Anterior Cervical Discectomy and Fusion - Justin Paquette, MD

Sechrest: Hello, I am Dr. Randale Sechrest your host for eOrthopodTV. Today I have with me as my guest Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, CA. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete a residency in neurosurgery at the Harvard Tufts Combined Program in Boston, MA. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar Sinai. Good afternoon Dr. Paquette.

Paquette: Good afternoon.

Sechrest: Today what I would like to discuss is a procedure that's a relatively long standing procedure in the cervical spine for disc disease in the cervical spine called anterior cervical discectomy and fusion. I think that's really a long name for taking the disc out and then fusing two vertebrae or more together. What do we do this procedure for?

Paquette: Sure. It's probably the second most common procedure that, as neurosurgeons we do, is the replacement of those discs and the locking together of two vertebrae in the cervical spine. It is generally done for a few different reasons but predominantly because the disc itself is now a flat tire. Because of degenerative disc disease the disc has collapsed down and then it herniated out and probably causing neck pain, but more importantly either having the nerve or the spinal cord and so these individuals usually present with symptoms in the arm or symptoms of spinal cord compression with actual walking difficulties, etc. The surgery for this is done from the front, usually through about a 2cm incision. It sounds very scary because we have lots of important structures here, we have the breathing tube, the swallowing tube, carotid artery and nerves, but in fact it's a relatively straight forward procedure, in fact we just have to cut the skin and most everything else is devised inside for us. Go down to the front of the vertebrae and under them microscope we are then able to take out the entire disc from the front and then replace that disc with a kind of a car jack which can be made of either a cadaver bone, plastic or, back in the older days, people would actually take pieces of that patient's hip, carve it down to size and then put it into the disc space.

Sechrest: Now let's go back a little bit and I would like to ask you a couple of questions. First is, what symptoms are you trying to attack when you're thinking about doing an anterior cervical discectomy and fusion, what are you trying to correct for the patient?

Paquette: Sure. The main symptoms that you're looking to improve are those that are caused by either the nerve or the spinal cord being pinched. Those are the main issues, so if somebody's got a severe burning right arm pain from the herniated disc, that's the main thing that you expect to get better. Numbness and weakness can get better also, but that may take a longer period of time. What's more of a dark horse sometimes is neck pain, because again neck pain can come from multiple different sources. You may have one bad disc that you're getting operated on but you probably have other discs that are not great, maybe some joint problems here and there, and so, you know, it's not realistic to think that you'll never have neck pain again. However, we do notice that if we operate on individuals that have a very badly degenerated disc, a lot of times their pain does improve significantly.

Sechrest: Now what if I'm a patient just with neck pain. If I don't have any signs of spinal cord compression, I'm not having any gait problems, I don't have any nerves that have been pinched so I'm not getting any pain or weakness or numbness or reflex changes in my arms, but I come to you and I say, you know, the biggest problem I've got is neck pain, my neck is killing me. Do you think anterior cervical discectomy and fusion is a procedure that will help that person?

Paquette: It's a very controversial question and in general most people would like to avoid doing surgery for those situations. Because the change of a good outcome is much less under just pure neck pain situations as opposed to somebody who had arm pain from an actual nerve being pinched. It doesn't mean to say that there aren't possible times that you could help with this but I still say that in most times you try to go with conservative things first, physical therapy, etc. There are times though, for example when there's a spondylolistheses or a slip in some of the bones or a curve to the bones or a malalignment or some other situation that can lead to pure neck pain. Those individuals actually do respond well to surgery. And somebody with a totally normal appearing neck on x-rays and pure neck pain, try to avoid surgery as much as possible.

Sechrest: Let's talk a little bit about what tests are required for you to make a decision as to whether surgery is indicated or not. Do you generally go on your clinical exam and x-rays and an MRI scan? Is that enough for you to recommend surgery?

Paquette: Those are really the main things for me. What I trust the most is my clinical history on the patient and my examination to see if there is any overt evidence of nerve or spinal cord impingement. I then combine that with what I see on the MRIs or the CAT scans and if those things are concordant and signify a significant problem, then that's enough for me to have to go ahead and do surgery. I only order supplementary tests like an EMG test or something like that if there's concern in my mind that I'm not clear exactly what the picture is.

Sechrest: Okay. Now many patients are now undergoing a test called a discogram. A discogram is a test where a needle is inserted into the disc, either in the neck or the low back, wherever, and two things are done. One is, fluid is injected into that disc and the whole goal is to just to see if it reproduces the neck pain. The other thing is dye is put in there and then a CAT scan is done so you can sort of get some feel as to what the integrity of the disc is. Whether there's some sort of deformity or something. Do you use a discogram to help make a decision?

Paquette: I almost never use discograms at all for anything in the spine. Only except in very certain cases and I almost never use them in the cervical spine. There's a significant risk of causing infections in the disc space, number one, with doing the procedure. Number two, the procedure itself is very controversial and there's a lot of people out there that say it's good, there's a lot more that say that it's not good. It's a very subjective test. It depends a lot upon the patient, a lot upon the tester, and I think that I would prefer to figure my plan based upon more concrete data points rather than the discogram results.

Sechrest: Okay. Well, let's say you get to the point to where you've been managing a patient or the patient has come to you for a referral and you've decided that it's in this patients best interest to have a cervical discectomy and fusion. What's next? What does that patient need to do to get ready for surgery? How big a surgery is this.

Paquette: Okay. So, the surgery itself if the patient is smoking needs to stop smoking and the better shape they're in, certainly the better that they'll respond to surgery. If they're taking large amounts of narcotic pain medicines, the more they can get down off of those will make their postoperative discomfort better. But the surgery itself, if we're talking about a one level, anterior cervical discectomy and fusion, takes less than an hour. The patient is up and walking that day. Sometimes they go home the same day, sometimes the next morning. People do not have to wear a hard collar but I might give them a soft collar to wear for comfort off and on. What I tell folks to expect the first few weeks is a hoarse voice and a little bit of a catch when you try to swallow which is from the swelling from the breathing tube and from the surgery itself. I tell them just to, you know, chew easily and swallow small pieces and it won't be a problem. Both of those symptoms will take care of themselves in a few weeks time. A lot of people are driving within about a week or so, can be back to work depending upon what they do within a couple of weeks. At six weeks out from surgery, everyone will go into an aggressive physical therapy program with core muscle strengthening, neck motion, neck mobility after which they're back to their full activities with no restrictions.

Sechrest: And how long do you think that it takes an anterior cervical fusion to heal? To actually get a fusion between the two bones?

Paquette: The actual time it takes for the bones to fuse can differentiate from person to person based upon how strong their bone is, what their genetics are, etc. What I tell most folks to expect some bone healing within six weeks, they're to be within 3-6 months about 90% of normal bone strength. It then continues to remodel and reform over the next year, year and a half, at which point it probably reaches about 97% the strength of normal bone.

Sechrest: So at the end of 18 months you figure if the surgery has gone as planned, everything should be stable and that person is probably as good as they're going to get at that point.

Paquette: Correct.

Sechrest: Now let's look at a little bit of the risks and the benefits of this procedure. As a neurosurgeon, I know you do this every day, everyone is concerned that this gentleman's operating near my spinal cord. Am I going to be paralyzed? What are the risks here? What do you worry about as a neurosurgeon when you do this procedure.

Paquette: Sure. So just again with the approach for the surgery, again it's a small incision, we hide it in a skin crease here, but as your going down there's lots of important structures there so we would take good care to protect the esophagus and the trachea, the breathing tube and the swallowing tube, the carotid arteries and the various nerves that are down there. It's very important to do minimally invasive as possible. So just go down right in the level you want to be at. That allows you to preserve all the nerves. If you make a big large opening, it's much more risky to have nerve problems. So be as minimally invasive as possible, just touch the level you want to do, make as little heat as possible 'cause coagulation can effect the nerves and so we just try to use as little bit of that as possible. What I'm concerned about during the actual surgery is obviously we're working right next to the spinal cord and the nerves and so where this is all done under a microscope with very small special instruments and we just take out time and make sure that everything is fully decompressed and well done. We do know that one of the risks of the surgery, an anterior cervical discectomy and fusion, when you operate on the fifth nerve, for some reason the fifth nerve is a little more susceptible than other nerves and even if it's not even injured, sometimes something just changed with the blood supply, whatever, and the person's going to have a C5 nerve problem for a few months afterwards which means that they have difficulties in raising their arm. It happens in probably less than 1% of the cases but certainly is an annoyance with the only good thing being that almost everybody gets better within a short period of time.

Sechrest: And are these fusions fairly successful? I mean, do you expect each fusion to go ahead and heal or do you get some that don't heal and don't go on the fusion.

Paquette: When you look at the history of this particular kind of surgery, initially the discectomy was performed meaning they would just take out the disc but there were no blocks of bone put in there and no metal was put in there. It had a very low success rates, 50/50 at best. And even worse, over time the neck would start to tilt forwards like this and cause even more problems. As time went on, as evolution of this surgery went on, people started putting in blocks of bone, usually from the patient's hip themselves. With improvement in the fusion rates, the problem is of course that the patient ends up developing severe pain in their hips, sometimes 20% of the time people would have severe persistent hip pain. The next stage in the process was the incorporation of the plate and it's a small titanium plate and screws that locks the level below and above together. This is how we commonly do it now. We do it with a combination of either cadaver bone or a special plastic, not the patients own bone, and this special titanium plate. With that we now have extremely high fusion rates.

Sechrest: Now, do you have to go back in and take the plate out or does that stay in forever?

Paquette: No, never take the plate out unless the patient needs to have further surgery for a different level.

Sechrest: And do you see any problems with the plate or anything like swallowing trouble or anything like that after surgery?

Paquette: Usually the plates are so thin, a couple millimeters in diameter, that it's never an issue. Every once in a while you may have somebody who's extremely thin that may have a little bit of a problem with swallowing and may have to get it taken out but that's very rare. What is more of an issue is if the bone doesn't fuse. Then the plate starts to move and the metal will ultimately fracture if the bone is not fused and the screws may back out, the plate will back out and then that's obviously going to be a significant problem.

Sechrest: So then you have to go back and take that plate out and redo the fusion and try to get it to heal. Any suggestions that you would have to patients who are looking at this type of a surgery. If they're faced with having an anterior cervical discectomy and fusion, how can they optimize their chance of success?

Paquette: In regards to advising patients for anterior cervical discectomy and fusions, I would first let them know that even though certainly it's anxiety provoking situation to undergo these surgeries, it's a very successful surgery. And under almost all conditions, these patient's do very well. It is important obviously if they want to get second opinions, I would do as much research as they possibly can to figure out if they're being done the same ways, or different ways, or even if there is other opportunities out there. Now these days we've come up with many new types of technologies that sometimes can be used instead of the old fashion fusion techniques.

Sechrest: Okay. This is wonderful information, I think, for patient's who are faced with neck pain and looking at the possibility of surgery. Any last comments you would like to make about this procedure called anterior cervical discectomy and fusion? Any parting comments?

Paquette: Nothing comes to mind.

Sechrest: Okay, thanks for coming.

Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopedic topic, be sure to visit eOrthopod.com and if you're an orthopedic surgeon or health care provider interested in participating as a guest on eOrthopodTV, you'll also find instructions on how to apply to become a guest on the eOrthopodTV. Thanks for watching.