Cervical Foraminotomy
What is a cervical disc prolapse?
A cervical disc prolapse is a protrusion of one of the discs in the neck. This protrusion frequently causes pressure on one of the nerves to the arm ("a pinched nerve"). Sometimes, a cervical disc prolapse can press against the spinal cord, causing symptoms potentially much more serious than those of a single pinched nerve. Disc prolapse is also called a protruding disc, herniated disc, slipped disc, bulging disc, ruptured disc or even a collapsed disc.
Cervical disc prolapse can be associated with bone overgrowth, which occurs as part of a degenerative process known as spondylosis. Spondylosis is extremely common. Almost everyone over 35 years of age develops some degree of this condition. With spondylosis, a disc prolapse is more likely to cause pressure on the nervous system, causing neurological symptoms.
Pressure on the nerve or spinal cord, in some cases, is caused by a spur of excess bone (an osteophyte), rather than a disc prolapse.
What causes a disc prolapse?
Over a number of years, the disc gradually deteriorates, causing minor or intermittent neck pain. Eventually, the weakened disc prolapses and the severe symptoms develop. Often, people develop severe symptoms without being aware of any specific injury or event. While some everyday activity, like a game of tennis or a day's gardening seems to have caused the prolapse, this is really only "the straw that has broken the camel's back". A normal, healthy disc does not prolapse unless a severe accident occurs.
What are the symptoms of a cervical disc prolapse or cervical osteophyte?
The most important symptoms are neurological - the symptoms due to the pressure on the nerve(s) in the neck. These symptoms are usually felt in one arm. Pain is often severe, especially in the shoulder and upper arm, and may shoot down the arm to the hand or fingers. Tingling or numbness in one or more of the fingers is very common. Loss of strength is also common, particularly at the elbow. The exact pattern of symptoms depends on which particular nerve is involved.
If the disc prolapse causes pressure on the spinal cord, then symptoms can occur in all four limbs. Pressure on the spinal cord causes tingling in the arms or legs (or both), as well as walking impairment as the result of unsteady gait. Bladder and bowel control can also be impaired. Neck pain and headache are also common but these are not usually due to the disc prolapse itself.
How is a cervical disc prolapse or cervical osteophyte diagnosed?
Often, a diagnosis can be made with CT scans of the neck, which your referring doctor may have arranged already. Before surgery, however, an MRI scan or myelogram is usually needed.
An MRI scan is a simple and safe test, similar in many ways to a CT scan. MRIs use a technique known as magnetic resonance imaging. No radiation is involved. There is no need to be admitted to hospital and usually no need for injections, although people prone to claustrophobia may find the examination stressful and should discuss their anxiety with medical staff at the time of the test. People with heart pacemakers cannot have an MRI.
Why do I need surgery?
The main reason for surgery is to relieve the pain that radiates down your arm. If there is evidence of nerve damage causing weakness in your arm, surgery may also be advisable, even if the pain is not severe. Surgery is not usually performed to relieve neck pain.
What kind of surgery is undertaken?
There are two main types of operation undertaken for cervical disc prolapse or osteophyte causing pressure on the nervous system. One is done through the front of the neck and the other through the back of the neck. Some surgeons perform all their operations in one way or the other, but most will weigh up which operation is best suited to the particular problem. Cervical disc replacement surgery is emerging as a third method of addressing the problems in selected cases.
The operation performed through the front of the neck is usually called an anterior cervical discectomy or anterior cervical fusion. The operation from behind is called a cervical foraminotomy.
What happens during a cervical foraminotomy?
Cervical foraminotomy involves an incision on the back of the neck, usually just to one side of centre over the lower part of the spine. The muscles are separated from the spine, and the bone overlying the point of pressure is exposed. Frequently, the x-ray department will have injected a small amount of blue dye into the spinal fluid just prior to the operation. The dye is visible to the surgeon near the point of pressure. This is an additional method often used to ensure that the correct point has been identified.
A highly sophisticated drill is then used to open the channel in the spine through which the compressed nerve passes. If the problem is due to bone spurs, then this is all that is required, as the opening of the channel involves removal of at least some of the bone spurs automatically.
If the pressure is due to disc prolapse, then removing the bone gives access to the part of the disc that is actually protruding. If this can be exposed easily, and particularly if there is a "loose" piece of disc jammed under the nerve, then that piece is extracted. The vast bulk of the disc is left undisturbed. If the disk is bulging, but not ruptured, then the surgeon may elect not to remove any of the disc at all, in which case the removal of bone is normally sufficient to relieve pressure on the nerve.
What risks and complications are there?
Serious complications are rare and the risk of death is remote. As with any operation, there may be general complications related to age and underlying disease. A 75-year-old with diabetes and heart disease has a greater risk of complications than, for example, a 40-year-old in perfect health. General complications can include stroke, heart attack, bleeding in the wound post-operatively, blood clots in the legs (which can travel to the lungs or heart) and infection.
Possible complications specific to a cervical foraminotomy include damage to one or more of the nerves travelling through the spinal canal, which could cause permanent numbness or weakness in the limbs, and affect control of the bladder or bowel.
Failure of the surgery to meet expectations (without anything going wrong) is a possibility. Sometimes, despite the best efforts of the surgeon and patient, symptoms do not respond to surgery as expected. This occurs in up to 10 per cent of cases.
What can I expect after the operation?
There will be some pain around your wound and shooting pains in your arm in the first few days. An intravenous drip inserted during the operation will provide strong pain relief in the first 48 hours or so. After that, you will be given tablets and occasional injections, as required. You should be able to stand about 48 hours after surgery, although you may feel able to try this sooner. After a few days, most people are able to get in and out of bed unassisted and walk around the ward quite comfortably. Bowel actions normally do not occur until four or five days after surgery.
Will I need physiotherapy?
Most patients see a physiotherapist during their hospital stay, mainly to ensure that they are doing simple movements, like getting out of bed, correctly. Usually, there is no physiotherapy during the first six weeks or so after discharge from hospital, and only a small number of people need on-going physiotherapy after that.
What should I do when I get home?
For six weeks when you get home, the most important thing to do is rest. Your wound needs time to heal, internally as well as externally. Avoid undue bending and lifting. It is advisable to avoid driving, and even sitting as a passenger, in a car.
Schedule two good walks of about 15 minutes each per day. Swimming is excellent exercise after spinal surgery but you should wait to begin until after your post-operative review, which is usually six weeks after surgery.
In most cases, the symptoms caused by pressure on the nerve will have eased within six weeks of surgery but this varies greatly from person to person.
Will I need rehabilitation?
If your neck problem is the result of a work injury, you may need a rehabilitation program (as an inpatient or outpatient) that takes account of the nature of your work, the size of your workplace, the duration of symptoms and the details of your surgery. The program may involve input from a number of people, including your family doctor, employer or rehabilitation service providers.
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