Cervical Disc Replacement

What is an Cervical disc replacement?

Just as orthopedic surgeons have replaced worn out hips, knees, and other joints in the body, surgeons now have the technology to replace worn out discs in the neck (cervical spine).
Cervical disc replacement is a surgical procedure that involves removing a damaged or degenerated cervical disc and replacing it with an artificial disc device.  Cervical discs are the cushions or shock absorbers between the bones (vertebra) of the neck (cervical spine).  Discs that become damaged either through trauma or degeneration can be a source of pain.  If part of a disc moves out of its normal position it can cause pressure on the central spinal cord or on the individual nerve roots that exit from the spinal canal at each vertebral level.  Over time, the body’s reaction to a disrupted disc is the formation of bone spurs called osteophytes which can also cause pressure on the spinal cord or nerve roots.  Disc disruption and degeneration can be a source of neck pain as well as cause neurologic symptoms which may include pain, numbness or weakness that radiates from the neck into one or both arms.

Benefits over standard Fusion surgery?

Cervical disc replacement does offer several practical and theoretical benefits over more traditional fusion surgery.

  • Using a disc replacement device preserves motion at the affected level which may protect against accelerated degeneration of the discs above and below the disc replacement.  While the goal of protecting of the adjacent disc levels is very important, it is not fully know exactly how much a fusion causes accelerated degeneration at the remaining discs.  It should also be noted that the protective effect of a disc replacement on the remaining discs has not yet been definitively proven.
  • Disc replacement surgery does not require any bone grafting.
  • Since the bones are not being fused together, the possibility of a non-healed spinal fusion (called a non-union or pseudarthosis) is eliminated.
  • With disc arthroplasty there is no need for a plate to be placed on the front of the spine.  Avoiding the need for a plate may potentially lessen irritation of the esophagus and reduce swallowing difficulty that sometimes occurs following anterior cervical surgery.
  • Cervical collar immobilization is typically decreased to a week or less, compared to the standard 4 to 6 weeks of immobilization usually prescribed after fusion surgery.

Who is a candidate for cervical disc replacement surgery?

Cervical disc replacement is used to treat symptomatic cervical disc disease that has failed to improve with nonsurgical care.  While in most cases disc replacement (arthroplasty) can be used instead of an anterior cervical discectomy and fusion, there are situations where arthroplasty is not an option.  Currently, disc replacement is only approved for use at one cervical level and is not approved for use adjacent to a previous cervical fusion.  The procedure should not be performed in children or when there is abnormal motion or instability at the affected level.  Advanced degenerative changes known as spondylosis affecting the facet joints in the back of the spine at the affected level also precludes the use of a disc replacement device.  A disc replacement device should also not be used in the presence of significant osteoporosis or an active infection.  It is important to note that cervical arthroplasty is a newer and technically challenging procedure whose exact indications continue to evolve.

What do you need to tell the doctor before surgery?

It is important that you tell your surgeon if you:

  • Have blood clotting or bleeding problems
  • Have ever had blood clots in your legs (DVT or deep venous thrombosis) or lungs (pulmonary emboli)
  • Are taking aspirin, warfarin, or anything else (even some herbal supplements) that might thin your blood
  • Have high blood pressure
  • Have any allergies
  • Have any other health problems

What Can I Expect? Before Surgery

  • You will have to get admitted atleast one day before surgery is planned.
    After admission if your pre operative tests were not undertaken before admission will be undertaken. These include blood tests, X-rays, ECG and 2D Echo as per your underlying other co-morbidities.
  • You will be checked by our team- spine surgeon/assistant, anesthetist and physician who will assess your test results and determine your fitness for the surgery.
  • You may also get all the investigations and fitnesses done as out patient 2-3 days days prior to surgery.
  • We follow-safety first, so surgery will be confirmed after achieving fitness from our anesthetists and physicians.
  • You may not eat or drink anything after midnight, the night before surgery.
  • Note: However, you may continue to take your routine medications (for example, heart and blood pressure medications), on the morning of surgery with a sip of water (unless otherwise directed).  Please bring all your regular medications with you to hospital.
  • Consult with your surgeon if you are taking blood-thinning medications, NSAIDs, or Insulin. Examples include Coumadin (Warfarin), Plavix/Clavix (Clopidogrel), and Aspirin; Nonsteroidal Anti-inflammatory Drugs (NSAIDs) such as Motrin (Ibuprofen), Aleve (Naproxen), Feldene (Piroxicam); or Insulin. We advice that above mentioned medicines be discussed with your operating surgeon/ team during out patient visit itself.
  • Please be sure to take the following to the hospital admission;
    • All investigation reports
    • OPD file and papers
    • All prescriptions by your physician
    • MRI/Xray/C.T Scans
  • On arrival at the hospital, inform the receptionist that you are there to have an operation. You will be asked to show the hospital OPD file and accordingly admitted.

Who will perform surgery? Who else will be involved?

Surgery will be carried out by your surgeon. A surgical assistant will be present and an experienced consultant anaesthetist will be responsible for your general anaesthetic.

What are the costs of surgery?

Private patients undergoing surgery will generally have some out-of-pocket expenses.

  • A quotation for surgery will be issued, however this is an estimate only. The final amount charged may vary with the eventual procedure undertaken, operative findings, technical issues etc.
  • If you are planning to avail insurance benefit, you will have to inform the insurance company as well as the hospital before admission. Hospital mediclaim department will guide you of all the necessary steps needed to avail this facility

Separate accounts will be rendered by the anaesthetist and sometimes the assistant, and hospital bed excess charges may apply. Medical expenses may be tax deductible (you should ask your accountant).

You should fully understand the costs involved with surgery before going ahead, and should discuss any queries with your surgeon.

What are the risks of this surgery?

The risks associated with cervical disc replacement surgery are very similar to those associated with an anterior cervical discectomy and fusion.  Nerve injury is extremely rare, but is a potentially catastrophic complication of this and most other spinal surgeries.  Bleeding is usually very limited with cervical disc replacement and the risk of infection is also low.  Swallowing difficulty is common with any anterior cervical surgery, but in most cases is self-limited.  Technical difficulties related to placement of the disc replacement device including an incorrectly positioned implant or movement of the device following implantation is possible and could require revision surgery.  Spontaneous fusion across the disc replacement level has been reported, but does not typically require treatment.

What is the consent process?

You and one of the relatives will be asked to sign a consent form before surgery. This form confirms that you understand all of the treatment options, as well as the risks and potential benefits of surgery. If you are unsure, you should ask for further information and only sign the form when you are completely satisfied.

The procedure and recovery

Cervical disc replacement is performed with the patient under general anesthesia.  Patients are positioned face up in the operating room and a one to two inch (3-5cm) horizontal incision is made on one side of the patient’s neck.  The damaged disc is then exposed and removed.  Magnification with a microscope or surgical loupe magnifying glasses is typically used to facilitate complete removal of the disc and decompression of the nerves.  After preparing the disc space, the disc replacement device is sized and carefully placed into position between the vertebrae.  Live x-ray called fluoroscopy is utilized to facilitate proper positioning of the disc replacement implant.  The incision is then closed.  We may choose to place a drain into the wound and this is typically removed at the bedside on the day following the procedure.

After Surgery

  • You will be in recovery room for an hour till for close monitoring.
  • Then first few hours on the ward, you will be monitored closely by the nursing staff. You will be given fluids by an intravenous drip. You will have a drain coming from your wound and a urine catheter. This is all normal procedure. You will be given a cervical collar. If you have any pain or feel any sickness it is important to inform the nursing staff so they can keep you comfortable and aid your recovery.
  • You will be asked to drink fluids and soft diet 6 hours after surgery.
  • In bed movement of your hands and feet and also turning will be begun immediately after you are shifted in the wards.
  • Unless specified by your surgeon, you will commence rehabilitation the day following your surgery.  You will be sat on the edge of your bed for meals and taken for short walks by the staff. The following day you will increase the amount of walking and may still require some assistance from the staff. You will sit out in the chair for short periods of time (meals etc.) It is very important that you do make every effort to get up and walk during this early stage of your rehabilitation.
  • Minor discomfort from the incision is common and can be relieved by pain medication.  You will be given regular pain relief but if this does not keep your pain under control, please speak to the nursing staff. Do not just wait till the next pain medication is due.  Some patients experience mild episodes of muscle spasms in their back and legs (after low back surgery) or in their neck and arms (after neck surgery). Ice/heat packs or muscle relaxants can be used to lessen the discomfort.
  • You may continue to experience pain, numbness, and weakness along the path of the nerve that was decompressed by surgery. These symptoms will gradually decrease over time.
  • Speak with your surgeon’s office about the timing of your first post-operative office visit.
  • The majority of patients discharge home after 2-5 days depending on the type of surgery you have had.

Preparing to Go Home

Post operative care and instructions:

  • Keep your dressing dry and clean for 7 days after surgery to prevent infection.  Leave dressings intact unless damp or ooze present from wound. (If dressing damp or wound has oozed, get someone to change it for you with the dressings provided to you from the ward.)
  • Ensure they wash hands carefully first.
  • You may have sponge baths avoiding the area of dressing.
  • It is important if you have a low toilet, to consider loaning a plastic extension, or over the toilet seat. These can be hired from some chemists.
  • Incision and dressing care may vary from patient to patient. Please make sure you understand your surgeon’s instructions before you leave the hospital.
  • Wear cervical collar provided for you at the hospital as instructed (if supplied).
    Change position regularly, do not lie in one position for too long (you will get stiff and sore).
  • Take pain medication regularly as prescribed and advised. (Do not keep taking pain medication unless you really need it once the pain of the operation has worn off).
  • No stooping, bending or twisting of your back. Keep your back straight and bend your knees using your thigh muscles.
  • No sitting in soft chairs or sofas that allow your back to curve. Sitting may be uncomfortable, so limit your time sitting in a chair (20-30 minutes).
  • Sit and stand straight, do not sit slouched or leaning over to one side in a chair.
  • No stretching to reach high cupboards or shelves.
  • No jogging. Short, frequent short walks are better than long walks.
  • No lifting, housework or yard work during the first six (6) weeks or until allowed by your doctor.
  • No driving or long car journeys until consulting with your surgeon at the first post-operative visit

Follow the Guidelines for Physical Activity after Surgery

  • Light activities such as walking may be started as per your surgeons advise from second day of surgery. Your physical activities should progress gradually by alternating activity with rest. Plan for short, regular walks with rest periods.
  • Each day increase your walking distance on a gradual basis.
  • Once your sutures have been removed and the wound has completely healed (usually 2-3 weeks post-operation) you may go swimming (mainly just walking in the pool and a little gentle swimming.  (No pool games or diving in.)
  • Sexual activity is permitted within the bounds of your comfort. Consult with your surgeon.
    Discuss returning to work during your doctor’s appointment.

What do I need to tell my surgeon about after the operation?

You should notify your surgeon and should also see your GP if you experience any of the following after discharge from hospital:

  • Increasing leg pain, weakness or numbness
  • Worsening back pain
  • Problems passing urine or controlling your bladder or bowels
  • Problems with your walking or balance
  • Fever
  • Swelling, redness, increased temperature or suspected infection of the wound
  • Leakage of fluid from the wound
  • Pain or swelling in your calf muscles (ie. below your knees) Chest pain or shortness of breath
  • Any other concerns

When to Call Your Doctor

Call Your Doctor if You Experience Any of the Following Symptoms

  • If you feel warm or chilled, take your temperature. Call your doctor with a temperature of 38.3 °C or above.
  • Increasing redness and swelling at the incision site.
  • Changes in the amount, appearance, or odour of drainage from your incision.
  • New or increased changes in sensation/presence of numbness in extremities.
  • Severe pain that is not relieved by medication and rest.
  • Questions or problems not covered by these instructions.