Elective Cervical Spine Surgery Reviews
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:
- Reviews of posterior cervical laminectomy and fusion
- Anterior Cervical Discectomy and Fusion
- Cervical adjacent segment disease: Risks and complications following cervical fusion
- Cervical artificial disc replacement complications
- Post Lumbar and Cervical Laminectomy Syndrome treatment options
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 patient for whom the 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, 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 spasm 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 (non motion) MRIs and x-rays are poor judges of this. Since these types of scans are very inaccurate to determine 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 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.
Cervical foraminal stenosis, cervical kyphosis risk factors after cervical laminoplasty
An August 2022 paper in the Spine Journal (3) 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 a change in the shape of your neck to a point where is has no curve, abnormally straight (military neck) or bent forward) after cervical laminoplasty may cause insufficient decompression (the surgery did not relive the pressure on the nerves that travel trough 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 increased 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.
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: 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 slight 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.(2)
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 on report 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 C2-C7 model.
- Posterior decompression with fusion and anterior decompression with fusion models’ average range of motion were 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 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 were 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.”
1 Lee NJ, Kim JS, Park P, Riew KD. A Comparison of Various Surgical Treatments for Degenerative Cervical Myelopathy: A Propensity Score Matched Analysis. Global Spine Journal. 2020 Dec 30:2192568220976092. [Google Scholar]
2 Nishida N, Mumtaz M, Tripathi S, Kelkar A, Kumaran Y, Sakai T, Goel VK. Biomechanical analysis of laminectomy, laminoplasty, posterior decompression with instrumented fusion, and anterior decompression with fusion for the kyphotic cervical spine. International Journal of Computer Assisted Radiology and Surgery. 2022 Jun 20:1-1. [Google Scholar]
3 Seo J, Suk KS, Kwon JW, Kim N, Lee BH, Moon SH, Kim HS, Lee HM. Cervical foraminal stenosis as a risk factor for cervical kyphosis following cervical laminoplasty. The Spine Journal. 2022 Apr 3. [Google Scholar]