusions compared to those getting one to two level fusions. The researchers write of their 97,081 patient case study: “The current study represents one of the largest comparative studies of patients undergoing one-, two-, three-, and four-level ACDF. While odds of 90-day adverse events were not greater for three- versus two-level cases, four-level cases had several that were higher odds than one-level cases. Reoperation and dysphagia rates were higher for four-level cases than lesser levels. . . Reoperation rates at five years for one level 13.0%, two level 13.5%, three level 50%, and four-level cases 22.1%”
Possible Anterior Cervical Discectomy and Fusion complications compared to other neck surgeries
In the image below the caption reads: Instability above a cervical fusion as documented by digital motion x-ray. Looking at the cervical joint above the fusion, an offset can be seen in neutral position (A) and in extension (C), which is widened during flexion (B). In this patient’s case Prolotherapy injections helped stabilize the patient’s neck. These injections are discussed below.
Doctors at the Department of Orthopaedics, Columbia University Medical Center in New York published their comparison findings on the different types of cervical spine surgeries for Degenerative Cervical Myelopathy. Here is the summary of their July 2022 research appearing in the Global spine journal.(18)
The researchers compared the short-term outcomes for Cervical laminoplasty, Cervical Laminectomy/fusion, and multi-level Anterior Cervical Discectomy and Fusion. There were 182 patients in each group.
Conclusions: Cervical Laminectomy/fusion carries the highest risk for morbidity, mortality, and unplanned readmissions in the short-term postoperative period. Laminoplasty and Anterior Cervical Discectomy and Fusion cases carry similar short-term complications risks. Anterior Cervical Discectomy and Fusion is significantly associated with the longest operative duration and shortest length-of-stay without an increase in individual or overall complications, readmissions, or reoperations.
Possible pulmonary complications following elective anterior cervical discectomy and fusion
A June 2022 study from the Mayo Clinic published in the Clinical neurology and neurosurgery (19) suggested predictive factors for post-surgical airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.
The researchers write: “While the procedure is generally well tolerated, respiratory and pulmonary complications are an unlikely yet possible complication following ACDF. Few previous studies have specifically identified risk factors associated with respiratory and pulmonary complications following ACDF.
- The researchers followed 52,575 patients in which an ACDF was performed of which 1454 admissions had an respiratory and pulmonary complications.
- Older patients were 1.03 times more likely to have an respiratory and pulmonary complications
- African American patients compared to Caucasian patients were 1.44 times more likely to have an respiratory and pulmonary complications
- Obese patients were found to be 1.64 to have an respiratory and pulmonary complications.
- Diabetic patients are 2.07 times more likely to have an respiratory and pulmonary complications.
- Hypertensive patients are 1.91 times more likely to have an respiratory and pulmonary complications
- Patients who underwent multilevel procedure were 1.32 times more likely to experience a follow-on respiratory and pulmonary complications.
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 (5) 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 a 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 (6) 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 cervical fusion 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.
What if I get into a car accident?
I was told that I needed an ACDF C3-C7. I do not want surgery. I was told if I’m in an auto accident it could be serious.
You may be getting cervical fusion 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 for surgery anyway.
Look at this research from Yale University that was published in the Spine Journal (7)
“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 catalog) 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 cervical fusion 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.
Surgeons caution against including asymptomatic levels in an anterior cervical fusion surgery
For some people they may have received a cervical fusion that went too far or included segments of their neck that do not need to be included: Doctors at the Department of Neurosurgery and Department of Radiology at the University of Utah published an August 2021 paper (8) in which they write: “Anterior cervical discectomy and fusions (ACDFs) are generally limited to the levels causing neurological symptoms, but whether adjacent asymptomatic levels should be included if they demonstrate severe radiographic degeneration is a matter of controversy. We evaluated whether asymptomatic preoperative magnetic resonance imaging (MRI) abnormalities at adjacent levels were predictive of reoperation for symptomatic adjacent-segment degeneration (ASD) after the initial Anterior cervical discectomy and fusions.”
What these researchers did was to review the medical charts of patients treated with Anterior cervical discectomy and fusions in 2000-2010 who had MRIs preoperatively and again more than three years after the first fusion surgery to evaluate new neurological symptoms. Patients were grouped by adjacent-segment degeneration severity score, calculated based on MRI features (and interpretations). What they found was that few patients, who had clearly seen degenerative features in the segments adjacent to the fusion pre fusion surgery, did not need further fusion surgery years later. The researchers wrote: “The prevalence of reoperation for adjacent-segment degeneration was low for patients who presented with new symptoms more than 3 years after the initial Anterior cervical discectomy and fusion. Our findings do not support including asymptomatic levels in an anterior fusion construct, even if severe MRI abnormalities are present preoperatively.”
“even patients with severe imaging abnormalities at the time of the index (first fusion) operation are likely to be managed nonoperatively at long-term follow-up”
Expressing this further, they suggest: “Considering these data, we caution against including asymptomatic levels in an anterior fusion construct, even if severe abnormalities are present on preoperative MRI. Although this population (those with new symptoms returning for an MRI more than 3 years after the index ACDF) may require reoperation (10%, 10/96 patients), after stratifying by the severity of preoperative MRI abnormalities, preoperative findings were only associated with reoperation in patients with the most severe abnormalities. In this group, the prevalence of reoperation was only 16% (5/31 total levels assessed). . . Thus, even patients with severe imaging abnormalities at the time of the index (first fusion) operation are likely to be managed nonoperatively at long-term follow-up.”
A comparison between physical therapy and anterior cervical decompression and fusion
After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.
The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. Spinal cervical fusion and decompression seem to offer a solution – short-term. This is supported in the medical literature. In one study in the medical journal Spine,(9) patients with cervical radiculopathy, treated with surgery and physiotherapy resulted in a more rapid patient improvement during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone.
However . . .
However, the differences between the groups decreased after two years. In this paper where surgery was touted as being so successful – the researchers concluded: “Structured physiotherapy should be tried before surgery is chosen.” After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.
That study is from 2013. What has happened in the years since?
In 2017, the same group of doctors in Sweden writing in the Journal of Spine, (10) evaluated the 5- to 8-year outcome of anterior cervical decompression and fusion (ACDF) combined with a structured physiotherapy program as compared with that following the same physiotherapy program alone in patients with cervical radiculopathy.
Citing the 2013 research above, the doctors noted that no study went beyond two years in describing the comparison effect of surgery vs. physical therapy for cervical radiculopathy.
In this study, Fifty-nine patients were randomized to ACDF surgery with postoperative physiotherapy (30 patients) or to structured physiotherapy alone (29 patients).
- The physiotherapy program included general and specific exercises as well as pain coping strategies.
- Patient results were measured as improvement in neck disability, neck and arm pain intensity, and a patient overall health assessment.
- After 5-8 years, the neck disability was reduced by an average of 21% (based on the standard scoring system) in the surgical group and 11% in the nonsurgical group.
- In this prospective randomized study of 5- to 8-year outcomes of surgical versus nonsurgical treatment in patients with cervical radiculopathy, anterior cervical decompression and fusion combined with physiotherapy reduced neck disability and neck pain more effectively than physiotherapy alone. Self-rating by patients as regards treatment outcome was also superior in the surgery group. No significant differences were seen between the 2 patient groups as regards arm pain and health outcome.
People have very successful fusion surgeries – Some do not – some have very successful second fusion surgeries, some do not. A story of C3-C7 fusion and C1-C2 instability.
Often we will get a story. This story has been edited so it could be told in third person and some explanatory notes could be added.
This person had Anterior Cervical Discectomy and Fusion surgery twice (once in 2018/once in 2019) to complete a C3-C7 fusion. All the discs were removed because they were ruptured. This surgery was very successful as far as stabilizing the person’s neck at C3-C7. But then this person started to suffer from neurologic-like, gastrointestinal-like and unexplained symptoms. This person wrote: “Although the ACDF’s gave some result/stability at those levels, the main symptoms remained. It appears to be exactly all these rare symptoms that Dr. Hauser describes in his video’s and (articles). After getting all this info I am 100% sure I have remarkable upper cervical instability. I think that the fusion from C3-C7 could never resolve these symptoms.”
Among these symptoms were:
- Brain fog and a sense of disorientation and dissociation
- Chronic dizziness, instability, vertigo, drunken gait
- Heart: sudden tachycardia’s (checked by cardiologist)
- Vision issues, unstable vision in one eye, pressure/pain on/around/behind the eyes (checked by eye doctor)
- Variable tinnitus, the hum, the hiss (all vestibular examination negative), feeling of sinusitis, eustachian tube issues
- Difficulty of breathing now and then
- Gastrointestinal issues
Some of the symptoms have been checked neurologically and by their specialty but it appears everything is fine, as they say.
Four-level and Five-level anterior cervical discectomy and fusion
Doctors at Rush University Medical Center and the Baxter Regional Neurosurgery & Spine Clinic, in Arkansas assessed patient outcomes in four-level and five-level anterior cervical discectomy and fusion. Here are the summary points of their research published in July 2022 in the journal World neurosurgery.(17)
- There were 34 patients (30 underwent 4-level and 4 underwent 5-level ACDFs) with an average age of 59.6 years; 55.9% were women.
- At three months, there were significant improvements in patient-reported outcome measure (PROMs) except for a mental component subscale, which showed modest improvement.
- At 12 months, there were significant improvements in patient-reported outcome measure (PROMs) except a physical component subscale which showed moderate improvement.
- The proportions of patients who met the MCID (minimum improvements need to be considered improvements after surgery) cutoffs ranged from:
- 35.3% (in one scoring system) to 75% (in another scoring system) at 3 months and 38.2% (in one mental health scoring system) to 65.5% (in another mental health scoring system) at 12 months.
- Shorter symptom duration was associated with significantly reduced postoperative pain and Neck Disability Index scores.
- Shorter length of stay was associated with significantly improved postoperative functional outcomes. patients undergoing 4-level compared with 5-level ACDF achieved better postoperative patient-reported outcome measure (PROMs).
- Shorter procedure duration was associated with improved patient-reported outcome measure (PROMs) at 3 months.
- No patient returned to the operating room within 30 days.
A March 2022 study published in the journal Scientific reports (23) examined outcomes after four-level anterior cervical discectomy and fusion (ACDF) in twenty-eight patients with a minimum of 12 months follow up. The average age at surgery was 58.5 years old. About 23 months later radiographic imaging follow up was done. Cervical lordosis was significantly improved postoperatively as well as significant improvement in pain and function scores. The most common perioperative complication was transient dysphagia (32%) followed by hoarseness (14%). Four (14%) patients required revision surgery at an average 11.5 months postoperatively.
Airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion
A June 2022 study (14) from the Department of Neurologic Surgery, Mayo Clinic Alix School of Medicine and published in the Clinical neurology and neurosurgery offered insights into which patients would have airway, respiratory, and pulmonary complications following elective anterior cervical discectomy and fusion.
In a patient base of 1454 patients who had respiratory and pulmonary complications, the researchers found:
- Older patients were 1.03 times more likely to have an respiratory and pulmonary complications.
- African American patients compared to Caucasian patients were 1.44 times more likely to have respiratory and pulmonary complications.
- Obese patients were found to be 1.64 times more likely to have respiratory and pulmonary complications.
- Diabetic patients are 2.07 times more likely to have respiratory and pulmonary complications.
- Hypertensive patients are 1.91 times more likely to have respiratory and pulmonary complications.
- Patients who underwent multilevel procedure were 1.32 times more likely to experience a respiratory and pulmonary complication.
Swallowing difficulties after cervical fusion
A June 2022 paper in the Journal of clinical neuroscience (15) Dysphagia following anterior cervical spine surgery is common. In this research, the investigators aimed to determine if change in intervertebral distraction (vertebral placement) following anterior cervical spine surgery is associated with early dysphagia (swallowing / Quality of Life difficulties). Among the 289 patients of this study, the incidence of dysphagia was 58.1% 1 week after anterior cervical spine surgery. Patients who underwent surgery involving C3/4 or involving three or more levels had worse symptom and function scores.
Dysphonia and Voice Hoarseness after cervical fusion surgery
Following anterior neck surgeries, recurrent laryngeal nerve palsy may occur as a complication due to trauma or irritation of the recurrent laryngeal nerve. A September 2022 paper in the journal World neurosurgery (22) reiterates: “Recurrent laryngeal nerve injury is common complication after anterior cervical discectomy and fusion (ACDF).” In this study, the researchers examined this problem by evaluating recurrent laryngeal nerve function during anterior cervical discectomy and fusion surgery using intraoperative recurrent laryngeal nerve monitoring with an electromyography-endotracheal tube (EMG-ET). The goals was to see if electromyography-endotracheal tube (EMG-ET) could alert surgeons of recurrent laryngeal nerve damage occurring during the surgery. These were the observations and outcomes:
- The study included 85 patients, 58 (68.2%) of whom had undergone surgery without an EMG-ET and 27 (31.8%) with an EMG-ET.
- Of the no EMG-ET group, 8 (13.8%) and 1 (1.7%) patient had developed immediate postoperative dysphagia and hoarseness, respectively, with complete recovery within 12 months.
- In the EMG-ET group, 2 (7.4%) and 1 (3.7%) patient had developed dysphagia and hoarseness, respectively, with complete recovery within 3 months for all 3 patients.
- Persistent postoperative RLN palsy had occurred in 5 patients (8.6%) without the EMG-ET but in none of the patients with the EMG-ET.
- Conclusions: “The use of an EMG-ET for RLN monitoring during ACDF surgery was helpful in detecting postoperative recurrent laryngeal nerve injury with fair sensitivity and high specificity and resulted in a shorter retractor time, thereby significantly reducing the risk of postoperative recurrent laryngeal nerve injury.”
The problems created by osteoporosis
In January 2023, doctors writing in The Journal of the American Academy of Orthopaedic Surgeons (25) examined the impact of osteoporosis, two-years after cervical neck fusion. In this study the doctors followed 136 osteoporosis patients and found that “patients with osteoporosis incurred higher rates of overall medical complication rates and individual surgical complications, such as nonunion. Osteoporosis was associated with medical complications, surgical complications, and (hospital) two years.
Pseudoarthrosis after cervical fusion
An April 2022 study in the journal Clinical spine surgery (13) described the problem of pseudarthrosis (failed fusion surgery). “Pseudarthrosis of the cervical spine represents a common and challenging problem for spine surgeons. Rates vary greatly from as low as 0%-20% to more than 60% and depend heavily on patient factors, approach, and number of levels.” If you have had failed spinal fusion, your doctor may have advised you that you developed pseudoarthrosis. The study continues: “While some patients remain asymptomatic from pseudarthrosis, many require revision surgery due to instability, continued neck pain, or radiculopathy/myelopathy.”
The complication of obesity in Anterior Cervical Discectomy and Fusion
A December 2021 paper from Rush University Medical Center published in the International journal of spine surgery (21) writes: “Body mass index (BMI) serves as a risk factor for complications and poorer outcomes following anterior cervical discectomy and fusion (ACDF). This study investigates the association between BMI and patient reported outcomes of surgery.
- Included in this study were 128 patients who underwent elective primary, single, or multilevel ACDF. The patients were divided into 4 groups based on BMI score.
- 74 patients in the non-obese group,
- 27 in the Obese (0verweight), 19 in the Obese (obese), and 8 in the Obese (very obese) groups.
- The average age was 50.0 years and 57.0% were male.
- The researchers found: “Among the assessed BMI subgroups, all experienced similar physical function scores during the preoperative and short-term time points. Patients with higher BMI demonstrated diminished physical function at long-term time points.
Postoperative dysphagia. ACDF and the posterior approach
A December 2022 paper in The spine journal (29) analyzed swallowing function after anterior/posterior surgery for cervical degenerative disorders.
- A total of 41 consecutive patients who underwent an anterior approach (anterior cervical discectomy/corpectomy (removal of all or part of the vertebrae) and fusion (ACDF, ACCF), hybrid surgery (ACDF+ACCF) and total disc replacement) and 44 consecutive patients who underwent a posterior approach (laminoplasty and laminoplasty/laminectomy with fusion) were compared.
Comparisons were made in pre- and postoperative functional oral intake scale (FOIS – the ability to take in food or liquid), dysphagia severity scale (DSS), esophageal dysphagia, anterior/superior hyoid (the u-shape bone at the base of the throat responsible for the movement of the tongue in swallowing and speech) movement, upper esophageal sphincter opening, pharyngeal transit time (from the time of the swallow to return to the normal non-swallowing position), among other observations.
- In the anterior approach, dysphagia severity scale, functional oral intake scale, the anterior and superior hyoid movements, maximum upper esophageal sphincter opening worsened postoperatively.
- In the posterior approach, dysphagia severity scale, functional oral intake scale, the anterior and superior hyoid movements worsened postoperatively
- Conclusions: “Each approach may decrease swallowing function, especially because of the limitation on the anterior hyoid movement.”
Digital motion X-Ray C1 – C2
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.
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 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 are 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 are 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, (12) 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 for an Anterior Cervical Discectomy and Fusion, you can get help and information from our Caring Medical Staff.
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This article was updated January 1, 2023