ACDF for myelopathy

Anterior Cervical Decompression and Fusion (ACDF) for myelopathy

Indications for surgery:

If the spinal cord is compressed both arms and the legs may be affected causing increased reflexes, lack of coordination and weakness. This represents spinal cord injury and is called myelopathy.

Patients with myelopathy usually describe a gradual loss of function in the hands and legs manifesting as clumsiness and difficulty with fine control actions such as doing up buttons and using a knife and fork. Walking may become slow and unsteady with a broad based gait due to lack of feeling and joint sensation as well as weakness.

Myelopathy represents damage to the spinal cord, which may not be able to recover after being decompressed. It is important to treat patients with myelopathy quickly to give them the best chance of improvement but usually the surgery does not result in full improvement but stops further deterioration.

Surgical technique:

Under general anaesthesia a small incision is made on the front of the neck and tissues are carefully opened to expose the spine. The correct disc level is found using x rays and the disc is removed using instruments whilst looking through a microscope. At the back of the disc where the nerve or spinal cord is being compressed the disc or bone is removed to decompress the nerve or spinal cord. A plastic spacer is placed in the disc space and a small plate with screws may be attached to the bones above and below the disc to encourage fusion of the bones to each other.

Evidence for surgery:

Decompression of the spinal cord is the only suitable treatment for myelopathy. The treatment should be performed urgently to minimise further deterioration.

Benefits of treatment:

Stop further deterioration in function.

Some patients will experience ongoing benefit and improvement in function between 6 months and 5 years after surgery

Risks of surgery:

Serious risks: Death, quadraplegia (paralysis in arms and legs) <1%

Other risks: Hoarseness of voice and difficulty swallowing ~20-30% of patients initially after surgery with ~5% of patients in longer term. This treatment option should be avoided in some patients eg, professional singers. Failure of fusion ~5%, worsened neck pain ~5%, shoulder pain ~5%, ongoing arm pain ~10%, worsened arm pain <5%, adjacent segment disease ~25% over 10 years. Wound infection ~1-2%, medical and anaesthetic risks.

Post operatively:

After your surgery you will be transferred to the ward. The ward will help you to mobilize on the day of surgery. After an x ray to check on the placement of the spacer +- and plates and screws, and after overnight observation.The duration of inpatient stay will depend on the severity of your weakness and functional change. Most patients with significant myelopathy will benefit from a period of rehabilitation following the surgery.

During your ward stay the nursing staff will monitor your breathing and neck to ensure there is no neck swelling or breathing difficulty. The day after your surgery a speech pathologist will check on your voice and swallowing. If there is hoarseness or difficulty swallowing they will give you advice regarding this problem. This problem usually settles without long-term problems.

Pain is typically well controlled with Paracetamol and occasional short term use of NSAIDS (longer term use of NSAIDS may impair fusion)

Smoking impairs bone fusion and healing and is strongly discouraged.

Mobility restrictions are designed to limit discomfort and reduce risks of disc recurrence. You should avoid the extremes of neck movement and avoid working above shoulder level. You should not lift anything heavier than a full kettle of water.

Driving should be avoided for the first 3 weeks post op as checking your blind spot involves extreme neck rotation. After this period driving should only be undertaken if there is no arm weakness and good range of movement without discomfort to allow the driver to easily be in full control in an emergency situation. If this is not the case the patient is legally bound to avoid driving.

Return to work is variable between different types of jobs and dependent upon your quality of function. We will discuss return to work at your 6 week follow up appointment.

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