neurosurg

Your neck operation

The normal neck

The bones of the neck are called vertebrae and they are connected by strong sinews (ligaments) which pass up and down the spine joining the bones together. Each vertebra has joints that allow movement between the bones. Between the main blocks of the vertebrae is a soft cushion of material in texture like crab meat which acts as a shock absorber between them. The spinal cord which carries messages to and from the brain and the arms and legs passes down the back of the body of the vertebrae and is encircled by a bony ring made of projections of bone from the back of the body of the vertebra (see diagram 1). At the level of each vertebra a nerve is given off on each side that runs to the arm. Pressure on the nerve at this point may give the feeling that there is pain in the arm although the cause of the pain is actually in the neck.


The normal neck
A normal neck

Degenerative changes
Degenerative changes

Degenerative disease

This is a medical term for wear and tear of the bones and joints in the body and is often referred to as osteo-arthritis. This is very common in anyone over the age of forty but fortunately not everyone experiences symptoms. If you imagine how the end of a stick that has been hit repeatedly with a mallet splays out, then this will give you an idea of what happens to the joints in the spine with wear and tear. The bony projections that result are called ‘osteophytes’ (diagram 2). There is also a degeneration in the ligaments or sinews that hold the joint surfaces together and this leads to thickening. In addition the discs themselves become worn and may project backwards. The combination of these factors leads to a narrowing of the space where the nerve runs out of the spine and may result in pressure on the nerve itself. The pressure on the nerve leads to pain felt in the arm and shoulder and also numbness and weakness in the limb. Similar problems may occur in the long term, with injury to the joints, ligaments and discs.

The pressure that occurs on the nerves may also be exerted on the spinal cord leading to weakness and stiffness in the legs which may in itself be disabling.


After removing the disc
After removing the disc

After inserting the bone graft
After inserting the bone graft

Treatment

The following does not apply to patients with neck fractures or dislocations who may have very different surgery carried out and need different advise.

The majority of patients only experience temporary symptoms which often disappear spontaneously. Those patients in whom investigations (such as MRI scanning or Myelogram) have shown that there is compression of the spinal cord or nerves in the neck may require surgical treatment.

There are in essence two approaches, from the front or from behind.

Surgery from the front is usually through a small wound at the front of the neck on the right side (although the operation is done in the midline by pushing the gullet and wind pipe out of the way). First the disc material is removed and then the bony projections or osteophytes that project backwards from the edge of the vertebra are drilled away. After this, a bone graft is inserted into the space that is left and after three months this heals soundly joining the two bones together permanently thereby eliminating the possibility of further disc material causing pressure.

The bone graft may be taken from the patients own hip or we use a piece of bone taken from the breast-bone of a calf or a piece of coral. This is specially treated to remove everything but the calcium of the bone (or coral) and it acts only as a framework for your own bone cells to grow into. If using coral a metal plate is used to hold the bones still to allow fusion and this plate is left in situ permanently.

The second approach is from the back of the neck. The operation consists of removing bone from the back of the arch of the vertebra to make room for the spinal cord and nerves. Bone grafts are not usually inserted in this operation.

All surgery has both risks and benefits. The particular risk of this type of surgery to the neck is that the spinal cord might be damaged at the time of surgery or that a stroke might occur because the pressure on the spinal cord has been so severe. If this were to happen then there is a chance that the patient could lose the use of all four limbs and lose control of bowel and bladder. The odds of this happening is thousands to one against however it is important to realise that these are not minor operations and are not done for minor symptoms that the patient can easily live with.

On the benefits side, most of the arm pain tends to resolve. There is usually a return of strength to the limb and there is a fifty percent chance of return of sensation in the area of numbness. One cannot guarantee precisely that all numbness or weakness will disappear as a proportion of this may be due to actual damage rather than just pressure and the surgery is designed to relieve pressure but cannot reverse damage done to the nerves. In addition to this most patients are left with aches and pains in the neck due to the wear and tear that caused the symptoms in the first place and we cannot after all replace the whole neck!

Post-operative care

Following surgery there will be a degree of discomfort in the operation site. This tends to be worst on the first post-operative night, but most patients are able to sleep because of the anaesthetic and also because you will be given strong pain-killing injections which will effectively relieve the discomfort. The second night is also sore and the third night tends to be bearable. Surgery from the front usually leads to discomfort on swallowing but this tends usually to be minor and only present during the first three days.

On return from the operating theatre you will be wearing a soft surgical collar which you should retain for three weeks. This is really a precaution to ensure that you rest your neck and allow the wound to heal. It is very rare for the neck to be unstable after this type of routine neck surgery. It is quite safe to remove the collar to eat and to wash during the first three weeks however. After three weeks the collar should gradually be discarded during the day. After three months an x-ray will be taken of your neck to ensure there is good bony fusion and then you will be advised to do some gentle exercises for your neck.

The morning after the operation an x-ray is taken of your neck to ensure that the bone grafts are in place. After the doctor on the ward has checked these you will be allowed to get out of bed and if a wound drain has been put in at the time of surgery this will be removed. Such drains are left to remove any blood that may collect after the operation thus preventing bruising.

The wound itself should be kept dry and clean during the first week but after this may be treated like a wound or cut anywhere in the body.

You should also be seen and advised by the ward physiotherapist before discharge. If this does not happen please ask the nurse to arrange this – it is important!

Most patients are discharged from the ward within the first week, depending on progress. During the first few weeks you should rest and for the first three months, no heavy lifting or prolonged bending or stooping or heavy exercise is recommended.

After returning home you should not be in severe pain. If you are, you should ring your General Practitioner who will advise you or you can ring the ward for advice. If in doubt check it out!

Return to work

Most patients may feel able to return to a sedentary occupation between two and three months. Physically strenuous work should not be attempted until the post-operative x-ray reveals good bony healing at the operation site. It is not recommended that patients with degenerative disease of the neck should be involved in occupations that involve constant bending stooping or heavy lifting and this is especially true after the type of surgery described above.

A few tips

It is sensible when you return home to have someone there to look after you. You will not be fit to do your own shopping, cooking or housework for a few weeks after surgery. Either arrange for a friend or relative to stay with you or make arrangements to stay with someone for the first week or two after discharge from hospital

If the wound becomes more and more tender or red or swollen or you develop ‘flu-like symptoms during the first few weeks this can be a sign of wound infection. Wound infections are fortunately very rare after neck surgery but if you are in doubt check with the ward or your G.P. as antibiotics may be necessary. If your wound is definitely infected or your G.P. feels this is the case please let us know as well, as we would need to see you.

You should not drive a car for six weeks, sometimes longer after this kind of operation. Individual consultants may give differing advice about this so it is advisable to ask your consultant about this.

If you are in doubt about any of the above advice, ask your consultant, or the ward staff whilst in hospital or ask your G.P.