Multi-level anterior cervical discectomy

If you have existing medical conditions, such as high blood pressure or diabetes, you may like to visit your GP practice to make sure that you are as fit as possible for your surgery.

Make sure you arrange your domestic and social situation so that it will be possible and comfortable for you to go home at the correct time. For instance:

• Arrange for somebody to collect you on discharge
• Make sure you have shopped for adequate food supplies for when you get home
• Tidy your house so you do not need to do housework when you get home
• Ensure you have a supply of mild pain killers available at home, such as paracetamol.
• If you think you will need some social support after discharge please speak to your GP and let us know as soon as possible.

We will:

• Arrange a pre-assessment check to make sure you are fit for an anaesthetic
• Organise appropriate scans or x-rays for your operation
• Write to you to let you know when your operation will be
• Answer any questions you may have about your operation

Anterior cervical discectomy is an operation to relieve the pressure on your spinal cord or the nerves that supply your arms and hands (peripheral nerves). ‘Anterior’ means that the operation is through the front of your neck, usually on the right side.

The neck bones (vertebrae) are separated from each other by discs that are soft and spongy. Occasionally a bit of the disc ‘slips out’ and can squash the spinal cord or the nerves. This can cause pain, tingling, numbness and /or weakness in the upper limbs. If the disc squashes the spinal cord, it can cause weakness in your arms and legs, creating difficulty in walking or problems with going to the toilet.

Sometimes ‘wear and tear’ can lead to bony outgrowths on the vertebrae, causing pressure on the nerves or spinal cord, again causing pain/tingling/weakness.

A discectomy is the surgical removal of the slipped disc, relieving pressure on the spinal cord or nerves.

The removal of pressure on the spinal cord or nerves is done to relieve the symptoms of pain/tingling/weakness.

Sometimes anterior cervical discectomy is performed when patients have few or no symptoms but may help to prevent problems in the future such as gradual weakness of the arms and legs and incontinence.

All operations have risks and your surgeon will explain all the benefits and risks of this operation to you. Your consultant will explain your risk in detail. This operation is performed under a general anaesthetic and your anaesthetist will talk to you about the risks of general anaesthesia.

Female patients must tell their anaesthetist and surgeon if they are or could be pregnant. Anaesthetic drugs and x-rays used during the procedure can be harmful to unborn babies.

Problems that may happen straight away

• There is a risk of damage to the oesophagus (gullet) and the nerves of the voice box, resulting in difficulty swallowing and a hoarse voice. The symptoms may last up to a week after the operation but in two to five percent of patients there is permanent damage.
• There is a small risk of damage to the spinal cord, nerve roots or both. This can result in a loss of power (strength and movement) and sensation (feeling). Less than one percent of people will experience a worsening of symptoms.
• Leakage of the fluid (cerebrospinal fluid or CSF) which surrounds the spinal cord may also occur in a small proportion of cases, but this is uncommon.

Problems that may happen later

• Infection may develop in the skin or deeper in the spine, but is uncommon with this type of surgery. We minimise this risk by giving a dose of an antibiotic at the start of the anaesthetic.
• Your symptoms may recur at a later date, often due to degeneration or deterioration of the vertebrae above or below the site of the operation. The risk of this happening is approximately 20 to 25 percent within the ten years following the operation. In this event further surgery might be required.
• Bone healing (fusion) across the space where the disc was removed may not happen, resulting in neck pain and further symptoms. This may require further treatment.

Problems that are rare, but serious

• Very rarely (in less than one percent of cases) the spinal cord can be permanently damaged resulting in severe neurological deficit (paralysis of limbs) or risk to life
• There is a less than one percent risk of major vascular (blood vessel) injury resulting in severe bleeding in the neck or a stroke. Such an event may require an urgent operation to remove a blood clot.

If you have compression of the nerve roots, there is a chance that your arm pain may get better by itself. However, the longer the symptoms persist, the less likely this becomes.

If you have compression of the spinal cord, your symptoms are likely to become worse. This can result in severe neurological deficit or problems controlling your bladder and bowels.

Your surgeon will discuss all alternative treatments and their risks and benefits with you. Alternative treatments include:

• Nerve root injections for pain (radiculopathy). These are day-case procedures and may offer temporary relief of symptoms. There is a risk of nerve damage. These injections will not improve the symptoms of spinal cord compression.
• ‘Watch and wait’. There is a risk that neurological problems could progress or symptoms worsen over time.
• Pain relief medicines prescribed by a GP may also help with symptoms.
• Physiotherapy. Physiotherapists provide advice about exercise and posture. Referral can be made by your GP.
• Surgical alternatives include cervical foraminotomy (nerve root decompression) and cervical laminectomy (spinal cord decompression). Both these procedures use a posterior (back) approach.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form.

This confirms that you agree to have the procedure and understand what it involves. Staff will explain all the benefits, risks and alternatives before they ask you to sign a consent form.

If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak with a senior member of staff again.

Before surgery, the nurse will complete a pre-operative checklist and give you a gown and anti-embolic (elastic) stockings to wear. A surgeon will mark your operation site on your skin with a pen and a member of the operating team will confirm your details. This is a safety check to confirm your identity and the operation you are having.

Once the anaesthetic is started and you are ‘asleep’ you will be moved to the operating theatre. The surgeon will make a small incision (cut) in the skin on the front of the neck. The oesophagus and trachea (windpipe) are gently moved out of the way and the neck muscles carefully separated down to the front of the spine. X-rays are taken to confirm the correct position. A microscope is then used to guide the surgeon in removing the disc until the outer covering of the spinal cord is visible and the nerve root is decompressed.

There are two ways commonly used to fix the gap left by the disc. The first is to insert a spacer device filled with bone chips or artificial bone graft. This is called a fusion. Sometimes a metal plate is also fixed over the front of the spine for stability. The second is by inserting a joint replacement – called an arthroplasty or disc replacement. Your surgeon will discuss these options with you beforehand including the risks and benefits of each.

The wound is closed with either metal clips, a dissolvable stitch or adhesive strips. At the end of the operation a wound drain may be placed under the skin to drain any blood and allow the wound to heal. The drain is a thin plastic tube secured to your skin by a stitch and attached to a plastic bottle. You can walk around with the drain in. This is removed the following day.

The operation usually takes two to three hours. You will stay in the recovery ward after surgery where you can be observed closely until you are ready to return to a ward.

Your consultant or a member of their team will provide you with specific instructions and information; the following are general guides only.

• Unless you feel sick, you can start to eat and drink gradually as you feel able. If you do feel sick, we can give you medicines to relieve this.
• You may find you have some mild difficulty swallowing for a few days, so choose softer food options.
• You will be sitting up and out of bed as soon as possible on the ward and walked to the toilet. A nurse or nursing assistant will help you until you feel steady enough to walk on your own. You will gradually increase your activity as you are able.
• You will be given regular pain-relieving medicine. Please tell your nurse if this is not effective so we can give more or have you reviewed by the doctor. Good pain relief is important to your recovery.
• Your consultant will decide if you need an x-ray.
• Most people feel the improvement in their arm pain immediately after the operation. Others may find it takes a few weeks before they feel the benefits.
• Before going home, you will be given an information booklet concerning your wound care. It is important to know how to care for your wound so please do not hesitate to ask any questions you may have.

• It is normal to feel a little tired for a couple of weeks after an operation. Try to do gentle activity regularly rather than too much at once. We would normally recommend three to six weeks off work depending on the nature of your work. If you have a manual job you may need to take several months off.
• Please discuss this with your surgeon before you leave hospital. You should avoid lifting heavy objects during this time.
• You can start driving again when you are in full control of your car, able to perform an emergency stop and can see out of all the car windows. Contact the DVLA and your insurance company for further information.

We will make a follow up appointment approximately six weeks after your operation. You will be notified by a letter in the post. It is important to attend this appointment so we can check on your progress. The information leaflet given to you on discharge contains contact details if you have any concerns or questions after going home.

If you have any concerns about your wound such as redness, discharge (leaking of blood or fluid), pain or if you redevelop any symptoms please seek medical advice straight away. You can contact your consultant or the spinal nurse specialist via their secretary (during working hours). The ward, your GP or your local Accident and Emergency Department can give you help and information at other times.

• Baaj AA, Mummaneni PV, Uribe JS, Vaccaro AR and Greenburg MS (2012) Handbook of Spine Surgery. New York. Thieme Medical Publishers

You may find the following websites helpful:

• www.brainandspine.org.uk
• www.spine-health.com
• www.spineuniverse.com
• www.back.com
• www.patient.co.uk

UCLH cannot accept responsibility for information provided by other organisations.

Victor Horsley Neurosurgical Department
National Hospital for Neurology and Neurosurgery
Queen Square
London WC1N 3BG

Switchboard: 0845 155 5000 / 020 3456 7890
Direct line: 020 3448 3568 / 3150 / 3395
Fax: 020 3448 3340