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Cervical intervertebral disc operations

In the cervical section we most often encounter the compression of neural structures (spinal cord and spinal roots) from the front. We find the causes in a herniated intervertebral disc, bone protuberances (osteophytes) or hypertrophied spinal ligaments. The aim of surgical treatment is to remove the compression by removing the discs, grinding bone protuberance or cutting ligament. We most frequently choose anterior surgical approach. We penetrate the anterior surface of the cervical spine and remove the compression from a horizontal incision made for cosmetic reasons in skin wrinkle.

The perfect decompression of neural structures is a prerequisite for the disappearance of the neurological manifestations of the disease. Reconstruction of the intervertebral space follows. The classic method, which we have excellent experience with still widely deploy, is mediating bone fusion (arthrodesis) between adjacent vertebrae. There are many ways of achieving this, but in our experience bone fusion using metal plates secured by an appropriate number of screws and the replacement of the disc with a bone graft has proved best.  We have gradually replaced bone grafts from the patients themselves with bone material harvested from deceased donors due to postoperative difficulties from collecting the bone graft. This kind of transplantation significantly reduces the duration of operations, prevents complications related to the bone graft while guaranteeing similar results as for the patient’s own grafts, and the risk of infection from the deceased donor is merely theoretical. We can use the patients own bone graft at their request.

However, prosthetic (artificial replacement) cervical discs are a big innovation. These are substitute intervertebral discs whose ideal result is the mediation of movement conforming with the movement of healthy cervical discs. The reason leading surgeons seek out such technology is the desire for the most natural operational result. The cerebral spine may react to the surgical removal of movement by accelerating degenerative changes in the adjacent sections. These can be overloaded during everyday stress and in some cases it may happen that changes in the adjacent motion segment result in the need for subsequent surgery.

Globally, technologies of dynamic cervical intervertebral disc replacements are in their infancy. Our facility is one of the centres which contributes to their development and has some of the most extensive experience. Our implementation method has been worked out in detail and we know what to expect in the postoperative period. Our optimistic view of this issue is supported by our years of experience and so we are not afraid to say that we see the future of intervertebral disc replacement in this technology.

Our view

Cervical intervertebral disc surgery is one of the most common neurosurgical procedures. Even though it is a minor procedure in neurosurgery, we do not underestimate it and strive to perfect it. Our facility was the first in the Czech Republic to routinely use mobile cervical disc replacements and participates in the research and development of these implants.

The cervical spine area is relatively delicate, there are often multiple damaged discs and the correct indication may represent a complicated decision. As with larger procedures, here we perform a collective assessment of each case. In our opinion, planned procedures on the spine require the maximum possible safety, technical support and care in carrying them out. We therefore perform all operations using an operating microscope, for removing protuberances we use a high-speed bone cutter. Contemporary lifestyles and an aging population are the main causes which increase the incidence of degenerative diseases of the cervical spine. The most frequent problem is osteochondrosis, that is increased wear of the cervical discs, while herniated discs are also common. Reduction in disc height, the formation of new growths and thickening of the ligaments are typical factors that compress neural structures, producing problems. We perform 150 cervical spine operations a year. Just like lumbar disc surgery, in its simplest form this is a minor procedure, unlike for trauma injuries performed to plan to remove painful problems.

Before surgery

The procedure itself is performed under general anaesthesia. Prior to the operation the patient cannot eat, drink or smoke. This ban is generally valid from midnight to morning. Before surgery patients carry out their bodily needs, wash themselves with special antibacterial soap and have stockings put on their lower extremities to prevent blood clots in the veins.

Patients are taken to the operating theatre, transferred to a wheelchair and after administration of their preoperative medication transported to the operating theatre. The anaesthetist puts the patient to sleep, then the patient is placed in the operating position, with the head and shoulders fixed in the required position by adhesive tape. X-ray targeting of the diseased discs is conducted, cutting lines are marked and the entire area is thoroughly disinfected. Then the whole patient is covered in sterile drapes.

During surgery

The surgical procedure begins with a transverse incision of approximately 5 cm in the front area of the neck, slightly to one side (usually the right). We try to use already existing wrinkles. By gradual preparation, through muscles and blood vessels we penetrate the anterior surface of the cervical spine, which we reveal and set retractors for the minimally invasive approach. After further X-ray inspection we cut and completely remove the disc first with forceps and then with a high-speed cutter. In the back of the intervertebral space we remove any herniate or protuberance compressing the nerve roots or spinal cord. Because the disc has been removed completely, we insert an implant between the vertebrae. Depending on the nature of the operation and disease this can be an independent implant (standalone cage), in which case we choose a bone graft (taken either from the patient’s pelvis area, or a graft donor). In strictly indicated cases we may use a mobile disc replacement.

In cases when bone grafts are used we then fix the vertebrae with a plate and screws, all the while supervising everything with the mainframe X-ray machine (C-arm). After work on the disc and vertebrae has been finished we remove the retractors and implement a suction drain (tubing) to remove residual blood. We stitch up the wound, using buried sutures on the skin, which bring good cosmetic results and can easily be removed. The operation takes 40-120 minutes according to extent and difficulty.

After surgery

After surgery, the anesthetist brings the patient out of their artificial sleep and after the effect of the medicaments has died down sufficiently the patient is transported either to the intensive care unit (neuro-ICU) or back to the standard ward, depending on the extent of the operation and any other diseases of the patient. The patient cannot eat or drink for at least 6 hours after the operation, after which they can receive a small intake of fluids (tea), taken by the teaspoon. The next morning drainage is removed, X-ray examination is performed and the patient gets up starts to walk with the help of a rehabilitation worker. Over the next days instruction on suitable exercises takes place and 2-4 days after the procedure the patient is discharged to home care.

Convalescence

After undergoing cervical intervertebral disc all patients are invited for check ups to specialized clinics – the first 6 weeks after surgery – the final report gives the exact date and approximate time. X-ray examination is performed and the subjective and objective condition of the patient is assessed. Regular check ups are repeated until the operated area is healed – that is until the fusion of the vertebrae.
One to two months of sick leave are usually recommended until full healing and the achievement of a normal physical routine have been achieved. Postoperative convalescence is highly individual and varies according to the severity of preoperative troubles and their duration, among other things. If the nerve root had been compressed by the herniate heavily and/or for a long time, some preoperative problems can endure even after successful surgery, in particular residual pain, numbness, feelings of electric shocks, residual numbness or weakened limbs. Correction of nerve function is a lengthy process and can take many months. After the procedure, the position of the surgical spine changes slightly, and needs to get used to the new situation, which is sometimes accompanied by pain in the neck and head. The optimal solution here is the gradual exercising and loading of the spine. Like any other surgical procedure, a disc operation is an intervention into the body and is felt by the patient, especially during changes of weather, greater exertion and so on.

 

During convalescence the patient adjusts their daily routine so as to cope with normal daily life and prepare to return to work. If the patient works on their rehabilitation, it is common for them to return to more demanding activities, sport and so on. As well as the character of the impairment and surgical procedure, the overall result depends heavily (even mostly) on the motivation and