Surgical Options in Cervical Radiculopathy
July 6, 2018
There are several causes of cervical radiculopathy (nerve pain radiating from the neck to the arm or shoulder blade) including a herniated disc or stenosis (tightness around the nerve from arthritis or degenerative disc disease). The two options include the more common Anterior Cervical Discectomy and Fusion (ACDF) and the Posterior Cervical Laminoforaminotmy.
The posterior approach is done via the back of the neck and can be done minimally invasively and is designed for those patients with only radicular pain without substantial neck pain. It involves removal of a small portion of the lamina and the joint to open up the space around the nerve. This is a good procedure if a patient has stenosis caused by arthritis (bone spurs) but not a herniated disc. This procedure alone does not result in a fusion but it takes time for the muscle to heal in addition to the nerve.
The gold standard in treatment of cervical radiculopathy is the ACDF. This procedure allow for direct visualization of the disc, spinal cord, and exiting nerve in a safe approach without muscle damage. However, a fusion is performed in this procedure which some suggest may lead to future degeneration at the levels above of below although this has not been proven.
The spine is approached through the front of the neck down to the level of the disc, the disc is removed along with the herniation, and the disc is reconstructed with bone graft (cadaver bone or a patient’s own bone) or an interbody spacer filled with bone graft. Other options include using no plate at all or a self retaining device (spacer with screws). Studies have shown that allograft (cadaver bone) with the use of plate results in a 95% fusion rate for a one level fusion. This is the most successful procedure that is performed in spinal surgery with good to excellent results. In certain individuals, using a disc replacement may be an option depending on the symptoms, the type of pathology in the disc and the age of the patient.
Bone graft options in this type of procedure can be either taking bone from the iliac crest (hip) or cadaveric bone or bone graft substitutes. In a review of 120 patients from my fellowship that had bone taken from their iliac crest, 80% had significant pain in the “hip” up to 6 months after the procedure with approximately 50% still having pain one year after the procedure. There have been attempts to fill the void in the bone with other substances but this did not decrease the rate of pain. Cadaveric bone is machined to fit in the space in various sizes and angle and has shown a high rate of fusion with a plate. The last option is the use of a spacer that is filled with one of the many bone graft substitutes such as demineralized bone matrix or synthetic bone.