Recent Research on Elective Cervical Spine Surgery

Ross Hauser, MD.

This article is part of a series on the different types of cervical spine surgery often performed for Degenerative Disc Disease or Degenerative Cervical Myelopathy. Other articles in this series:

Understanding Cervical Spondylosis

It can be said that Cervical Spondylosis is an umbrella term used to describe degenerative changes in the cervical spine when there is no clear answer as to why you or a particular patient continues to suffer from any one of a long list of symptoms that your doctor has attributed to a problem in your neck. Cervical spondylosis can cause varying degrees of stenosis of both the central spinal canal and intervertebral neural foramina causing compression on many structures including the spinal cord itself.
Factors contributing to this narrowing include degenerative disc, osteophytes, and hypertrophy of the lamina, articular facets, ligamentum flavum, and posterior longitudinal ligament.
In the many patients we have seen, there is confusion, there is frustration, and there is seemingly no plan that these people can see that will help them.

Many patients who visit us have stories of a long medical history. They will tell us about their decades-long battle managing their “health problems.”

Patients will tell us about their dizziness and their diagnosis of Cervical Vertigo and Cervicogenic Dizziness
Patients will tell us about their neck pain and vision problems
Patients will tell us about their headaches
Patients will tell us about a numbness or pins and needles sensation on one side of their face. Some will even have a diagnosis of Trigeminal neuralgia
Patients will tell us about fainting or nearly passing out from turning their head one way or another and problems we attribute to Vertebrobasilar insufficiency
Of course, there will be long medical histories and treatments and possibly surgeries for continued neck pain that radiates into their shoulder, back, arms, and even into their feet.

Many people with cervical conditions, including cervical spondylosis, choose neck surgery as a treatment option.

When a single nerve root is involved from a herniated disc, a posterior microdiscectomy is performed.
When nerve roots (whether single or multiple) are involved because of cervical spondylotic osteophytes, a posterior decompression with a laminectomy and foraminotomy can be performed.
There are various different operations to take out the bone, disc, and even ligaments to give the nerves more space. These include anterior cervical discectomy or corpectomy, posterior microdiscectomy, posterior cervical laminectomy, and of course, if the surgeon feels that so much tissue had to be taken out that the spine is now unstable, then a fusion also has to be performed. When compression of the spinal cord occurs because of severe cervical instability, anterior cervical decompression, and fusion are often the operations of choice, though artificial disc replacements are gaining in popularity.

The reasons for spinal arthrodesis or fusion of the cervical spine include:

(1) to support the spine when its structural integrity has been severely compromised (to reestablish clinical stability),

(2) to maintain correction following mechanical straightening of the spine in scoliosis or kyphosis following osteotomy/laminectomy of the spine,

(3) to alleviate or eliminate pain by stiffening a region of the spine (i.e., diminishing movement between various segments of the spine), and

(4) to prevent the progression of deformity of the spine as in scoliosis, kyphosis, and spondylolisthesis. The risks of spinal surgery include infection; excessive bleeding; adverse reaction to anesthesia; chronic neck or arm pain; inadequate symptom relief; damage to the nerves, nerve roots, or spinal cord; spinal instability; damage to the esophagus, trachea, or vocal cords; injury to the carotid or vertebral arteries; and subsequent stroke and non-healing of the fusion.

In the almost 30 years I have been a physician, there is not one body part where the surgical technique is the same today as it was when I started. Unfortunately, most of the surgeries that I assisted in my training are basically not even done anymore because they were such dismal failures.

Unfortunately, patients and many surgeons do not consider factors such as the loss of cervical lordosis, vertebral body subluxation, and most importantly cervical instability in the mix, as all of these are treatable. Many are left with the belief that it is just osteoarthritis and nothing can be done about it or that the bone spurring has to be taken out by surgery.

Is surgery the right answer?

Many people have successful cervical spine surgery. Some people do not. In our clinic, we do see some people following successful cervical spine surgery who have a little instability or neck malalignment that they would like addressed. These people were very happy with the surgery and for the most part, would have it again if given the same choice. Unfortunately, we see many more patients for whom cervical spine surgery was not successful. Why did this happen to them?

Traditional pain management care involves trying to find the pain-producing structure and then doing something to it to calm the nerve pain impulses down. An example of this would be if someone has severe pain down their arm, and a subsequent MRI shows a lot of arthritis narrowing the intervertebral neural foramina, so surgery is done.

The decompressive surgery removes the bone spurs and makes more room for the nerve root. However, people sometimes have continued pain after this operation because the nerve was not getting compressed in the cervical spine but more toward the shoulder area.

For the nerve to make it from the neck to the skin and muscles of the arm it has to travel through and by a lot of structures including muscles, fascia, and nearby joints such as the shoulder. The nerve complex of the arms (called the brachial plexus) runs between the scalenus anterior and scalenus medius muscles. Since the scalene muscles attach the transverse processes of the middle to lower cervical vertebrae to the first two ribs, instability in any of these joints would cause muscle spasms and potential hypertrophy of these muscles. This could, in turn, lead to compression of the nerves from the neck in the brachial plexus. In addition, shoulder instability can compress the brachial plexus nerves, as the nerves run just anterior to the shoulder joint. So knowing exactly where the joint instability is located is crucial to curing chronic neck pain and its sequelae and, as you will find out, static (nonmotion) MRIs and X-rays are poor judges of this. Since these types of scans are very inaccurate in determining what is causing pain, when a person is told they need surgery to resolve chronic pain, a non-surgical option should be examined as well.

Cervical laminoplasty, Cervical Laminectomy/fusion, and multi-level ACDF

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. (1)

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.

Anterior Cervical Discectomy and Fusion required the longest operative time versus cervical laminectomy/fusion and cervical laminoplasty.
Anterior Cervical Discectomy and Fusion required the shortest hospital stay
Anterior Cervical Discectomy and Fusion had lower overall complications (Anterior Cervical Discectomy and Fusion 3.9%, laminoplasty 7.7%, laminectomy/fusion 11.5%), mortality (ACDF 0%, laminoplasty 0.55%, laminectomy/fusion 2.2%, p, and unplanned readmissions (ACDF 4.4%, laminoplasty 4.4%, laminectomy/fusion 9.9%.
No significant differences were seen in the other outcomes including deep-vein thrombosis (DVT)/PT, acute renal failure, urinary tract infection, stroke, cardiac complications, or sepsis.

Conclusions: 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 and risks. Anterior Cervical Discectomy and Fusion are significantly associated with the longest operative duration and shortest length of stay without an increase in individual or overall complications, readmissions, or reoperations.

Cervical laminoplasty and cervical laminectomy with posterior fixation

A November 2022 paper (2) compared the back approach cervical laminoplasty against cervical laminectomy with posterior fixation. Writing “There is still controversy concerning the technique in terms of outcome and complications,” the researcher’s aim was to analyze and compare these from the clinical and radiological points of view these 2 techniques.

The medical records of 39 patients were reviewed (12 laminectomies with posterior fixation and 27 laminoplasty).
Significant differences were observed in the postoperative improvement in the laminoplasty group.
In laminectomy with posterior fixation there is a tendency for a greater improvement, but cannot be confirmed because of the low sample size of this group.
Conclusions: Laminoplasty and laminectomy with posterior fixation are both safe and effective procedures in the treatment of cervical degenerative myelopathy.

Returning to the above research, the study authors continue: “However, since most people with Chronic cerebrospinal venous insufficiency present with obvious neurological symptoms, surgical decompression alone cannot completely reverse the pathological changes. It is reported that between 11% and 38% of patients still have some degree of dysfunction after decompression and delayed treatment can lead to worse outcomes or even lifelong disability.

Changes in spinal cord biomechanics after laminectomy with fusion, laminectomy, and laminoplasty

An April 2023 study led by the Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin (3) compared changes in spinal cord biomechanics after laminectomy with fusion, laminectomy, and laminoplasty using a computer-generated model of a patient’s neck who suffered from degenerative cervical myelopathy. The researchers write: “Spinal cord stress/strain during neck motion contributes to spinal cord dysfunction in degenerative cervical myelopathy (DCM), yet the effect of surgery on spinal cord biomechanics is unknown.” They add, “It is expected that motion-preserving and fusion surgeries for degenerative cervical myelopathy (DCM) will have distinct effects on spinal cord biomechanics.” Therefore it is expected that surgery will help.

What the researchers did was use the computer-generated model of a patient’s neck and give that patient a virtual reality multilevel laminectomy with fusion, laminectomy, and laminoplasty. Spinal cord stress and strain during neck flexion-extension, lateral bending, and axial rotation were recorded. Segmental range of motion, intradiscal pressure, and capsular ligament strain were also measured.

Here is what they found after the virtual surgery:

Spinal cord stress increased after laminectomy for neck flexion (+50%), neck extension (+37.8%), and axial rotation (+23%).
Spinal cord strain increased in neck extension (+118.4%) and axial rotation (+75.1%) after laminectomy.
Laminoplasty was associated with greater spinal cord stress in neck flexion (+57.4%) and increased strain in lateral bending (+56.7%) and axial rotation (+20.9%).
Compared with laminectomy and laminoplasty, spinal cord biomechanics for laminectomy with fusion revealed significantly reduced median extension stress, lateral bending strain, axial rotation stress, and axial rotation strain. Compared with motion-preserving approaches such as laminectomy and laminoplasty, laminectomy with fusion was associated with the lowest spinal cord stress and strain in flexion-extension, lateral bending, and axial rotation of the neck.

Anterior cervical decompression fusion vs. posterior laminoplasty

A December 2022 paper in the Journal of Neurological Surgery (4) examined outcomes in patients undergoing anterior cervical decompression fusion or posterior laminoplasty for four-segment cervical spondylotic myelopathy.

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 length of hospital stay than those in the posterior laminoplasty (LAMP) group.
Following the surgical procedures, certain disability and pain scores in the ACDF group were significantly lower than those in the LAMP group at the final follow-up.
Results indicated that ACDF can improve cervical lordosis better than posterior laminoplasty (LAMP) and patients who may have a better improvement of cervical lordosis may have a better prognosis.

A May 2023 paper from Linköping University in Sweden and published in the medical journal BioMed Central musculoskeletal disorders (5) provided a more than 20-year follow-up on pain and disability after anterior cervical decompression and fusion surgery for degenerative disc disease and a comparisons between the two surgical techniques. (Cloward Procedure(discectomy) and the carbon fiber fusion cage (decompression).

The researchers said of their study: “Follow-ups more than 20 years after neck surgery are extremely rare. No previous randomized studies have investigated differences in pain and disability more than 20 years after ACDF surgery using different techniques.”

Questionnaires were sent to 64 people, at least 20 years after ACDF due to cervical radiculopathy.
Fifty people (average age 69, 60% women, 55% carbon fiber fusion cage surgery) completed questionnaires.
In these people, an average of nearly 22 and one half years had passed since surgery.
Primary outcomes that were followed were:
- neck pain
- neck disability index (NDI).
- Secondary outcomes were
  - frequency and intensity of neck and arm pain,
  - headache,
  - dizziness,
  - self-efficacy (personal belief in ability to function and perform tasks, (yes I can, No I can’t),
  - health related quality of life or global outcome.

Results: Neck pain and neck disability index (NDI) score significantly improved over time, with no group differences in primary or secondary outcomes.

Eighty-eight per cent of participants experienced improvements with some a full full recovery,
- 71% (pain) and 41% (neck disability index (NDI) had clinically relevant improvements.

Conclusion: The researchers suggest that one fusion surgery was not superior to another over a long period of time. “Pain and disability improved substantially over time, irrespective of surgical technique. However, the majority of participants reported residual disability . . . Pain and disability were correlated to lower self-efficacy and quality of life.

The end result here:

71% had pain improvement, 29% did not have clinically relevant improvement
41% had functional improvement, 59% did not have clinically relevant improvements.

Cervical foraminal stenosis, cervical kyphosis risk factors after cervical laminoplasty

An August 2022 paper in the Spine Journal (6) investigated the relationship between preoperative cervical foraminal stenosis and kyphotic changes after cervical laminoplasty. The researchers write: “Cervical laminoplasty is an effective spinal cord decompression method for patients with cervical myelopathy. However, cervical kyphosis (Cervical kyphosis is a change in the shape of your neck to a point where it has no curve, is abnormally straight (military neck) or bent forward) after cervical laminoplasty may cause insufficient decompression (the surgery did not relieve the pressure on the nerves that travel through the neck) of the spinal cord.” The researchers tell surgeons: “prevention of cervical kyphosis after cervical laminoplasty and identification of its risk factors are essential.

The patients of this study were divided into the kyphosis group (25 patients) and the cervical lordosis ( That this cervical instability has caused you to lose the natural curve or LORDOSIS in your neck) group (83 patients).

Research learning points:

Preoperative foraminal stenosis significantly increases the risk of kyphosis.
Preoperative cervical foraminal stenosis is an independent risk factor for cervical kyphosis following Cervical laminoplasty.
Cervical laminoplasty may not be a suitable surgical option for cervical myelopathy combined with foraminal stenosis.

Anterior cervical discectomy and fusion (ACDF), cervical disk arthroplasty (CDA), and posterior cervical foraminotomy (PCF)

A February 2023 paper in the journal Spine (7) compared the pre-surgery problems of patients with complications and reoperation rates after anterior cervical discectomy and fusion (ACDF), cervical disk arthroplasty (CDA), and posterior cervical foraminotomy (PCF) in patients being treated with cervical radiculopathy. The researchers found: “The rate of surgical site infection was higher in posterior cervical foraminotomy (PCF) compared with anterior cervical discectomy and fusion (ACDF) and cervical disk arthroplasty (CDA). New-onset cervicalgia was higher after anterior cervical discectomy and fusion (ACDF) compared with posterior cervical foraminotomy (PCF) and cervical disk arthroplasty (CDA) at short-term follow-up. Revision surgeries were highest among those undergoing cervical disk arthroplasty (CDA) and lowest in those undergoing anterior cervical discectomy and fusion (ACDF).”

Cervical spines can be divided into 1 of 6 categories. Many of these spinal deformities are the reason for cervical neck surgery.

A: Normal “C” cervical lordosis: a normal cervical curve with lordosis.
B: Hypolordosis: loss of optimum curvature, but still lordotic
C: Military: complete loss of lordosis resulting in a straight spine
D: Hypokyphosis: “R” reversed curve, a slightly flexed posture of the cervical curve.
E: Degenerative hyperkyphosis: extreme reversal of cervical curve (sideways “V”).
F: Sigmoidal “S”

In June 2022, doctors at the Yamaguchi University Graduate School of Medicine in Japan teamed with doctors at The University of Toledo to analyze cervical laminectomy, cervical laminoplasty, cervical posterior decompression with instrumented fusion, and cervical anterior decompression with fusion (Anterior Cervical Discectomy and Fusion) for the kyphotic cervical spine. (8)

The researchers note:

Anterior and posterior decompressions for cervical myelopathy and cervical radiculopathy may lead to clinical improvements. However, patients with kyphotic cervical alignment have sometimes shown poor clinical outcomes with posterior decompression. There is a lack of reports of mechanical analysis of the decompression procedures for kyphotic cervical alignment.
In preparing the mechanical analysis the doctors used computer-created three-dimensional images of the cervical spine (C2-C7) with the pre-operative kyphotic alignment model and compared the biomechanical parameters (range of motion (ROM), annular stresses, nucleus stresses, and facet contact forces) for four decompression procedures at two levels (C3-C5); cervical laminectomy, cervical laminoplasty, posterior decompression with fusion, and anterior decompression with fusion. The researchers then created an anatomical load on the C2-C7 model.

Results:

Posterior decompression with fusion and anterior decompression with fusion models’ average range of motion was 40% at C2-C7 less than the pre-operative kyphotic alignment, cervical laminectomy, and cervical laminoplasty models. The Posterior decompression with fusion and anterior decompression with fusion models provided less post-surgical stability.
The annular and nucleus stresses decreased by more than 10% at the surgery levels for anterior decompression with fusion, and posterior decompression with fusion, compared to the pre-operative kyphotic alignment, cervical laminectomy, and cervical laminoplasty models. In other words, Posterior decompression with fusion and anterior decompression with fusion models showed a 10% better-reduced stress on the disc at the surgical level.
- However, the annular stresses at the adjacent cranial level (C2-C3) of anterior decompression with fusion were 20% higher.
- The nucleus stresses of the caudal adjacent level (C5-C6) of posterior decompression with fusion was 20% higher, compared to other models.
- The posterior decompression with fusion and anterior decompression with fusion models showed a less than 70% decrease in the facet forces at the surgery levels, compared to the pre-operative kyphotic alignment model, cervical laminectomy, and cervical laminoplasty models.

“The study concluded that posterior decompression, such as cervical laminectomy or cervical laminoplasty, increases ROM, disc stress, and facet force and thus can lead to instability. Although there is the risk of adjacent segment disease, posterior decompression with fusion and anterior decompression with fusion can stabilize the cervical spine even for kyphotic alignments.”

Postoperative dysphagia

A December 2022 paper in The Spine Journal (9) analyzed swallowing function after anterior/posterior surgery for cervical degenerative disorders and factors related to the occurrence of postoperative dysphagia.

A comparison of 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) was made.

Outcome measures: The researchers compared the 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, the 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
The factors associated with dysphagia were a surgical site above C3, blood loss, operative time of more than 200 minutes in surgery, and an extensive surgical field of more than three intervertebral levels. The decline in swallowing function after the posterior approach was related to aging.
Conclusions: “Each approach may decrease swallowing function, especially because of the limitation on the anterior hyoid movement.”

Re-operation rates

Researchers writing in The Spine Journal (10) examined reoperation rates and reasons for reoperations after cervical spine surgery within 30 and 90 days.

In this study of over 13,000 patients, the overall reoperation rate was 1.24% within 30 days and 3.30% within 90 days.
At 30 days, the main factors for reoperation were initial procedures involving four or more levels, posterior only approach, and longer length of hospital stay
Within 90 days, male sex, coronary artery disease (CAD), previous spine surgery, procedures with 4 or more levels, and longer length of stay had significantly increased odds of returning for a second surgery.
- The most common specified reasons for return to the surgery within 30 days were hematoma (19%), infection (17%), and wound dehiscence (11%).
- Within 90 days, reoperation reasons were pain (10%), infection (9%), and hematoma (8%).

Return to work

A February 2023 study in the journal Spine (11) found that approximately half of the patients who had cervical radiculopathy surgery returned to work within four months, and by the end of the first year after surgery, 66.9% of the study patient group had returned to work. By the third year after surgery, the number of people working three years later was about equal to the number of people who were working before the surgery. People who took fewer sick days pre-surgery tended to have better success returning to work after surgery. The doctors here did note: “Although we observed a substantial improvement in disability and pain after surgery in all groups, the rate of return-to-work among the same population was disproportionally lower than expected from the clinical improvement.”

Nutritional disorders as a risk factor

A December 2022 paper from the Department of Orthopaedic Surgery, Gunma University Graduate School of Medicine in Japan and published in the European Spine Journal (11) discussed the impact of the preoperative nutritional status on postoperative kyphosis in geriatric patients undergoing cervical laminoplasty.

In this study ninety patients without preoperative kyphotic alignment (without spinal curvature deformity) and an average age of 73.5 years old and 41% female) were followed post-surgery.

Twenty-one patients (23.3%) had malnutrition status.
Postoperative kyphosis was more prevalent in the malnutrition group (33.3% vs. 7.2%).
Conclusion: Among geriatric cervical spondylotic myelopathy patients, preoperative malnutrition was closely associated with the increased occurrence of cervical kyphosis after laminoplasty.

The researchers underscored the importance of preoperative nutritional assessment and management in geriatric populations undergoing cervical spine surgery

References

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