Cervical Spine Surgery Decision FAQ’s
Cervical Spine Surgery Decision FAQ’s
1. Why is surgery recommended?
For the most part, it is because patients can no longer tolerated the pain, numbness or weakness associated with the condition. In some instances such as fracture, infection, or a tumor, surgery is a emergent situation and surgery should be performed on a timely basis. In situations of rapidly progressive weakness, surgery is also an emergent situation. But, for most part, it is because the patient has tried the traditional non-surgical treatments, and after more than 6 weeks, the pain and effects are no longer tolerable.
2. What are the non-surgical options that most will try before surgery?
Patience and time is very important. A vast majority of patients do see improvement just by waiting 6 weeks. But, during that 6 weeks, most will also require additional help. Typically, medications such as anti-inflammatory medications like motrin, naprosyn, or the many other NSAIDS available on the market can be used. Everyone however should know that there are always risks to any medications, even the over the counter ones you can buy in the pharmacy without a prescription. Cautious use of narcotics sometimes is necessary for extreme pain. Muscle relaxers have a role in some patients with muscle spasms, although the evidenced based medicine measures do not seem to support their use.
Home stretching exercises, or physical therapy can help in keeping the muscles and joints loose, and prevent development of muscle atrophy. Chiropractic care can be beneficial as well.
Use of oral steroid medications have demonstrated a better anti-inflammatory effect, although there are always the concerns for side effects.
Steroid shots, in the form of trigger point injections, facet injections, and epidural steroid injections can also be helpful. But, again, the patient must be informed of the potential risks.
So called alternative treatments such as acupuncture, massage therapy, bio-feed back, etc. also has its supporters.
The bottom line is patients should wait at least 6 weeks in non-emergent medical situations (unless infections, tumors, fractures, or rapidly developing muscle weakness or paralysis) to let the body naturally start the healing process. Physicians know patience is a very difficult concept when in pain. You do need a good emotional support system to get you through that time. But, if you are not better, and there is a well defined surgical cause, an operation can become an option.
3. How does the physician determine the need for surgery?
First, your surgeon will obtain a history. A history includes your prior medical situations, and the events pertaining to this current set of cervical (neck) spine complaints. It is important to know if you have had similar complaints in the past. Prior medical conditions can be very important, as the surgeon wants to know if the complaints are secondary to non-surgical causes such as a neurologic condition, diabetes, or other nerve problems not related to the spine. In addition, the surgeon wants to assess your overall health, as the decision for surgery is also related to the relative risk of doing surgery on someone who has other conditions such as a bad heart, bad lungs, kidney disease, etc. After all, a successful spine surgery also requires successful handling of the anesthetic risks as well.
The surgeon will then perform a physical exam to see if your complaints of pain, weakness, numbness, etc. are demonstrated by physical findings of the same. Your physical exam needs to match your verbal complaints. If they do not, usually the surgical outcomes may not be as predictable.
Finally, the diagnostic testing such as x-rays, MRI’s, CT scans, and electrical testing should also match up with your history, and physical exam. Assuming you have failed non-surgical care, and your medical risk for surgery is acceptable, and your diagnostic studies match up well with your physical findings and history, your surgeon must then determine if a planned surgery will have a predictably positive outcome. In the most ideal of circumstances, which is a single level disk herniation with corresponding physical findings in a health normal body weight patient, the success rate approaches 95%. With each additional level of involvement, and with more complex surgery, the success rate unfortunately becomes less. The surgeon and the patient must decide which situations warrant the additional risk, and which situations are better treated with continued non-surgical treatment.
4. How does the Surgeon determine the best surgical option?
That is based on the physical findings and the diagnostic tests. Regarding the cervical spine (neck), there are two basic approaches. Anterior means going through the front of the neck. Posterior means from the back. In some instances, both approaches may be necessary on the same day of surgery, or in a staged manner. In addition, the options include removing disk and bone material only, which is discectomy or laminectomy/laminotomy. Then, depending on the reason for cervical surgery, a fusion may be necessary. A fusion is a process by which more than one bone is joined together into a single bone. That is accomplished by making the body think the bones are actually fractured, so the body reacts in a manner to unite the bones. Fusion usually means using bone grafting, and instrumentation including rods, plates, cages and/or screws. The decision for the type of surgery is based on the complexity of the problem, and the training and experience of the physician. This is where there is a art to medicine and surgery. Every situation is slightly different, and may require a different approach. Also, reasonable, well trained, competent surgeons may have completely different surgical approaches to the same problem with the same predictable outcome rates. For complex surgical procedures, most surgeons welcome second opinions from other surgeons.
5. Can Cervical Spine Surgery be performed on an Outpatient Basis?
Yes. In fact, there are several studies demonstrating the efficacy and safety of outpatient cervical spine surgery. Even single and double level neck fusion surgeries are being performed routinely now in an outpatient setting on a frequent basis.
Still, patients and physicians need to respect the significant nature of spinal surgery, and in more complex, or medically sicker patients, an inpatient stay may be necessary.
It is true that there are also cost differences in doing a surgery in a free standing surgery center, versus having the procedure performed in a hospital. Currently, our practice performs outpatient spinal surgery in the hospital, knowing that there may be some increased costs. At this time, my thought pattern, my “Surgical art”, is to prepare for that one episode where an outpatient procedure needs to be converted into an inpatient stay. I feel having the full support and expertise of a full service hospital is an important safety feature. If I perform the surgery in a free standing outpatient center, the patient will need to be transferred by an ambulance to a hospital, that is likely unfamiliar to the patient and their family.
But, in the future, the costs may be too prohibitive to have the outpatient surgery performed in the hospital setting. When that time comes, the patient must then decide if it is worth the cost for that additional level of comfort and safety.
Last modified: October 22, 2019