What is Cervical Fusion Surgery? What is Three-level Cervical Fusion Surgery? What are the indications for a Three-Level Cervical Fusion Surgery? Are there different types of Cervical Fusion Surgery? What are the potential complications from a Three-Level Cervical Fusion Surgery? Are there alternatives to Three-Level Cervical Fusion Surgery? What is the SANS approach? Let's dig in.
What Is Cervical Fusion Surgery? (Mending Two Bones Together)
Cervical fusion is a major surgery that involves joining one or more of the spinal bones together using screws, bolts, and plates (1). The hardware may be placed in the front ( anterior) or the back( posterior) of the cervical spine. The disc between the spinal bones is often times removed and replaced with a bone graft or a spacer.
The neck of composed of 7 boney building blocks that are numbered from 1-7. The letter C is associated with the numbers to designate the cervical spine. Hence the bones in the neck are C1 through C7. Sandwiched between neck bones are important shock absorbers called discs. A cervical fusion surgery removes this important shock absorber and joins the adjacent bones together with hardware.
What Is a Three-Level Cervical Fusion Surgery? (3 Discs Cut Out)
A Three-Level Cervical Fusion is a major surgery where 3 discs are removed and hardware is placed to stabilize the neck. the procedure is performed in a hospital and takes several hours..
Cervical fusion surgery is popular. The rate of posterior cervical fusions in the US has increased by 2.7 fold from 2001-2013 (2).
What Are the Indications for a Three-Level Cervical Fusion Surgery?
Indications for Three-Level Cervical Fusion include:
Tumors
Spinal Bone Fractures
Infections (Osteomyelitis)
Narrowing of the Spinal Canal (Stenosis)
Trauma
Spinal cord injury
Curves in the spine (scoliosis)
Severe arm pain with numbness and tingling
A curve in the spine is called Scoliosis
Are there Different Types of Three-level Cervical Fusion Surgeries? (Front and Back)
Side View X-ray of Anterior Cervical Discectomy (ACDF)
There are many different types of Cervical Fusion surgeries. They can be divided into two principal types based upon the surgical approach.
Anterior (FRONT)
The surgeon removes the discs through an incision in the front of the neck. Removal of the disc is called a discectomy. The screws and plates are placed on the front of the neck. This type of surgery is commonly referred to as ACDF (Anterior Cervical Discectomy and Fusion)
Posterior (BACK)
Side View X-ray of Posterior Cervical Discectomy (ACDF)
During a posterior fusion, the surgeon removes the discs through an incision in the back of the neck. The screws and plates are placed in the back of the neck. This type of surgery is commonly referred to as a PCF (Posterior Cervical Fusion). This approach requires the removal of important spinal bones in addition to the disc called the lamina. The lamina provides critical support and protection of the spinal cord.
Three Level Cervical Fusion Surgery Complications
Difficulty Swallowing
Difficulty swallowing is called dysphagia and can occur after neck fusion. The incidence of dysphagia after Cervical Fusion Surgery in one study was 12.7% (3). Difficulty swallowing can compromise calorie, fluid intake, and healing.
Failed Fusion
This is BAD news. Failure of the bones to fuse is called non-union or pseudoarthrosis. It means that despite the surgery, the inserted screws and plates, the extensive rehabilitation, and the pain the bones did not fuse. The intended surgery has failed and now there is instability in the neck. The incidence of non-union is striking and in one study was found to be 52% (4). The treatment for non-union is terrible as it involves another surgery where the fusion is revised and oftentimes the fusion is extended up or down an additional level.
Continued Neck Pain
Despite Three-Level Fusion, many patients continue to have ongoing neck pain that requires oral narcotics. In a recent study 1 year after neck fusion only 39% of patients were able to return to work. (5)
Increases the Risk of Complications
When compared with a Two-Level Cervical Fusion, a Three-Level Fusion is associated with a higher rate of failure and complications (6)(10)
Spinal Fluid Leak (CSF)
The Dura is the outermost membrane that covers the brain and spinal cord. This important membrane can be punctured during surgery causing a leak of spinal fluid. The incidence ranges from 1-17% (7). Severe headache is a common symptom of Dural Leak. If left untreated, a spinal fluid leak can lead to infection, brain abscess, and bleeding (8).
Nerve Injury
Nerves can be damaged during surgery and the incidence varies from 0.18% to 2.6% (9). Nerve injury can include exiting nerves as well as the spinal cord itself. After Three-Level Cervical Fusion Surgery patient may awaken after surgery with new-onset left arm, face, or lower extremity pain.
Changes in Spinal Curve
The natural C curve in the neck is important for optimal function as it ensures proper alignment of all the bones, tendons, and ligaments in the neck. Cervical Fusion Surgery not only alters the natural C curve in the neck but also adversely affects the curve in the low back. Ouch! A new study demonstrated that patients who underwent cervical fusion noted changes in both the neck, tailbone, and pelvis curves. This oftentimes leads to the onset of pain and injury (11).
Infection after cervical fusion
Infection
Infection is a devastating complication and was found to occur in 16.6% of patients in a recent study. (12). Infection can involve the skin, muscle or bone. Treatment involves antibiotics, wound care, and 47% of patients in a recent study required additional surgery for wound care and skin grafting.
Adjacent Segment Disease
Adjacent Segment Disease (ASD) is a common complication of neck fusion with an incidence of 21% (13). It occurs as a direct result of the fusion surgery. Why? The neck discs are designed to absorb the forces of daily living. Fusing one or more discs together results in additional forces being placed on the disc and facet joints above and below the fusion. This additional pressure results in wear and tear and degeneration often times requiring additional surgery. See our video below:
Restricted Motion
Patients who underwent 3 or 4 level fusion have significant loss of range of motion. A recent study demonstrated patients had significant loss of range of motion in all planes after surgery (12). Bending forward was affected the most with a 39.5% reduction. On average the loss of range of motion was:
More than 25% for bending forward and backward (flexion/extension)
More than 25% for side bending
About 14% for rotation of the neck
Restricted range of motion can significantly impact one's day-to-day activities. Activities most commonly impacted include:
Washing Your Hair
Shaving
Trimming Toenails
Backing Up a Car/Truck
Alternatives to Three Level Cervical Fusion Surgery
At the Centeno-Schultz Clinic, we are experts in the treatment of neck pain. We are also experts in the use of PRP and stem cells in the spine. In 2005 we become the first clinic in the world to inject bone marrow-derived stem cells into the disc. We are also leaders in the field of regenerative medicine and interventional orthopedics. We have published extensively in recognized, peer-reviewed journals. Our list of publications is available here.
Our approach is different. Unlike the rushed, brief exam in most orthopedic offices, we spend a dedicated amount of time reviewing your chief complaint, its duration, aggravating and alleviating factors, treatment to date, past medical history, medications, and events that led to the injury. We also review in detail all imaging. This includes x-ray, MRI, and CT scans.
Our approach is comprehensive in nature as we believe the body functions as a unit. For example examination of the shoulders is critical when evaluating patients with neck pain. This is because many patients with low neck pain also have ongoing shoulder problems. Common examples include AC joint arthritis, bursitis, or rotator cuff injuries. The approach is referred to as SANS and discussed in detail below.
At the Centeno Schultz Clinic, platelet and stem cells are both precisely injected into the neck using x-ray and ultrasound guidance. The injections are challenging and can not be performed by your surgeon, chiropractor, or physician assistant. To watch a Centeno-Schulz Clinic injection click on the video below.
SANS Approach at the Centeno-Schultz Clinic
At the Centeno-Schultz Clinic, we utilize a systematic approach in our evaluation of each patient. This approach is called SANS.
SANS stands for the following:
Stability
Articulation
Neuromuscular
Symmetry
Stability in a mechanical sense means resistance to falling apart. In the context of your joint, stability refers to a joint that moves with all the surfaces in general alignment all the time.
Articulation refers to the boney surfaces that make up the joint. They are covered with cartilage which is protective and allows the smooth, painless gliding of joints.
Neuromuscular refers to the concept that nerves provide electrical impulses to muscles. These impulses tell the muscle when to contract and relax. Without this important electrical input, the muscles can not provide support and stability for a given joint.
Symmetry refers to the right side being the same as the left. Why? Symmetry is important for the body to function optimally. Have you ever tried driving when one of your tires is very low? The steering and ability to drive is compromised. So too with the human body. If one side is shorter, weaker, misaligned in comparison to the other injury, pain and limitation can occur.
In Conclusion
Cervical Fusion is a major surgery that involves joining one or more of the spinal bones together using screws, bolts, and plates. A three-level cervical fusion is a surgery where three cervical discs are removed and hard is placed to stabilize the neck. Cervical fusion is a popular surgery with an increase in the number of procedures performed annually. The most common indications for Three-Level Fusion Surgery include spinal bone fractures, infections, spinal stenosis, trauma, spinal cord injury, scoliosis, and tumors. There are two major types of Cervical Fusions that describe the placement of the hardware: Anterior and Posterior. Complications from Three-Level Cervical Fusion surgery are significant. There are 9 key complications that you need to know.
Failed Fusion
Continued Neck Pain
Increased Risk of Complications
Spinal Fluid Leak
Nerve Injury
Changes in Spinal Curve
Infection
Adjacent Segment Disease
Restricted Motion
****If you are considering disc replacement as an alternative to cervical fusion, we'd ask you to read this blog post.
PRP and stem cell injections are effective alternatives to Cervical Fusion Surgery. The Centeno-Schultz Clinic are experts in the treatment of neck pain. They were the first clinic in the world to inject stem cells into the human disc. As leaders in the field of regenerative medicine and interventional orthopedics, we have distinguished ourselves with peer-reviewed publications, the publication of clinical results, and a comprehensive clinical approach. SANS is the clinical approach that evaluates stability, articulation, neurologic, and symmetry.
If you or a loved one suffer from ongoing neck pain please schedule a telemedicine consultation from the comfort of your home or office. A board-certified, fellowship-trained physician will review your medical history and radiographic images to determine your candidacy. Cervical Fusion Surgery has significant risks and complications with no guarantee of clinical improvement. Want to be free of around the clock narcotics or NSAIDs? Schedule a second opinion today and learn more about your non-surgical options.
1.Srikhande NN, Kumar VAK, Sai Kiran NA, et al. Clinical presentation and outcome after anterior cervical discectomy and fusion for degenerative cervical disc disease. J Craniovertebr Junction Spine. 2019;10(1):28-32. doi:10.4103/jcvjs.JCVJS_87_18
2.Youssef JA, Heiner AD, Montgomery JR, Tender GC, Lorio MP, Morreale JM, Phillips FM. Outcomes of posterior cervical fusion and decompression: a systematic review and meta-analysis. Spine J. 2019 Oct;19(10):1714-1729. doi: 10.1016/j.spinee.2019.04.019. Epub 2019 May 7. PMID: 31075361.
3.De la Garza-Ramos R, Xu R, Ramhmdani S, Kosztowski T, Bydon M, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016 Jun;24(6):885-91. doi: 10.3171/2015.10.SPINE15795. Epub 2016 Feb 19. Erratum in: J Neurosurg Spine. 2016 Jun;24(6):996. PMID: 26895527.
5. Faour M, Anderson JT, Haas AR, et al. Return to Work Rates After Single-level Cervical Fusion for Degenerative Disc Disease Compared With Fusion for Radiculopathy in a Workers' Compensation Setting. Spine. 2016;41(14):1160-6.DOI: 10.1097/BRS.0000000000001444.
6.De la Garza-Ramos R, Xu R, Ramhmdani S, Kosztowski T, Bydon M, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. Long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion. J Neurosurg Spine. 2016 Jun;24(6):885-91. doi: 10.3171/2015.10.SPINE15795. Epub 2016 Feb 19. Erratum in: J Neurosurg Spine. 2016 Jun;24(6):996. PMID: 26895527.
7.Tosun B, Ilbay K, Kim MS, Selek O. Management of Persistent Cerebrospinal Fluid Leakage Following Thoraco-lumbar Surgery. Asian Spine J. 2012;6(3):157-62. doi: 10.4184/asj.2012.6.3.157.
8. Fang Z, Tian R, Jia YT, Xu TT, Liu Y. Treatment of cerebrospinal fluid leak after spine surgery. Chin J Traumatol. 2017;20(2):81-3.doi: 10.1016/j.cjtee.2016.12.002.
9. Cheung JP, Luk KD. Complications of Anterior and Posterior Cervical Spine Surgery. Asian Spine J. 2016;10(2):385-400.doi: 10.4184/asj.2016.10.2.385
10. Bum-Suk Yu, Farid Yudoyono, Seong Yi, Yoon Ha, Keung Nyun Kim, Do Heum Yoon, Dong Ah Shin. Analysis of Surgical Results According to the Number of Fused Levels in Anterior Cervical Discectomy and Fusion: A Retrospective Study. Nerve. 2017;3 (2): 32-37.Publication Date (Web): 2017 August 01(Clinical Article). doi:https://doi.org/10.21129/nerve.2017.3.2.32
11. Kim JH, Park JY, Yi S, et al. Anterior Cervical Discectomy and Fusion Alters Whole-Spine Sagittal Alignment. Yonsei Med J. 2015;56(4):1060-1070. doi:10.3349/ymj.2015.56.4.1060.
12. Barnes M, Liew S. The incidence of infection after posterior cervical spine surgery: a 10 year review. Global Spine J. 2012;2(1):3-6.doi: 10.1055/s-0032-1307252
13. Wu XD, Wang XW, Yuan W, et al. The effect of multilevel anterior cervical fusion on neck motion. Eur Spine J. 2012;21(7):1368-1373. doi:10.1007/s00586-012-2157-7
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