Cervical adjacent segment disease: Risks and complications following cervical fusion

Ross A. Hauser, MD. Danielle R. Steilen-Matias, MMS, PA-C. Brian R. Hutcheson, DC. 

Understanding Anterior Cervical Discectomy and Fusion surgery, risks and complications following surgery

Many people have great success with cervical fusion surgery. These are the people we do not see in our clinic. The people seeking our help and the people we see at our center did not have such great success with their surgery. They developed more neck pain, more neck instability, and bone spurs. The need for more fusion has been recommended to them as well.

Let’s look at the journey some patients take after cervical neck fusion. Some of these stories may sound like yours. In many cases, we can help people with post-surgical pain.

I am taking more painkillers now than I did before the surgery

I recently had Anterior Cervical Discectomy and Fusion. The fusion was only at two levels. The fusion did not help my arm pain or neck pain. It made these pains worse.  I now suffer from more problems including headaches and head pressure. I am taking more painkillers now than I did before the surgery. My doctors are not that concerned but I am. I was not told that these complications may be a risk for fusion surgery.

Again, let’s point out that many people have successful surgeries. A person like this would have to better understand their problems leading up to surgery and whether the surgery itself directly caused the headaches or whether the surgery fixed one area but left another area of the neck under more stress.

What are we seeing in this image?

In this image, we see adjacent segment disease severely impacting the non-fused C6-C7 area. After two fusion surgeries, this 15-year-old patient’s only natural moving cervical segment is at C1-C2. This unfortunately is a classic case of fusion surgery causing more problems than it helped.

In this image we see adjacent segment disease severely impacting the non fused C6-C7 area. After two fusion surgeries, this 15 year old patient only natural moving cervical segment is at C1-C2. This unfortunately is a classic case of fusion surgery causing more problems than it helped. 

 

My sinus headaches and posture problems after fusion

Listen to this person’s problem. How can we help with something like this?

I have had chronic facial pain and sinus headaches following a neck fusion a little over a year ago. It has limited my working out, I can no longer ride my bike because it hurts worse to lean forward. I feel constant pressure in my sinuses now and occasional pain between my shoulder blades. I do not have pain going down my arm or into my fingers. I have been through many spine surgeons and neurosurgeons. I do NOT want to have any more surgeries and fusion in my opinion is the worst operation ever on the neck.

In a person like this, once hardware failure or surgery caused nerve damage is explored and excluded, we would focus on the adjacent neck segments to see if the fusion made a condition of worsening instability in the neck.

My ACDF was successful except for my new problems

Sometimes ACDF is needed when there is a clear neurological impact impacting one’s ability to walk or have control of their bladder. Sometimes ACDF can successfully correct these problems but leave behind others.

I had a successful ACDF last year, I had balance and sense of space issues that caused me to stagger when I walked. The surgery restored strength and stability in my arms and legs. However I am experiencing worsening pain in my C1-C2 area, my fusion was C3-C7. I am now experiencing jaw pain and problems in my throat. I was told by my surgeon to have patience, my neck bones are fusing. I think the longer I wait to do something, the worse I will get. I get the feeling that my surgeon considers me successful and thinks that I do not need more help. 

Again, many people have very successful surgeries. Stories like those above represent the small minority of cases post-surgery. However, people do have problems and sometimes we can help them with our various neck repair programs and injections.

“Delayed and progressively worsening neurological problems following multisegmental cervical spinal fusion.”

Now let’s explore the research that stories like the ones above have a base in medical research. That they do happen.

First, we are going to explore a March 2020 paper presented in the Journal of Craniovertebral Junction and Spine (1) by a group of neurosurgeons from the Department of Neurosurgery, King Edward Medical Hospital, and Seth GS Medical College. The paper reports on adjacent-segment “central” or “axial” atlantoaxial instability and C2-C3 instability as the cause of delayed and progressively worsening neurological problems following multisegmental cervical spinal fusion.

The neurosurgeons described the cases of three male patients: a 34-year-old man, a 56-year-old man, and a 70-year-old man who all had C3-C6 fusion

In this paper, the neurosurgeons described the cases of three male patients. A 34-year-old man, a 56-year-old man, and a 70-year-old man, all who had surgery for cervical spondylosis by multilevel C3-C6 cervical interbody fusion some six to eleven years earlier. After an initial improvement for a few years, the patients observed relatively rapid clinical deterioration. When admitted, all three patients were severely quadriparetic (they had severe weakness and function problems in both arms and legs) and were brought to the hospital in a wheelchair (they could not walk.)

In all three men, central atlantoaxial instability was diagnosed. More surgery was required The patients underwent atlantoaxial and C2-C3 fixation, on average 21 months after the new surgery the patients were able to walk independently again.

This paper concludes with an understanding of how this happened to these three men and how it happens to other patients

 “The general understanding is that neurological symptoms are a result of direct neural compression (the nerves are getting pinched or impinged) or deformation. Recent studies have identified that rather than compression, neurological symptoms are secondary to instability-related subtle and repeated micro-injuries to neural structures. There could be instability of the spinal segments even when the bones are in alignment on dynamic imaging. Our recent classification identifies atlantoaxial instability even in the absence of any bone mal-alignment or directs neural or dural compression by odontoid process (spinal cord compression of the C2).”

Here are the learning points of this paper concerning cervical spine instability caused by cervical fusion and the resulting adjacent segment instability it can cause:

The damage that instability is causing can be on the micro-level, invisible to MRI or other imaging devices.

What is the evidence a patient has Atlantoaxial Instability? A past C2-C3 Fusion causing problems at C3-C7

Another paper presented in the March 2020 edition of the Journal of Craniovertebral Junction and Spine (2) by the same group of neurosurgeons looked at patients who had symptoms related to cervical myelopathy and had a previous C2-C3 fusion and the presence of single or multiple level nerve compression of the subaxial (C3-C7 levels) cervical spinal cord attributed to “degenerative” spine.

In this study, the researchers examined seven adult males were analyzed who had long-standing symptoms of progressive cervical myelopathy and where imaging showed the presence of C2-3 fusion, no cord compression related to the odontoid process (at C2), and evidence of single or multiple level lower cervical cord compression conventionally attributed to spinal degeneration. Conclusion: The presence of C2-C3 fusion is an indication of atlantoaxial instability and suggests the need for atlantoaxial stabilization (more fusion). Effects on the subaxial spine and spinal cord are secondary events and may not be surgically addressed. (If you fix the instability the pressure on the spinal cord can resolve itself. In our office we use non-surgical means to achieve this same treatment goal.)

This is a video case study of a patient that we are seeing in Caring Medical Florida

The patient was in a car accident

Surgery

The rapid formation of bone spurs, adjacent segment disease, neck pain, and cervical spine instability following surgery

The vertebrae are sliding away from each other.

This image shows digital motion x-ray of a bone spur at the adjacent level (C4-C5) that has formed since cervical fusion surgery. Cervical spine instability at C3-C4 is also shown in the offset above the fusion

This image shows a digital motion x-ray of a bone spur at the adjacent level (C4-C5) that has formed since cervical fusion surgery. Cervical spine instability at C3-C4 is also shown in the offset above the fusion.

After the surgery: Problems you may not have anticipated – For one: Your doctors don’t believe that there is anything wrong with you

A patient will tell us a story that foes something like this:

I have neck pain for years. I have had many treatments seen many doctors. I was told a long time ago to have a cervical fusion. I did not want the surgery so I tried chiropractic, physical therapy, various neck braces, collars, and traction devices, acupuncture, yoga, supplements, and anything I could buy online that looked like it would help. Finally, my pain was getting worse and I was losing function. 

I had fusion for cervical stenosis. My surgeon told me the surgery was a success. My stenosis symptoms have vanished. But, since my surgery, I now have tinnitus, fullness in the ears, headaches, vision problems, balance issues, and nausea. I get hot and my skin gets blotchy red patches when I move my neck. I also have blood pressure swings. Then I developed an inability to keep my head up. The physical therapist called this dropped head syndrome.

My doctors do not think my fusion is causing these problems which I think is from upper neck instability. The answer is to send me back to physical therapy. Some of my doctors think this is a phycological problem. They have never heard of my symptoms occurring after fusion.

In the video above we present one case study of worsening problems after cervical spinal fusion. We see many patients with even worse situations and we are not alone in this. Here are post-fusion problems discussed in the medical literature.

A change in voice or voice damage

A February 2021 study in the International Journal of Spine Surgery (3) wrote that: “Injury to the recurrent laryngeal nerve has been implicated as a common complication following anterior cervical discectomy and fusion (ACDF) surgery.” The goal then of this research was to assess the “true incidence of voice hoarseness and recurrent laryngeal nerve palsy following ACDF surgery, to determine the reliability of symptoms in the diagnosis of recurrent laryngeal nerve injury, and to evaluate factors related to the development of these symptoms.” Let’s explore what these researchers found.

Conclusions: From the results of this study, the recurrent laryngeal nerve remained functional even a month after surgery despite several cases of postoperative dysphagia, aspiration, and voice changes.

Clinical relevance: “Voice hoarseness does not necessarily indicate recurrent laryngeal nerve injury after ACDF but may be caused by compressive forces on laryngeal tissue during retraction or intubation.”

Problems of constipation and stressful bowel movements

Likely need narcotic pain medications

Long-term therapy

Things you can’t do anymore

Cervical fusion after a shoulder arthroscopic surgery – unforeseen problems

Surgeons at Brown University wrote in the journal World Neurosurgery, (4) “Patients who undergo Anterior Cervical Discectomy and Fusion surgery with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy”

The need for painkillers after surgery is a dangerous need

Here is a disturbing study from July 2019 published in the journal Pain Research & Management. (5)

In the April 2019 issue of Lancet, (6) researchers at the University of Pennsylvania and Harvard wrote that “excessive prescribing of opioids for pain treatment after surgery has been recognized as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm.”

As mentioned above, when your cervical vertebrae are fused to limit cervical instability and related symptoms, the force and energy in your neck movements are transferred to the vertebrae below the fusion and above the fusion. This is why people suffer from the same symptom at different locations a year to 3 years later. This is why many people are sent back to surgery to fuse more segments and why many get the symptoms back and they can even be worse. Let’s explore research from some of the leading universities and research hospitals that support these findings.

Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery

In September 2019, researchers at The Johns Hopkins University and University of Virginia suggested in their research published in the Spine Journal (7) that “Patients undergoing ACDF commonly receive high-dose opioid prescriptions after surgery, and certain patient factors increase the risk for chronic opioid use following ACDF. Interventions focusing on patients with these factors is essential to reduce long-term use of prescription opioids and postoperative care.” One of these factors was that some of these patients were already taking high dose opioid doses prior to surgery and continued to do so after surgery.

Within 10 years, 1 in 4 patients can be at risk of clinical adjacent segment disease.

These are some of the things we hear from patients and people who email us with questions who have to contemplate another procedure.

Doctors at the University of Alberta noted in the Canadian Journal of Neurological Sciences(8) “Cervical spine clinical adjacent segment pathology has a reported 3% annual incidence and 26% ten-year prevalence. Its pathophysiology remains controversial, whether due to mechanical stress of a fusion segment on adjacent levels or due to patient propensity to develop progressive degenerative change.”

Simply,  within 10 years, 1 in 4 patients are at risk of clinical adjacent segment disease because of unnatural stress and destructive forces being placed on the cervical spine.

Some patients did not have a full understanding of what the fusion outcome will be.

In this video, Danielle R. Steilen-Matias, MMS, PA-C explains the challenges of adjacent segment disease

A case presented

Anterior cervical spondylosis surgery: a retrospective study with long-term follow-up found that fusion significantly and negatively alters the curve in the neck

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

In February 2018, orthopedic surgeons wrote in the Journal of Orthopaedic Surgery and Research (9) about their investigation of the incidence and causes of non-fusion segment disease, both adjacent and non-adjacent to a fused segment, after anterior cervical fusion.

Here are the results of their investigation:

The conclusion: “The incidence of symptomatic non-fusion segment disease after anterior cervical arthrodesis has multifactorial causes. Postoperative cervical lordosis and disc degeneration in non-fusion segments were major factors in the incidence of non-fusion segment disease.”

The second cervical spine fusion makes the cervical lordosis even worse


Surgery failed to restore or maintain the cervical lordosis

In May 2018, spinal surgeons operating in Germany and Egypt wrote in the medical journal Spine (10) about the problems of the second cervical neck surgery to fix the problems of cervical adjacent segment disease

Let’s focus on the fact pointed out by the researchers:

We want to stress this point too: People benefit from this surgery, this article is for the people who don’t or maybe poor candidates for this type of surgery.

The learning point of this research is all about the curve of the neck

CONCLUSION: Adjacent segment disease occurred predominantly in the middle cervical region (C4-6); especially in patients with preexisting evidence of radiological degeneration in the adjacent segment at the time of primary cervical fusion, notably when this surgery failed to restore or maintain the cervical lordosis.

The curve of the neck will be discussed further below

The surgery to fix the surgery. Revision and more fusion is no easy fix


The removal of implants secured through the endplates of adjacent vertebral bodies

Doctors at the Swedish Neuroscience Institute, Swedish Medical Center, in Seattle Washington led a study examining the failure patterns in standalone Anterior Cervical Discectomy and Fusion Implants. The study appeared in the September 2017 edition of the journal World Neurosurgery. (11)

Take home points:

Patients with cervical instability are getting surgeries that cause more instability and deformity

Doctors at South Korea’s Pusan National University published this research in the Journal of Korean Neurosurgical Society. (12)

What these researchers are warning is that the cervical spine and its attachment to the thoracic spine are more unstable than thought. This presents a paradox, patients with cervical instability are getting surgeries that cause more instability and deformity. Here is the result of this research:

The quick points:

The findings:

Surgical correction of the cervical spine curve during fusion surgery. Does it help? Why doesn’t it help?

We would like to point out again that some people derive great benefit from anterior cervical fusion surgery, again, these are the people we do not see. We see the people who had less than hoped for success.

In our non-surgical regenerative medicine injection techniques, we recognize that to help the patient who suffers from chronic neck pain, we must address and correct problems of the curvature of the cervical spine to achieve the best results. Surgeons also look at the curvature of the spine and its correction as a possible aid in helping their patients.

In December 2018 in the medical journal Therapeutics and Clinical Risk Management, (13) surgeons asked: “Is correction of segmental kyphosis necessary in single-level anterior cervical fusion surgery?” Here is how they answered that question:

What does this mean? It means that fusion is a complicated surgery and affects the natural movement of the neck, even when the natural curve of the spine is restored. Let’s go back to this study. The researchers focus on disc height at the fusion level.

The benefits and risks in summary

As stated earlier in this article. There are patients who do very well with cervical fusion surgery. Some report 100% improvement some report close to 100% improvement. Others get some improvement and they are happy with that. As in any medical treatment, there has to be a realistic understanding of what the benefit may or may not be.

Here is an August 2020 paper published in the Journal of Orthopaedic Surgery and Research. (14) It gives a surgeon’s view of the realities of fusion surgery:

“For patients with two-level symptomatic adjacent segment disease, both anterior and posterior decompression and fusion were effective for improving the neurological function. For patients with radicular symptoms, Anterior Cervical Discectomy and Fusion surgery had less surgical trauma, better restoration of lordosis, and less postoperative neck pain, but a higher chance of recurrent adjacent segment disease. Posterior decompression and fusion was an effective surgical option for older patients with myelopathy developing in adjacent segments.”

When you have fusion you can develop adjacent segment disease over the years and the challenges they bring are things to be considered when the first surgery is suggested.

The final outcome of a successful cervical fusion is that the vertebrae can no longer move.

The final outcome of a successful cervical fusion is that the vertebrae can no longer move. This will prevent the nerve from getting pinched, BUT,  the neck still moves. The neck’s motion is now transferred to the vertebrae below the fusion and above the fusion. In essence, the problem the surgery sought to fix only transferred excessive pressures to the vertebrae below it and above it. This is why people with cervical fusions inevitably, a year to three years later get the symptoms back.

Now, by definition, that means if somebody is recommended a cervical fusion it means that the doctor is saying that it’s instability causing the problem. In my opinion, the best treatment for cervical instability is Prolotherapy of the neck, not cervical fusion. If it is the excessive movement of the vertebrae that is pinching on the nerves causes terrible pain, migraine headaches, vertigo, all types of symptoms, then Prolotherapy can strengthen the cervical ligament, address the symptoms and not rob the patients of their natural neck movements.

Bone spur development after cervical fusion

We are going to review a recent case:

At 0:34 of the video, the patient’s digital motion x-ray shows problems surrounding her cervical fusion.

Ross Hauser, MD at 1:05 talks about cervical fusion

Bone spurs caused fusion in the adjacent segments can anything be done?

At 2:29 of video

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical adjacent segment disease. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References:

1 Goel A, Ranjan S, Shah A, et al. Adjacent-segment “central” atlantoaxial instability and C2-C3 instability following lower cervical C3-C6 interbody fusion: Report of three cases. J Craniovertebr Junction Spine. 2020;11(1):51-54. doi:10.4103/jcvjs.JCVJS_7_20 [Google Scholar]
2 Goel A, Jadhav D, Shah A, Rai S, Dandpat S, Jadhav N, Vaja T. Is C2-3 fusion an evidence of atlantoaxial instability? An analysis based on surgical treatment of seven patients. Journal of Craniovertebral Junction and Spine. 2020 Jan 1;11(1):46. [Google Scholar]
3 Gowd AK, Vahidi NA, Magdycz WP, Zollinger PL, Carmouche JJ. Correlation of Voice Hoarseness and Vocal Cord Palsy: A Prospective Assessment of Recurrent Laryngeal Nerve Injury Following Anterior Cervical Discectomy and Fusion. International journal of spine surgery. 2021 Feb 1;15(1):12-7. [Google Scholar]
4 Li NY, Patel SA, Durand WM, Ready LV, Owens BD, Daniels AH. Increased Risk of Chronic Opioid Use and Revision After Anterior Cervical Diskectomy and Fusion in Patients with Prior Shoulder Arthroscopy. World Neurosurgery. 2019 Nov 28. [Google Scholar]
5 Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk Factors and Prevention Strategies for Postoperative Opioid Abuse. Pain Research and Management. 2019;2019. [Google Scholar]
6 Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. The Lancet. 2019 Apr 13;393(10180):1547-57. [Google Scholar]
7 Harris AB, Marrache M, Jami M, Raad M, Puvanesarajah V, Hassanzadeh H, Lee SH, Skolasky R, Bicket M, Jain A. Chronic Opioid Use Following Anterior Cervical Discectomy and Fusion Surgery for Degenerative Cervical Pathology. The Spine Journal. 2019 Sep 16.
8 Jack A, Hardy St-Pierre G1, Nataraj A. Adjacent Segment Pathology: Progressive Disease Course or a Product of Iatrogenic Fusion? Can J Neurol Sci. 2017 Jan;44(1):78-82. doi: 10.1017/cjn.2016.404. [Google Scholar]
9 Wang Z, Zhou L, Lin B, Song K, Niu Q, Ren D, Tang J. Risk factors for non-fusion segment disease after anterior cervical spondylosis surgery: a retrospective study with long-term follow-up of 171 patients. Journal of orthopaedic surgery and research. 2018 Dec;13(1):27. [Google Scholar]
10 Alhashash M, Shousha M, Boehm H. Adjacent Segment Disease After Cervical Spine Fusion: Evaluation of a 70 Patient Long-Term Follow-Up. Spine. 2018 May 1;43(9):605-9. [Google Scholar]
11 Alonso F, Rustagi T, Schmidt C, Norvell DC, Tubbs RS, Oskouian RJ, Chapman JR, Fisahn C. Failure Patterns in Standalone Anterior Cervical Discectomy and Fusion Implants. World Neurosurgery. 2017 Sep 20. [Google Scholar]
12 Lee SH, Lee JS, Sung SK, Son DW, Lee SW, Song GS. A Lower T1 Slope as a Predictor of Subsidence in Anterior Cervical Discectomy and Fusion with Stand-Alone Cages. Journal of Korean Neurosurgical Society. 2017 Sep;60(5):567. [Google Scholar]
13 Lu J, Sun C, Bai J, Tian S, Zhang B, Tian D, Kong L. is correction of segmental kyphosis necessary in single-level anterior cervical fusion surgery? an observational study. Therapeutics and clinical risk management. 2019;15:39. [Google Scholar]
14 Cao J, Qi C, Yang Y, Lei T, Wang L, Shen Y. Comparison between repeat anterior and posterior decompression and fusion in the treatment of two-level symptomatic adjacent segment disease after anterior cervical arthrodesis. Journal of Orthopaedic Surgery and Research. 2020 Dec;15(1):1-8. [Google Scholar]

This article was updated June 8, 2021

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