What Is a Discectomy with Fusion?

Anterior cervical discectomy and interbody fusion

Anterior cervical discectomy and interbody fusion

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Anterior cervical discectomy and interbody fusion

Alias: Anterior cervical discectomy and fusion; anterior cervical discectomy and fusion; anterior cervical discectomy and fusion; anterior cervical discectomy and interbody fusion.

Chinese name

Anterior cervical discectomy and interbody fusion

Alias

Anterior cervical discectomy and fusion

Anterior cervical discectomy and interbody fusion

Alias: Anterior cervical discectomy and fusion; Anterior cervical discectomy and fusion; Anterior cervical discectomy and fusion; Anterior cervical discectomy and interbody fusion

Orthopaedics / Spine Surgery / Cervical Spondylopathy

ICD code: 80.5101

Cervical spondylosis can be divided into anterior cervical approach, lateral anterior decompression and posterior laminectomy, hemilaminectomy and laminoplasty.

Anatomy of anterior cervical discectomy and interbody fusion.

Anterior cervical discectomy and interbody fusion is suitable for:

1. Single-segment cervical spondylotic myelopathy or cervical spondylotic myelopathy, which cannot be relieved by non-surgical treatment, and the symptoms and signs are gradually aggravated.

2. Cervical spondylotic myelopathy is aggravated in a short period of time and surgery should be performed as soon as possible.

3. Sudden cervical spondylosis or trauma-induced paralysis of the limbs.

4. Cervical intervertebral disc herniation is severe or progressive, and non-surgical treatment cannot relieve it.

1. Poor general condition, or complicated with important organ diseases, unable to withstand surgical trauma.

2. Complicated with other diseases such as ossification of the posterior longitudinal ligament of the cervical spine.

3. The diagnosis is not clear. Although there are symptoms similar to cervical spondylosis, but the imaging examination and neurological examination are questionable.

4. Elderly patients who have lost normal self-care ability and cannot cooperate with preoperative preparation and postoperative treatment are not suitable for surgery.

5. The long course of cervical spondylosis, combined with paralysis of the limbs, muscle atrophy, and joint stiffness, indicates that the spinal cord is severely damaged, and even if decompression, spinal cord function is difficult to recover.

1. Trachea and esophagus training

Especially for those who use superficial cervical nerve block anesthesia during operation, trachea and esophagus must be trained before operation. The anterior cervical approach is through the cervical visceral sheath and the vascular nerve sheath to reach the front of the vertebral body. Therefore, the splanchnic sheath must be pulled to the opposite side during the operation to reveal the front or side of the vertebral body. If the preoperative stretch is not satisfactory, the operation may be forced to be aborted due to the inability to retract the trachea. If reluctantly performed, it may damage the trachea or esophagus, and even cause laryngeal spasm and edema after surgery.

2. Bedriding and urination training

There will be several days of bed rest after surgery. In order to reduce the difficulty of urination and defecation after surgery and urinary tract infection caused by catheterization, urination and defecation exercises in bed must be performed before surgery.

Due to the need for intraoperative reduction and severe traction, general anesthesia with tracheal intubation is appropriate. If pure anterior cervical decompression is performed, cervical plexus anesthesia can also be used. The patient lies supine on the operating table. The shoulder pads are soft pillows, and the head and neck are naturally stretched backwards. A sandbag or a pack of sponge-like cork pillows is placed at the back of the neck. The back pillows are cushioned with soft headbands. Intraoperative rotation. Avoid excessive back tilt of the patient's head and neck during anesthesia to avoid aggravating spinal cord injury. If skull traction has been performed before surgery, do not remove the skull traction arch.

Incision

For patients undergoing intraoperative reduction, an oblique incision on the right side of the anterior neck is often used. This incision has a wide field of vision, a loose incision, and is conducive to intraoperative stretch. For those who simply undergo anterior decompression, an anterior cervical lateral right incision can be used. This incision has smaller scars and better postoperative appearance. The incision length is generally 3 to 5 cm.

2. Exposure of the vertebral body and anterior disc

Cut the skin and subcutaneous tissue, cut off the platysma, and make a blunt and sharp separation on the deep side of the platysma after hemostasis, 2 to 3 cm above and below, to expand the vertical exposure range. The sternocleidomastoid muscle is relatively loose between the medial margin of the sternocleidomastoid muscle and the cervical visceral sheath, which is an ideal surgical approach.

3. Positioning

Fresh cervical trauma with vertebral fracture or anterior longitudinal ligament injury can be located with visual observation. For patients with old fractures or simple disc injuries, sometimes it is difficult to distinguish under direct vision. The most reliable method is to remove the tip with an injection needle to retain a length of 1.5 cm, insert the disc, and take a lateral X-ray of the entire cervical spine. According to X-rays or C Perspective positioning of the arm machine.

4. Open the vertebral body and reduce

To perform an intraoperative reduction, an anterior cervical spine expander is required. Screw the spreader screws in the center of the upper and lower vertebral body of the dislocation segment, and then insert the spreader on the spreader screw to spread it up and down. For fresh cervical spine fractures and dislocations, those who have undergone posterior surgery for reduction, open the vertebral body will help to restore the height of the injured intervertebral space, reduce the compression of the spinal cord, and facilitate operation during discectomy. For those who haven't been reset, the vertebral body can generally be restored by anterior approach, and even for those with old fractures and dislocations, some can also be reset. For those who cannot be reset, anterior decompression can be performed simply.

5. Removal of the intervertebral disc

The anterior longitudinal ligament is cut in I-shape or Z-shape and peeled to both sides, exposing the outer layer of the fibrous ring of the intervertebral disc. Use a long-handle sharp knife to cut the fiber ring, with a depth of 2 to 4 mm. The nucleus pulposus is extended into the intervertebral space through a fibrous ring incision, from shallow to deep, and the nucleus pulposus is removed in stages from one side to the other. Apply force slowly and do not open the jaws too much. If the intervertebral space is narrow and the nucleus pulposus is difficult to extend, you can use the vertebral body expander to expand the intervertebral space appropriately, or instruct the staff to traction the occipital and jaw of the patient. To strictly grasp the depth of the nucleus pulposus forceps into the intervertebral space, the depth of the nucleus pulposus forceps into the intervertebral space is generally controlled to 20 ~ 22mm. If it is too shallow, it will not be able to grasp the prominent nucleus pulposus, and if it is too deep, it will easily damage the spinal cord. In order to prevent the nucleus pulposus forceps from reaching too deep and causing spinal cord injury, a holster can be placed on the head end of the nucleus pulposus forceps as a depth indicator. When approaching the posterior edge of the vertebral body, use a curette to scrape away the remaining disc tissue and cartilage plate. Using a neurostripping device, the posterior edge of the vertebral body and the epidural space were unobstructed, and there was no residual pressure. At this time, the decompression was complete.

6. Bone removal and bone grafting

Cut a small bone graft with a osteotome at the left condyle and trim the rule. Scrap the endplate cartilage above and below the intervertebral space until there is bleeding. With the cancellous bone surface of the bone graft facing up and down, hit the intervertebral space with a mallet. The end of the bone graft is 1 to 2 mm lower than the anterior edge of the vertebra. gap. Loosen the vertebral body spreader to insert the bone graft block tightly.

7.Fix

For those who have not undergone posterior reduction and fixation, anterior cervical plate fixation must be used. A short steel plate is used to fix the dislocated vertebral body, so that the anterior column of the cervical spine can obtain immediate stability. Otherwise, the dislocation destroys the stability of the posterior column, and the anterior decompression destroys the stability of the anterior column. The stability of the three columns of the cervical spine is damaged, and bone grafting is difficult to achieve bone healing. For those who have stabilized the posterior column, it is best to use anterior cervical plate when conditions permit.

8. suture incision

Rinse the wound repeatedly with iced saline, suture the anterior cervical fascia, place a half-tube drainage strip, and close the incision by suture layer by layer.

1. The anatomical level must be paid attention to during the exposure process. Accurate identification is the key to prevent damage to vascular nerves and internal organs of the neck. The carotid sheath is located on the outside of the exposed part of the incision. After distracting the trachea and esophagus, attention should be paid to the thyroid blood vessels, and the blood vessels should not be ligated as much as possible.

2. Accurate positioning is performed on the basis of full exposure. There are many positioning methods, but it is most reliable to take a lateral view of the cervical spine during the operation.

3. When the anterior vertebral body is opened and reduced, care should be taken to avoid excessive force to open it, and do not forcefully reduce it, so as not to damage the spinal cord and ligaments. For those who cannot be reset, only anterior decompression can be performed.

4. The discectomy should be carried out gradually, because the disc is already protruding, compressing the spinal cord, and rough movements are likely to aggravate spinal cord injury.

5. The transplanted bone mass should not be too small, and it must be hammered tightly during implantation, otherwise it will easily cause the bone graft mass to fall off and cause spinal cord compression.

6. Emphasize the role of vertebral spreader and anterior cervical plate.

1. After 24 to 48 hours, the drainage strip was removed.

2. If the dura mater is disturbed more during the operation, dexamethasone 20mg and furosemide 20mg should be applied after surgery, and the drug should be discontinued 5-7 days later. Appropriate application of antibiotics to prevent infection.

3. For the use of internal fixation, cervical collar protection for 4 to 6 weeks. Without internal fixation, the jaw-neck plaster was fixed externally for 3 months until the bone graft healed.

Spinal cord and nerve root injury

Spinal cord and nerve root injuries are serious complications, and severe cases can lead to paralysis and even death.

2. Vertebral artery injury

Vertebral artery injury is a serious complication, which can be fatal if the treatment is ineffective.

3. Injury to the esophagus and trachea

Esophageal and tracheal injuries are mostly caused by excessive stretching, which can also cause accidental injuries during deep operation. Such complications are rare, but they can cause mediastinal infections, and the mortality rate is quite high, so you must be alert enough.

4. Postoperative local hematoma formation

Local hematoma formation is a serious complication after surgery. It usually occurs within 12 hours after surgery. Severe cases can cause suffocation, which must be closely observed after surgery.

5. Injury of superior laryngeal nerve and recurrent laryngeal nerve

Ligation and cutting of the upper thyroid blood vessels on one side may cause damage to the ipsilateral superior laryngeal nerve. When the trachea and esophagus are distracted, the superior laryngeal nerve on the contralateral side may be pulled, and postoperative drinking cough will occur. Can recover. It may damage the recurrent laryngeal nerve when processing the subthyroid blood vessels. The injury of the recurrent laryngeal nerve on one side can cause hoarseness and belching. Most of them are temporary, and usually recover within 1 to 3 months after injury.

6. Cerebrospinal fluid leakage

Cerebrospinal fluid leakage caused by dura mater, promotes the occurrence of infection and is easy to spread to the central nervous system, hinders healing of the incision and even causes the incision to crack, which can also cause lower intracranial pressure and fluid loss. The key to preventing cerebrospinal fluid leakage is to apply microsurgical techniques during the operation to avoid unnecessary dura mater damage. If the dura mater is opened, continuous lumbar puncture and drainage of cerebrospinal fluid are performed for 3 to 4 days after operation. Treatment often heals on its own, and larger defects often require repair with fascia sheets or fibrin glue.

7. Bone graft loss

Bone graft loss is a serious complication. The repaired bone graft should be 2mm longer than the bone window. When inserted, the cervical vertebrae are opened to slightly expand the intervertebral space. After inserting the bone mass, move the cervical spine and observe whether the bone graft is loose. If it is loose, insert it again or repair it and then tighten it again.

8. Bone graft does not heal

Bone graft nonunion rarely occurs. As long as the endplate, bone graft, and effective internal fixation are properly handled during the operation and effective braking is performed after the operation, this complication can be minimized.

9. infection

Anterior cervical surgical incision infection rate is not high, but incision infection can spread to spinal canal and spinal cord and cause serious consequences, so we must pay attention to prevention. Strict repair of dura mater and suture incision to prevent cerebrospinal fluid leakage and incision dehiscence and eliminate residual cavity are the key to prevent postoperative infection.