Neck | Cervical Spine
The cervical spine consists of seven vertebrae with soft disks in between them. As one ages, the disks can bulge or herniate and push against either the spinal cord itself or the the nerves that go into the shoulders, arm, or hand. Often times, patients do not have much neck pain but it is the pain shooting down the shoulder or arm that is more troublesome and is often accompanied with arm weakness as well. Often the disk or the vertebrae forms large spurs which push against the spinal cord or nerve roots. Some patients also develop arthritis or loss of disk space and lose the normal lordosis or curvature of the neck, and have difficulty holding their head up.
Below are example cases of actual patients. Patient consent was obtained and all identifying markers were removed. I generally try conservative care before progressing to surgery. This includes physical therapy, anti-inflammatory medications, and cervical injections. These patients had anterior cervical discectomy and fusion (ACDF) surgery. This is a minimally invasive surgery through the front of the neck which avoids any significant musculuar dissection. With the use of a microscope, the disk is removed to the spinal cord, as are any bone spurs which may be pushing on the spinal cord or nerve roots which can cause arm pain and weakness.
Once the disk is removed a specialized type of plastic called PEEK is fitted in place of the disk to keep the bones well separated and allow plenty of room for the nerve roots. This also restores the normal lordosis (curvature) of the neck. A titanium plate and screws then holds the bones together so that they can mend together (fuse). The plate is only about 3mm thick and the screws are about 3.5 mm thick. These patients generally stay overnight and can go home the following morning, or if they prefer, can go home the same day. After two weeks of wearing a hard collar there are minimal restrictions and patients can return to most daily activities.
MRI Cervical Spine
This is an image of a cervical spine MRI. We can see the bones which are marked as C1, C2, C3, etc. The disks are in-between the bones, and each level is named by the disk level, for example the C5/6 level. In this image, we see that there is a C6/7 disk herniation that is impinging on the spinal cord. Note how the level below, the C7/T1 level has a white, plump disk. This is a normal disk. The C5/6 and C6/7 appear black because they are degenerated. I believe it is important to learn the names of the structures and lingo to allow for improved decision-making when discussing options with your surgeon.
This is a patient of mine with a C4/5 disk herniation that is pushing on the spinal cord. This caused her to have both neck pain as well as pain radiating to her shoulders and down her arms.
Patient 1. Post-Op lateral film
This patient underwent an Anterior Cervical Discectomy and Fusion (ACDF) surgery. The offending disk was completely removed and a PEEK implant was placed in-between the C4 and C5 body. A titanium plate and screws were then placed to hold the bones together so they can fuse (heal together).
Patient 1. Post-Op
This is the front (AP) view of the same patient showing the plate placement.
Patient 2. MRI
This is the MRI for patient two which shows significantly degenerated disks at C5/6 and C6/7 which corroborates with our x-ray. However, it also shows that the disks are bulging and pushing onto the spinal cord at both of those levels.
Patient 2. 2 Level ACDF
Patient 2 had severe neck and arm pain. As you can see, the C5/6, and C6/7 levels have degenerated to the point that it is bone on bone. There are spurs both in front of the vertebra, and behind pushing on the spinal cord. Also, there is a fractured (broken) fragment of bone off of the C5 body.
Patient 2. Post-Op
On this lateral post-operative x-ray we can see significant improvement of the overall spaces between the bones by placing the plastic (PEEK) spacers.
This is another picture of an incision for ACDF surgery. This is at the two-week mark at first office visit. There is some visible redness at the first visit which dissipates over the upcoming months. It is important to note that patients with fair skin have less visible incisions while people with darker skin may have thicker scars.
Post-op Neck picture
This is what an average neck incision looks liks after it has healed. They are approximately 1 to 1.5 inches in length depending on the girth of the patients neck and how many levels are addressed. I use absorbable sutures and plastic surgery techniques to obtain this type of result. A special glue similar to a "second skin" is placed after closure which allows us to not use a dressing and allows the patient to immediately shower.
This is a a preoperative lateral x-ray of a patient with 3 level degenerative disk disease. One can see there is three level significant degenerative disk disease from the C4 to the C7 level. More importantly, there are bone spurs in the posterior (back) of the vertebrae which pinch the spinal cord and the nerve rootlets that go to the arms. This causes pain and weakness down the arms.
Patient 3. 3 Level ACDF
Patient 3. Post-op AP
This is the post-operative AP x-ray image of a 3-Level fusion. Although this plate looks large, it is only 14mm in width and about 3mm thick. As one can see on this film, it is in a midline position.
Patient 3. Post-Op Lateral
This is the lateral post-operative x-ray of a 3 level ACDF. One can see that all the remnant disk and bone spurs which were pressing on the spinal cord have been removed. There are now plastic (PEEK) spacers between the bones which are opening up the disk space and giving room for the nerve roots which go to the arms. The plastic spacers cannot be seen on xray except for the small metal markers which are placed to allow optimal placement during surgery. The plate is well-placed alloweing room for surgery at the level above C3-4 if necessary in the future. I try to place the screws all the way to the back of the vertebrae where the bone quality is of higher quality and excellent fixation is obtained. This allows us to minimize the time needed in a cervical collar.
Patient 4. 4 Level ACDF
This is a pre-operative x ray of an elderly gentleman who had severe neck pain and inability to turn his head to either direction. He had also lost function of his right arm. As you can see, his neck is collapsing forward, and he has multi-level severe degenerative disk disease (arthritis)
Patient 4 MRI
On the MRI we can see that the cervical spine is collapsing forward. The spinal cord is being severely compressed at the C5/6 level, but the levels above and below also have stenosis. Stenosis means narrowing of an opening, in this case the spinal cord. This is fairly evident higher up at the C3/4 level as well.
Patient 4 Post-op Lateral
On this lateral x-ray we can see a four level fusion in place. Compare the overal alignment to the pre-operative x-ray and you can see that it is no longer in a kyphotic, or bent forward position. This patient was very lucky and was able to regain the function of his right arm.
A newer fusion technology we have started using is a stand-alone PEEK cage. This is the exact same surgery as a fusion with a similar PEEK cage as an inter body device. However, the difference is that a plate in the front is no longer necessary. This will decrease the likelihood of swallowing difficulties long term. Also, if further surgery at levels above and below are necessary this simplifies the process by not requiring larger dissections to remove the previous plates.
The disadvantage is this construct is not as strong as a plate and thus puts it at a slightly higher risk of non-union or failure to complete fusion. I have heard various results from differing surgeons regarding this as well as studies. This is another option that we offer .
Stand-Alone Cervical Fusion
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This is an AP view of the same stand-alone fusion device. A total of three screws hold the plastic (PEEK) device in place to allow fusion to occur.
These are images of an artificial disk replacement for the cervical spine. This is the same surgery as a fusion with removal of the disk and bone spurs. However, instead of placing an inter body device that fuses the level, this device allows motion to occur. This of course allows further range of motion, and decreases the stress above and below the fusion level.
I am a big proponent of this device and when I first started seeing this device used I believed it would be the future of cervical spine surgery. Unfortunately, multiple factors have kept it from becoming mainstream. It is not approved by Medicare and many insurances follow Medicare guidelines. This makes obtaining insurance approval difficult or even impossible. Also, it needs to be placed exactly in the middle of the vertebral body and even a couple of millimeters of misplacement can cause a poor result. These devices also have FDA approval for one level. So this image on the left showing a two-level artificial disk replacement would be performed under "off-label usage". This just means the implant company did not go through the FDA process of getting the device approved for multiple levels due to the significant time and money that would take.
Artificial Disk Replacement
Dr. Sep Bady, MD is a fellowship trained orthopedic spine surgeon in the Las Vegas valley who specializes in the treatment of a variety of orthopedic conditions and performs several orthopedic procedures including minimally invasive spine surgery, spinal artificial disc replacement surgery, scoliosis surgery, fracture care, as well as general orthopedic surgery. The includes arthroscopy of the knee and shoulder, knee and hip replacement, and fracture repair
This is the same implant used for patient 6, except it is a 3 level fusion. So again instead of a plate in the front, the screws are integrated within the PEEK cage. We decided to go with this implant choice as the patient was concerned about swallowing difficulties. Also, the level above the fusion, the C3/4 level, is significantly degenerated, and will likely have to be addressed in the future. With no plate, this will allow the next surgeon to be able to fuse or place artificial disk at the C3/4 level without having to remove a plate, making it a much simpler and more minimally invasive surgery.
Again this implant choice is FDA approved for one level, not two, or three levels. Thus this is considered "off-label" usage. This may be an issue getting approval with certain insurance companies. Also, placing an artificial disk above a fusion would be considered off-label as well.
3 Level Stand-alone fusion
This is an AP view of the 3 level stand-alone fusion. Again, the disadvantage of this
One Level Artificial disk replacement
This is an AP view of one my patients who had a C5/6 Artificial Disk Replacement. It is critical on the AP view to get the implant exactly in the middle of the vertebral body. This is a Synthes Prodisc C implant which is my implant of choice due to its long track history of good outcomes. It is only FDA improved for one level. Multi-level artificial disk replacement with this implant would be considered "off-label", but is still performed by many surgeons if insurance approval is possible. A newer spine implant company has received two level FDA approval.
This is the lateral view of the one level artificial disk replacement. It is important for the implant to cover as much of the bone as possible to prevent subsidence (implant settling into the bone).