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| Patient Education -- Cervical
Spine |
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Cervical
Spine
You have probably been referred to see a neurosurgeon
because of pain in your neck or shoulder, or perhaps tingling
or numbness in your arms. You may also have experienced
some weakness when using your arms or hands.
You may be wondering if there is a chance that everything
will return to normal or whether the surgery that may
have been talked about is very risky. These questions
and concerns can be addressed by your neurosurgeon, who
is a physician trained in the surgical treatment of disorders
of the nervous system.
He or she will ask a number of questions and then perform
a neurological examination. Following a review of any
x-rays or other diagnostic tests you may have brought
with you, additional tests may be ordered if further information
is needed. Finally, he or she will propose a course of
treatment which may or may not involve surgery.
The decisions regarding your care should be reached after
discussions between you, your family and your neurosurgeon.
This booklet will help educate you about the issues involved
in your care.
Understanding the Problem
Your neck is part of a long flexible column extending
through most of your body often referred to as the spinal
column, or backbone. The neck region of the spinal column
(the cervical spine) consists of seven bones (vertebrae)
shaped like building blocks, which are separated from
one another by shock absorbing pads (intervertebral discs).
These discs allow the spine to move freely and act as
shock absorbers during activity. Attached to the back
of each vertebral body is an arch of bone that forms a
continuous hollow longitudinal space much like a tube
that runs the whole length of your back. This space is
the spinal canal, through which runs the spinal cord and
nerve bundles (Fig. 1b). The spinal cord is surrounded
by fluid (cerebrospinal fluid) and three layers of protective
membrane: the dura, the pia and the arachnoid.
At each vertebral level a pair of spinal nerves exit through
small openings called foramina (one to the left and one
to the right). These nerves serve the muscles, skin and
tissues of the body and thus provide sensation and movement
to all parts of the body. The delicate spinal cord and
nerves are further supported by strong muscles and ligaments
that are attached to the vertebrae.
Cervical Disc Disease
With age, injury, poor posture or diseases such as arthritis
there can be damage to the bone or joints of the cervical
spine. The cervical discs may become worn out and abnormal
growths (bone spurs) may form as a result of repetitive
movement of the disc. (Fig. 2a) Sudden movement or injury
such as whiplash may cause the disc to slip or herniate.
The herniated disc or bone spurs may narrow the spinal
canal through which the spinal cord runs or the small
openings (foramina) through which spinal nerves exit.
What problems might you experience?
Pressure on a nerve by a herniated (slipped) disc or a
bone spur may irritate the nerve resulting in pain in
the neck and arm, incoordination, or numbness or weakness
in the arm, forearm or fingers. Pressure on the spinal
cord in the neck (cervical) region can be a very serious
problem because virtually all of the nerves to the rest
of the body have to pass through the neck to reach their
final destination (arms, chest, abdomen, legs); therefore,
the function of many important organs is potentially at
risk.
Initially, the symptoms of cervical disc disease may be
limited to neck pain and later arm pain; weakness or numbness
may also occur along with difficulty walking or incoordination
of the legs. Further progression may lead to severe impairment
or even paralysis.
Diagnosis
Your doctor will document your symptoms and find out the
extent to which these symptoms affect your life. The physical
examination will include an assessment of sensation, strength
and reflexes in various parts of your body to help pinpoint
which nerves or what parts of your spinal cord are affected.
Your doctor may then order studies to confirm the diagnosis
and determine more precisely the nature and extent of
the disease process. These studies may include:
• X rays: A simple x-ray will show the bones of the
neck and determine if there is significant wear and tear
or disease of the bone. It will also show whether the
bones are lined up properly.
• Myelogram: The myelogram is an x-ray with a special
dye that highlights the spinal cord and nerves. The dye
is usually injected into the spine with a needle and then
the x-rays are obtained.
• Computed Tomography (CT): A CT (also known as CAT
scan) of the spine is a computerized map of an x-ray of
the neck. The CT will show the anatomy of the neck in
more detail and from different angles. It will also better
define the relationship of the disc or bone spurs to the
spinal cord and nerves. The CT may be done in conjunction
with a myelogram of the neck to provide additional information.
• Magnetic Resonance Imaging (MRI): The MRI uses
a powerful magnetic field rather than x-rays to produce
a detailed anatomical picture of the neck and the structures
within it. During the study you will hardly feel that
anything is going on.
• Electromyogram and Nerve Conduction Studies (EMG/NCS):
Unlike the previous tests, which help your doctor determine
anatomy and structure, these tests primarily study how
the nerve and muscles are actually working together. This
information can assist in determining which nerves or
muscles are functioning abnormally.
Treatment
Cervical disc disease does not always mean that you require
surgery. In fact, many of your symptoms can be relieved
by nonsurgical management.
Your doctor may prescribe medications to reduce the pain
or inflammation and allow time for healing to occur. Bed
rest, reduction of physical activity or a cervical collar
may also be prescribed. The collar provides support for
the spine, reduces mobility and may reduce the pain and
irritation.
To further relieve the pressure on the nerves in your
neck your doctor may prescribe a cervical traction device
(Fig. 3). This device is attached to your head and pulls
up on it using a pulley system and weights. It is usually
applied a few times a day and can be used while sitting
or lying in bed.
What kind of surgery may be helpful?
There are several operations that may be used to treat
cervical disc disease. The selection of which operation
and the determination of when to perform the operation
depend on many factors, which obviously differ for each
patient and doctor combination. However, some general
factors include the kind of disc disease you have (herniated
disc or bone spurs), whether there is pressure on the
spinal cord or spinal nerve, the presence of one or more
areas of disease within the cervical spine, and if the
spine is dislocated in addition to pressure on the cord
or nerves.
Other factors are determined by your age, how long you
have had the disease, other medical problems, previous
operations on the neck, and so on.
The particular combination of these and other factors
will determine the choice of surgical treatment.
Anterior Cervical Disectomy
This operation is performed on the neck to relieve pressure
on one or more nerve roots, or on the spinal cord. The
procedure is performed from the front, or anterior, approach.
Discectomy means to remove the disc.
Surgery for anterior cervical discectomy is performed
with the patient under general anesthesia lying on his
or her back. The surgeon may place a traction device to
pull on the neck. During the course of the operation x-rays
may be obtained to assist the surgeon in the surgery.
The surgeon will make an incision in the front of your
neck; if only one disc is to be removed it will typically
be a small horizontal incision in the crease of the skin.
If the operation is to be more extensive, the incision
may be oblique (slanted) or longer.
The soft tissues within the neck are separated to allow
the surgeon to reach the front of the spine, following
which the intervertebral disc and bone spurs are removed
(Fig. 4b). An operating microscope may be used to better
display the area while part of the disc is removed with
forceps. Other instruments such as a drill or bone-cutting
instruments may be used to enlarge the disc space. This
will help the surgeon to relieve any pressure on the nerve
or spinal cord due to bone spurs or the ruptured (herniated)
disc.
Sometimes the space between the vertebrae is refilled
with a small piece of bone (fusion). The bone may be yours
(for example, from your hip bone) or it may be taken from
a bone bank. In time, the vertebrae may fuse, or join
together. In addition to the piece of bone, some surgeons
may place a metal plate at the fusion site to strengthen
it.
The neck incision is closed in several layers. Skin suture
material may need to be removed or the surgeon may use
absorbing sutures and strips of tape which you can later
remove by yourself.
Historically and statistically, there are few surgical
risks with anterior cervical discectomy; however, some
risk is unavoidable and the unexpected may occur resulting
in complications.
Although every precaution will be taken to avoid complications,
common risks possible with surgery are: infection, excessive
bleeding (hemorrhage) and an adverse reaction to anesthesia.
Other risks possible with anterior cervical discectomy
include: stroke; injury to the recurrent laryngeal nerve,
which causes hoarseness and may or may not be permanent;
and injury to the involved nerve root(s) or the spinal
cord, both of which can cause varying types and degrees
of paralysis.
The process of informed consent is designed to make you
familiar and comfortable with the reasonable expectations
and foreseeable risks. Your surgeon and anesthesiologist
will discuss these with you and assist you in your decision-making.
Cervical Corpectomy
This operation is an extension of the discectomy procedure.
Also using an anterior approach, the surgeon removes a
part of the vertebral body to relieve pressure on the
spinal cord (Fig. 4c). One or more vertebral bodies may
be removed including the adjoining discs. The incision
is generally longer. The space between the vertebrae is
filled using a piece of bone (fusion) and maybe a metal
plate. Because more bone is removed, the recovery process
for the fusion to heal and the neck to become stable again
is usually longer than with anterior cervical discectomy.
Cervical Laminectomy and Discectomy
This operation is performed through a vertical incision
in the back of the neck, generally in the middle. Through
this opening the surgeon will use an instrument (a retractor)
to pull aside the strong muscles of the neck and expose
the arch of bone (lamina) that forms the spinal canal.
A drill and bone cutting instruments are used to remove
the bone around the spinal cord (laminotomy) or the bone
around the nerve opening (foraminotomy). Once the nerve
is located, it is moved gently aside and an incision is
made on the outside covering of the disc through which
the disc material is then removed.
Recovery After Surgery
Following surgery, you will be taken to the recovery room
for a short while and then spend a few days in a hospital
room. When you awake you may have a collar or brace around
your neck or a drainage tube coming out of your neck.
Typically, the drainage tube is removed in a day or two.
If you had an anterior cervical discectomy or corpectomy,
your throat may be slightly sore. If a piece of bone was
taken from your hip, the area of incision is usually sore.
Your physician will give you appropriate medication to
address these problems. Fortunately, most of them are
temporary.
Intravenous (I.V.) fluids will be ordered during the early
recovery period.
Discharge from the Hospital
Your length of stay in the hospital will be determined
by your progress and by your home situation. When you
are ready to leave the hospital you will be provided with
instructions regarding your brace, care of your incision(s)
and physical activity.
Generally, you will wear a brace for a few weeks, but
this is variable and it may be much longer. Usually you
have to keep it on continuously, but your doctor may allow
you to take it off for short periods. It is unlikely that
you will be allowed to drive, lift heavy objects or engage
in contact sports or vigorous physical activity for a
while. Keep your incision clean and dry and report any
signs of drainage or inflammation promptly to your doctor.
Unless instructed otherwise, you may take a shower after
surgery. This should be done with a dressing in place
to protect the incision.
Practice good posture and body mechanics even during routine
daily tasks. It is normal to have some pain, especially
in the incision area; pain in the neck or arms is also
not unusual, and is caused by inflammation of the previously
compressed nerve. It will slowly lessen as the nerve heals.
Medication may also help. Discomfort is normal while you
gradually return to normal activity, but pain is a signal
to stop what you are doing or proceed more slowly.
Follow-up
Your doctor will see you in the office after surgery and
examine your incision. He may remove skin sutures and
will evaluate nerve and muscle function. X-rays may be
ordered to check on the fusion of the bone graft. Physical
therapy may be recommended.
Numbness or tingling sensations are often the last symptoms
to leave. Your doctor will help determine when you can
return to work and with what limitations.
Driving a motor vehicle will be possible once your doctor
determines that you have recovered full coordination and
are experiencing minimal pain and that your neck is stable.
The Role of the Neurosurgeon
If you are perceiving problems in your cervical spine
caused by pressure on the nerves, a neurosurgeon is the
appropriate medical professional to direct your treatment.
Although his or her primary concerns will be diagnosis,
interpretation of test results (when necessary) and surgery,
you will most likely have other medical professionals
involved in your treatment as well, such as anesthesiologists,
physical therapists and other specialists.
Neurological surgery is the medical specialty concerned
with the diagnosis and treatment of disorders of the nervous
system, the brain or the spinal cord. Neurosurgeons treat
patients with injuries to the head, spinal cord or nerves;
patients with a stroke or in danger of a stroke due to
clogged arteries in the neck; patients with tumors or
malformations of the brain or spinal cord; as well as
patients with back or neck pain associated with a slipped
disc.
Neurosurgeons undergo six to eight years of rigorous training
following medical school. After successfully completing
this training, two years of medical practice and a written
examination, neurosurgeons can become Board Certified.
Glossary
Anesthesiologist: Physician who administers pain-killing
medications during surgery.
Anterior (Front): Refers to the direction from which the
surgeon removes the cervical disc.
Cervical Spine: The seven vertebrae in the upper part
of the neck.
CT Scan (computed tomography scan): A diagnostic imaging
technique in which a computer reads x-rays to create a
three-dimensional map of soft tissue or bone.
Degeneration: Deterioration or worsening of a structure
or condition.
Disc: A small mass of elastic, gristle-like tissue located
between each vertebra in the spinal column which acts
as a "shock absorber" for the spinal bones. The disc is
composed of an outer, tough covering and a softer, gelatinous
material within.
Fusion: The surgical joining of vertebrae.
Herniated Disc: Condition in which gelatinous disc material
slips or bulges out of position and puts painful pressure
on surrounding nerves.
Laminectomy: Surgical removal of the rear part of a vertebra
in order to gain access to the spinal cord or nerve roots,
to remove tumors, to treat injuries to the spine, or to
relieve pressure on a nerve.
Ligament: Fibrous connective tissue linking bones at a
joint.
MRI (magnetic resonance imaging): Diagnostic test that
produces three-dimensional images of body structures using
powerful magnets and computer technology rather than x-rays.
Myelogram: An x-ray examination in which injected dye
outlines the spinal cord and associated nerve roots to
illustrate spinal tumors and other conditions affecting
the nerves and spinal cord.
Nerves: Fibers that conduct impulses (messages) from the
brain and spinal cord to the muscles and glands, or from
sensory organs to the brain and spinal cord.
Spinal Cord: Bundle of nerve fibers enclosed in the vertebral
column.
Spinal Stenosis: Narrowing of the vertebral column, resulting
in pressure on the vertebral column or pressure on the
spinal cord or nerve roots arising from the spinal cord.
Vertebrae: The 33 individual bones composing the backbone
or spine.
X-ray: Application of electromagnetic radiation to produce
a film or picture of a bone or soft tissue area of the
body
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