Should you Have Surgery for Cervical Radiculopathy?

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Neck Surgery for Radiculopathy Symptoms

Neck bones
Bones that make up the neck. Science Picture Co/Getty Images

Cervical radiculopathy may be a mouthful to say, but if you've experienced it, you are likely well-acquainted with its symptoms. These include pain, weakness, numbness and/or electrical sensations that go down one arm.

Cervical radiculopathy is a condition in which one or more spinal nerve roots in your neck become irritated or compressed. It may be caused by herniated disc, spinal arthritis or stenosis or other conditions.

Spinal nerve roots are bundles of nerve fibers that emerge from the main spinal cord. There's one on either side at every level of the spinal cord. From the root, peripheral nerves branch off into all areas of the body to relay messages of sensation as well as movement.

Do you need surgery for cervical radiculopathy?

The short answer is maybe, although according a 2011 review of cervical radiculopathy, published by the Hospital for Special Surgery (in their journal) most of the time, patients get better without it.

The authors report that both passive and active non-surgical therapies may help patients avoid invasive procedures.

But, they say, surgery may be necessary when your radiculopathy is accompanied by movement impairment or debilitating pain that responds neither to conservative care, nor to the passing of time.

Other reasons to have surgery, the authors concede, is when radiculopathy symptoms are disabling and your neck is also unstable.

If any of these scenarios describe your experience, you may want to know what types of surgeries are commonly performed on people with cervical radiculopathy. The review mentioned above describes two types of invasive procedures. These are discussed later in this article.

A third type of surgery, disc arthroplasty, is newer, but shows a lot of promise. We'll talk about that next.

 

 

 

 

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Disc Arthroplasty — Should You Preserve the Motion in Your Spine?

Neck surgery
Neck surgery. MedicImage/Universal Images Group/Getty Images

Disc arthroplasty, one of the many names given to spinal disc replacement surgery, is a newer type of procedure for the reduction of radiculopathy symptoms. It's used more in the neck than the low back, although the manufacture of artificial disc devices for the low back is also a robust industry. Perhaps the reason more disc arthroplasties are done in the neck than in the low back is that the neck lends itself to an anterior, or front, approach which many surgeons prefer. (This is discussed in more detail in the next section.)

As the name suggests, in a disc replacement procedure, a prosthesis designed to mimic the shape and function of a natural disc is inserted to replace the one that has worn out. Of course the old disc is removed, and the area cleaned out before the artificial one is put in.

Disc arthroplasty is also called "motion preservation spine surgery." The more established surgery types generally involve fusing the area, which removes the possibility of ever moving that area again, once the procedure is complete.

But with an artificial disc, the motion is supposed to be preserved. But actually realizing the promised motion preservation benefits is not fool proof, and it's possible that you might undergo this surgery and come out of it unable to move your neck.

Similar to other spinal procedures, disc replacements are used to address cervical radiculopathy and discogenic pain. They're also used for revision surgery.

How Does Disc Arthroplasty Compare to More Commonly Given Neck Surgeries?

Is disc arthroplasty a superior option to tried and true spine procedures?

The jury is still out on that, but experts at Medscape report that, as of 2014, no evidence exists to say that preserving the motion — the main advantage touted by advocates — results in the prevention, or reduction of degenerative changes above and below the surgery site.

This type of degeneration is called adjacent segment degeneration or ASD, and the risk of it is a sticking point for the other types of surgery. Reducing the possibility of ASD showing up in joints above or below the original spinal fusion site is, according to disc replacement advocates, the reason disc arthroplasty was developed in the first place.

Since that time, more research studies and reviews of studies have been released. A study on the long term effects of disc arthroplasty published in the June 2016 issue of Spine found that at 7 and 10 years out from the procedure, the devices were still working and the outcome of arthroplasty was comparable to those of conventional ACDF procedure for radiculopathy symptoms, in the same time frame.

Another study by Shangguan, published in the March 2017 issue of PLoS One, found that disc arthroplasty shortened the time patients were in surgery, and also resulted in better range of motion at the surgery site. 

Other than those two measures, disc replacement surgery outcomes were similar or comparable to those from ACDF, but not better. Such measures include how much blood is lost during the procedure, neck and arm pain scores post-operatively, and problems, called "adverse events" that crop up later, also post-operatively.

And finally, sometimes it's not as simple as having just one disc replaced. Often people with cervical radiculopathy or discogenic pain need repair at more than one level.

A 2017 meta-analysis published in the European Spine Journal that compared disc arthroplasty with ACDF at two adjacent levels found the procedures to be about equal in terms of most surgical outcomes. That said, the patients' of range of motion was a little better in those who had their discs replaced.

But even with these results, the authors caution that the use of disc replacement at more than one level of the spine is considered "controversial."

 

 

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Anterior Cervical Discectomy with and without Fusion

Spinal surgery hardware
Spinal surgery hardware. BSIP/UIG/Collection:Universal Images Group/Getty Images

Anterior Cervical Discectomy

The first, and likely the most common, surgery for cervical radiculopathy symptoms is the anterior cervical decompression, aka ACD.  In this surgery, the disc is removed to help relieve pressure on the spinal nerve root.

And as we'll talk about below, a fusion is also done with ACD and in that case, the acronym is ACDF.

An anterior cervical discectomy is a procedure in which the surgeon cuts into the neck from the front (in the throat area, to be exact) to reach and remove damaged intervertebral disc material. In an anterior cervical discectomy, the neck muscles are moved away to expose several structures, namely, the  trachea, esophagus, disc, and spinal bones.

The authors of the review mentioned earlier say that in general, surgeons prefer the anterior approach because it provides them with the best opportunity to restore the natural neck curve, to stabilize the spine and to predictably decompress the spinal nerve root.

Anterior Cervical Discectomy with Fusion

Anterior cervical decompression is done with and without fusion, but most surgeons prefer to fuse.

That said, the "to fuse or not to fuse"decision for 1 or 2-level ACD surgeries is a controversial topic among spine specialists. A 2016 study published in the Journal of Neurosurgery: Spine found the more levels being decompressed and fused, the greater the risk for post operative neck and arm pain as well as other problems.

The insertion of hardware, i.e., plates, cages, screws and the like my help your chances of a successful fusion, according to the authors. The authors also say that hardware may help decrease posture issues (kyphosis, in particular) as well as some types of bone graft complications.

Generally when you have more than one level being fused, your surgeon will use an anterior plate. This is for your safety and the success of the procedure.

But complications can and do happen. In this case your doctor may suggest removal of the old hardware from the ACDF surgery, which will require yet another invasive procedure.

Should You Consent to Fusion?

This is a tricky question that depends on a variety of factors. Again, if your surgeon is operating on more than one contiguous level of your spine, the answer may be yes. But a 2012 review of literature published in the Open Orthopedic Journal found minimal, if any difference between results from ACD and ACDF. The same researchers found only limited evidence that having a fusion along with an ACD (i.e., ACDF) surgery yielded better surgical outcomes than the full ACD.

It's best to discuss your options with your surgeons thoroughly, and get a second opinion if you have questions or concerns on this important decision.

 

 

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Laminoforaminotmy for Cervical Radiculopathy Symptoms

Vertebra or spinal bone
Vertebra or spinal bone. MedicalRF.com/Getty Images

The next most common surgery for cervical radiculopathy, called posterior cervical laminoforaminotomy, takes a posterior, or back, approach.

About Laminoforaminotmy for Cervical Radiculopathy Symptoms

Before you run away from this scary-looking term, let’s break it apart to understand what the procedure is about. As we’ve already discussed, posterior refers to an approach from the back, and cervical refers to your neck. The suffix –otomy means to cut into but not necessarily remove.

The terms “lamino” and “foramino” refer to areas of the spinal bone and/or column.

The lamina is a part of the bony ring in back of an individual vertebra. The lamina extends behind the transverse process on one side of the vertebra, to the base, on the same side, of the spinous process in back.

The term foramina means hole, and when talking about the spine, it refers to the holes on either side of the spinal column at every level, made by pairs of neighboring, stacked (1 upper and 1 lower) vertebrae.

The foramina house the spinal nerve root, and the lamina is the part of the individual bone that forms the roof and floor of the foramina.

Put it All Back Together — What is a Laminoforaminotomy?

Putting it back together again, the term posterior cervical laminoforaminotomy is a procedure in which the surgeon enters through the back of the neck to cut into, but not necessarily remove one, two or both of these areas of the spine; this would be the lamina, which is located at the back part of an individual bone, and also one or more of the holes at the side.

This procedure is done to make room for nerves. The goal of the surgery is to allow the passage of nerves through the foramina to occur unimpeded. By removing bone material in the lamina and/or the foramina, the spine is said to be “decompressed.”

Posterior Approach to Neck Surgery — The Benefits

The benefits to using a posterior approach are that fusion is generally not necessary and that the surgeon can maintain good spinal balance and alignment.

The drawback is that the amount of decompression that can be done in a surgery like this is limited. Consequently, according to review referenced above, the best use for a posterior approach may be to remove soft disc fragments that cause neuroforaminal spinal stenosis, a condition that can and does cause cervical radiculopathy.

When it comes down to it, the choice of surgery has more to do with your surgeon's preferred technique and the ability to maintain spinal alignment and balance during and after the procedure, the review concludes.

Sources

Botelho, Richardo, V., et. al. The Choice of the Best Surgery After Single Level Anterior Cervical Spine Discectomy: A Systematic Review. Open Orthop J. March 2012. Accessed Jan 2016.

Caridi, John M., M.D., Pumberger, Matthias, M.D., Hughes, Alexander, P., M.D. Cervical Radiculopathy: A Review. Hospital for Special Surgery. Sept. 2011. Accessed Jan 2016.

Sasso W. Long-Term Clinical Outcomes of Cervical Disc Arthroplasty: A Prospective, Randomized, Controlled Trial. Spine. June 2016. https://www.ncbi.nlm.nih.gov/pubmed/27333341

Shangguan, L. Discover cervical disc arthroplasty versus anterior cervical discectomy and fusion in symptomatic cervical disc diseases: A meta-analysis. PLoS One. March. 2017 https://www.ncbi.nlm.nih.gov/pubmed/28358860

Zou, S. Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. Eur Spine J. April 2017 https://www.ncbi.nlm.nih.gov/pubmed/27314663