What to ask the spine surgeon when considering neck surgery?
“Well, the MRI of your neck reveals a herniated disc at the C5-C6 level. That’s the bad news. The good news is that we’ll try spinal injections first to see if that relieves symptoms without surgery. But if spinal injections don’t resolve the symptoms, a surgery should relieve your symptoms of numbness and weakness in your arm and hand….”
That’s a fairly predictable dialogue that a person with a herniated disc will likely hear from the doctor. Spinal injections should be recommended first as a non-surgical treatment option, where medication is injected into the disc area to relieve pressure on a nerve root. While the disc isn’t healed or repaired, inflammation can be reduced which may relieve symptoms temporarily or in some cases permanently.
But many times with disc herniations, surgery is required. The most serious symptom ironically is not radiating pain. A person can use watchful waiting for a few months for that symptom. The more serious symptom of a herniated disc in the neck, however, is numbness or weakness in a hand or arm. Similarly, the most serious symptom of a herniated disc in the low back is numbness or weakness in a leg or foot. In both cases, this type of “neurological deficit” if left untreated for a couple weeks, could become permanent and lifelong.
Consequently, if non-surgical options don’t relieve the symptoms, surgery will be necessary to remove the herniation. This is called a discectomy, where the damaged disc is removed. Once a disc herniates, where the nucleus of the disc breaks through the disc wall, it can’t be repaired, but instead the disc is typically removed. This requires that something is put back into that disc space to keep the vertebrae apart.
This is the crucial part of the doctor patient discussion. That’s because most spine surgeons are still recommending a spinal fusion for neck herniations — which unfortunately is state of the art medicine circa 2010.
Technically, this surgery is called an Anterior Discectomy & Fusion (ACDF), which has been around since 1955. According to government statistics each year nearly 150,000 ACDFs are performed. But that number is expected to fall over the next 10 years as cervical fusions are replaced by artificial disc surgery in the neck. The issue is how fast spine surgeons will embrace the most current technology for the patient. It takes significant training and expertise to perform artificial disc replacement, and some surgeons prefer traditional fusion — even though there are great patient benefits realized from the motion preservation provided by the artificial disc.
According to Dartmouth Medical Atlas which does extensive research on spine surgery, there is tremendous variation in spine surgeons, with some regions of the country more advanced than others related to minimally invasive spine surgery techniques and new technology like disc replacement.
As one of the first spine surgeons in Colorado trained and proficient with more than four different FDA-approved artificial discs for the neck, I believe strongly in motion preservation in my spine specialized practice in Denver.
In addition to artificial disc replacement in the neck, I also perform two specialized neck surgeries that preserve the natural motion of the neck vertebrae. These two surgeries are not typically provided by most spine surgeons because they require advanced training and experience, and proficiency with minimally invasive instrumentation:
- Cervical Lamino-Foraminotomy
- Cervical Laminoplasty
Both of these surgeries are motion-preserving non-fusion neck surgeries. These surgeries require specialized expertise in neck surgery because they involve a posterior approach (from the back of the neck) and the use of tiny instruments and a surgical microscope in the operating room. The benefit of these two surgeries is that they are minimally invasive, non-fusion, and motion preserving approaches that provide a faster return to activity.
The advantages of a Cervical Lamino-Foraminotomy and Cervical Laminoplasty include:
- Less invasive surgery;
- non-fusion;
- retains natural movement of the neck; and
- a faster return to work/activity.
The reality is that the most advanced spine surgery capabilities are rarely found in rural or secondary cities. That’s because to become proficient with these instruments and artificial discs a spine surgeon needs to perform more than 100 of these surgeries a year. Like anything else, practice makes perfect. The more often a spine surgeon implants an artificial disc the better they get at it.
Consequently, if you’ve been told you need neck surgery, you will have to travel to a larger city to find a spine surgeon who does a high volume of artificial disc.
Here is some good advice for patients searching for a spine surgeon for neck surgery.
Q. My local surgeon recommends an ACDF? Why is spinal fusion in the neck a problem?
A. Because you have only 6 discs in the neck, fusing one level leaves only 5 disc levels for your neck to have rotation. Research has documented that when you fuse one level, it can cause herniations at the other levels. So a person who has an ACDF can in a year or so be facing ANOTHER neck surgery for other disc levels, which really prevents normal rotation. Even driving a car and being unable to turn your head would be problematic. Anyone wanting to stay active with golf, tennis, or pickle ball would need to preserve the rotation in the neck.
Q. I’ve seen something on reversal of spinal fusion. If I have a spinal fusion can this be reversed if there is a concern about other disc levels?
A. While there are some spine surgeons providing this, reversal of a spinal fusion is a complex surgery and sometimes may result in a new pain symptom. The problem is that the bone graft can often become fused to the facet joints at the back of the spine. Cutting out and removing the bone graft can then cause a new pain symptom related to the disrupted fact joints. The surgeon will have to do a very detailed CT scan to determine if the bone graft is separate from the facet joints. This explains why it’s best to explore an artificial disc at the first surgery decision point rather than trying to reverse a fusion.
Q. My surgeon provides artificial disc surgery but says I am not a candidate. Why?
A. Not everybody qualifies to have their herniated disc replaced with an artificial implant. If your surgeon is indeed proficient in artificial disc surgery and does a high volume of it, he probably has determined correctly that you would not have a good outcome from an implant. There can be a variety of reasons for this.
Q; Why are there so many different disc designs?
A. The artificial disc implant for the neck is relatively small, about the size of a quarter. When they first artificial discs were introduced, they were all the same size. But now some manufacturers — like the Prodisc Vivo — have introduced different sizes that are a better fit for a woman vs. a large man as the vertebrae in those two people are significantly different. The Prodisc Vivo, for example, comes in four different sizes so the spine surgeon can better match the disc implant to the patient. Secondly, artificial discs differ in how they are designed to implant between the vertebrae. Some have a keel on top and bottom that firmly locks into place during artificial disc surgery. This design can affect how the disc fixates between the vertebrae. This can also impact how difficult the disc would be to remove if revision surgery is needed down the road. All these factors are considered by the trained spine surgeon.
Q; What should I ask my spine surgeon to determine his proficiency with artificial disc replacement?
A. The best approach is to ask how many disc replacement surgeries they perform each year. Doing more than 40 disc replacement cases a year means an average of more than 3 disc replacements a month. Another thing to ask is if they provide more than one artificial disc option. The more experienced disc replacement surgeons have learned that some discs have features that benefit certain patients. Many times the spine surgeon can do these cases in an outpatient ambulatory surgery center (ASC) where the patient goes home the same day. But this can also depend on the complex patient base that is being referred to them. The more complex the cases, the less they are able to use outpatient surgery.
Q; Why does my health insurance carrier not want cover an artificial disc?
A. Insurance companies are often slow to embrace new technology. There are many examples of surgical implants and procedures that have been widely used in Europe for decades that are slow to be approved for use in the United States. That is changing as patients put more pressure on their health insurance companies to cover new technology.
In summary, if you’ve been diagnosed with a herniated disc in your neck, and your spine surgeon recommends a spinal fusion, YOU NEED TO GET A SECOND OPINION BEFOREHAND from a regional spine center that specializes in artificial disc replacement. That way you will be confident that you are receiving the most advanced and current surgical procedure that’s best for you.