Jeffrey R. Carlson, MD, MBA, FAAOS, CPE
As a Spine Surgeon, I often must perform cervical spine fusion procedures on my patients who have spinal instability in the neck. These patients may or may not have nerve compression and I may or may not have to perform other procedures at the same time, such as a decompression or laminectomy, to relieve pressure off the nerve root or spinal cord. I often am asked “What determines where you make the incision in the neck – the front or the back – when you perform fusion surgery on the cervical spine?” That’s a great question and one that I will answer here in this article.
There are physical indications that guide me to the correct surgical approach for cervical fusion surgery. One that tells me I must approach from the front of the neck, or the anterior approach is kyphosis in the cervical spine. Kyphosis is the exaggerated forward rounding of the upper back. If I went through the back of the neck, I would not be able to correct the bent spine as well as gain access to remove the disc material and secure the vertebrae. It would be a more difficult surgery with a worse outcome.
Another physical indication that tells me I should approach the spine fusion through the back of the neck, or the posterior cervical approach, is if the patient needs a fusion of multiple vertebral levels due to instability. When you go in to do surgery from the front, the esophagus must be moved out of the way to access the spinal column while I’m operating. The longer it is held, with pressure, out of the way, the more of a chance the patient could have problems with speaking (dysphasia) or have long-term throat pain or a chronic cough. When I only have to fuse one level, I can do that surgery, from the front, in less than an hour and the patient may have some temporary hoarseness and a mild sore throat for a few days, but nothing that lasts a long time. If a person sings or speaks for a living and needs a multi-level fusion, I’d recommend a posterior approach.
There are drawbacks to the posterior approach which must be considered. An important one is recovery time. In the anterior (front) approach, no muscles are cut during surgery. In the posterior approach, muscles in the back of the neck are split getting to the spinal column and they must heal after surgery. This adds weeks to the recovery time. Anterior recovery = two weeks in a cervical collar, while posterior (greater than one level) = six weeks in a cervical collar.
Anecdotally, infection rates are said to be higher for posterior surgeries than anterior surgeries, although I have not seen this in my practice. I am careful to administer antibiotic prophylaxis to prevent infection, so this doesn’t seem to be an issue.
A rare complication is a C5 nerve palsy that can happen after cervical fusion surgery. It causes weakness and/or pain in the deltoid and/or the biceps muscles. Researchers aren’t sure why it happens to some people and not others, but it is temporary and usually goes away within three months. However, it has been known to last up to a year. Physical Therapy has been shown to improve symptoms.
Posterior Cervical Fusion surgery is outpatient and patients are sent home the same day as their surgery in their cervical collars, with pain medication and muscle relaxants, to take for one-two weeks. Patients will wear their cervical collars most of the time during this period of recovery. They will have a drain inserted in their incision which will be removed by the Home Health Nurse the day after surgery.
I highly recommend walking to my patients to help them regain their stamina after surgery. A physical therapist will come to the house to check on the patient’s mobility and function in the home. Patients will follow up with me in the office in 10-14 days post-surgery to have stitches/staples removed and to check on their progress.