A Tidelands Health spine surgeon has performed the region’s first cervical disc replacement. The innovative procedure is designed to relieve nerve pain caused by herniated cervical discs and cervical arthritis that affects a significant number of patients.
The procedure, which takes about an hour, involves removing a patient’s cervical disc, at one or two levels, and replacing it with a titanium disc about the size and shape of a dime. The titanium disc is expected to last a lifetime.
Listen in as Dr. Ellison explains how this surgery is less invasive than traditional fusion surgery and may allow patients to resume their normal routines more quickly. The surgery, which can be performed on an outpatient basis, has been shown to reduce the rate of subsequent cervical spine surgeries by decreasing degenerative changes in the discs above and below the disc replacement.
Cervical Disc Replacement Surgery
From the Show: Tidelands Health - Better Health Radio
Summary:
Air Date: 7/13/16
Duration: 10 Minutes
Transcription:
Bill Klaproth (Host): Neck pain is less common than lower back pain but still, many experience neck pain which can be debilitating and quite serious, sometimes requiring surgery. Here to tell us about cervical disc replacement surgery is Dr. T Scott Ellison, a physician at Tidelands Health with a specialty in spinal surgery. Dr. Ellison, thank you so much for being on with us. Most people get the occasional stiff neck but what are the symptoms that signal something serious is going on?
Dr. T. Scott Ellison (Guest): Well, it's very common, people in the middle age- below and older middle age--to have neck problems and, typically, neck pain is due to muscle strain and improves spontaneously within a few days or a few weeks with conservative care. However, some people have bone spurs in their neck, what we call “spondylosis”, or what the lay public would term arthritis, or they can have a disc herniation in their neck and the result of that is agonizing and persistent headache, usually in the back of the neck and back of the head. Many times, these individuals will have radiating pain that goes from their shoulder blade all the way down one or both arms to the hand and fingertip areas with pain and/or numbness and tingling.
Bill: So, you mentioned conservative care--taking aspirin, standing under a hot shower, potentially, or is it ice pack? I get that confused. If you have a muscle spasm, is it ice pack or is it heat?
Dr. Ellison: Typically for an acute onset of a problem, we typically use ice or cold packs, not necessarily ice, but cold is a very, very good enemy, so to speak, of pain. It's a great analgesic. It's one of the best that we have, actually. However, some people feel better with heat and massage and, quite frankly, it comes down to someone's individual preference. With an acute injury such as an ankle sprain we typically don't start off with cold or ice or a cold pack but for a neck injury, it's not unusual that a physical therapist might give them the green light to try heat or cold and many people prefer one or the other. There’s no preponderance. There's no right answer. I just tell people to try what feels better and, typically, people fall right in the middle: half the people tend to like cool, half the people tend to like heat.
Bill: That's good to know. I guess I always get confused what is proper but I guess it comes down to an individual and what feels right to them, and I guess, eventually, what works. So, that's conservative care for those of us who wake up with the occasional stiff neck, like you said. So, headache, radiating arm pain, etc. Can you talk about that? So, the next step is, I've a stiff neck. What is the time to go to the doctor? Like a couple of weeks or really a persistent problem? Does that signal that it's time to go to the doctor and have it checked out?
Dr. Ellison: That depends on the patient's baseline of function and how it affects their activities of daily living. But, anywhere between 1, 2, 3, 4, 6 weeks with persistence of pain, many individuals will present to their primary care physician or they can present to me, either one, which is fine and which is appropriate to start investigating and trying to treat for this persistence of pain, usually over a few weeks or so.
Bill: And, how do you diagnose it? Is there an MRI or can you do that by just touch and feel and going through the range of motion? How do you typically diagnose more severe neck issues?
Dr. Ellison: Depending on the scenario, if there's been an acute traumatic event, such as a car wreck or a fall, of course, then we would typically immediately perform necessary imaging such as an MRI or CT scan to rule out any type of bony, nerve or ligament injury. However, in the absence of trauma, typically the first place we start is the history, actually, and let the patients talk to you and let you know what's wrong. Typically, by the history, you're fairly accurate in what you're going to find. We’ll do a physical exam and based on those findings and depending on the length of time of the discomfort, we may recommend someone going to physical therapy and trying an anti-inflammatory or depending on the severity of the dysfunction, we may recommend proceeding with an MRI scan. Many people in our society have had cardiac pacemakers placed or they have stents or they have some type of device in their system so they cannot undergo MRI testing. The next best test out there would be a CT scan.
Bill: Okay, then what do you look for? When is surgery necessary, then?
Dr. Ellison: Typically, surgery is a consideration when the patient fails 6 weeks of conservative care and the pain is progressive and, most notably, if they tend to have a motor deficit, if they have a particular motor group or muscle group that is weak that correlates with the MRI findings. For instance, with a C5-6 disc herniation an individual may have normal motor function except for weakness in the wrist and the reflexes at that level may be depressed. When you have an individual with those findings and you have a history of the patient that matches with the physical exam and the imaging studies, typically after having failed conservative treatment for about 6 weeks, it's reasonable to consider surgical intervention at that time, depending on the severity of dysfunction as far as it relates to the patient's activity.
Bill: So, if that is the next step, then, is cervical disc replacement surgery the traditional way to treat the neck issue?
Dr. Ellison: No, it is not. Cervical disc replacement is a newer trend. The traditional tried and true treatment for cervical disc pathology, whether it's a bone spur or a disc herniation, with appropriate indications for surgery, for years, has been called a “cervical disc discectomy and fusion”. We use the term ACDF, or anterior cervical discectomy and fusion. It is a very good operation. It is usually performed through the front of the neck because that way it's less painful, and the pathology can be approached from the front of the neck instead of having to go through the back of the neck, which has a history of causing agonizing neck pain after surgery. So, for many, many years the standard of care for this type of pathology was a one or two level, sometimes more, anterior cervical discectomy and fusion performed as an outpatient. Cervical disc replacements came about and were thought about for years and then the trials were performed in the ‘90s and 2000s, because one of the downfalls of the anterior cervical discectomy and fusion, the ACDF, is the fact that it causes a fused segment in the spine—in the neck--and it's a short segment. What happens is that you lose the motion at the affected disc and therefore that motion, the energy, is transferred to the disc above and below the fusion. And theoretically, at about a 25% rate over 10 years, there's a chance that the disc above and below can wear out, what we term as an “adjacent segment disease”. Again, there's a 25% chance that at 10 years that those adjacent segments might be considered degenerative in nature to the point where they could be symptomatic as well and be considered for more surgery.
Bill: Okay.
Dr. Ellison: Therefore, the cervical disc replacement was conceived and the purpose of that is, that instead of fusing that area in the neck - the surgery is essentially the same - the pathology is removed through the front of the neck, so we take out the bone spur and/or disc herniation that are causing the primary problem as best as we know, and then instead of placing a bone graft in a plate at that level, we put in a disc replacement device, similar to a knee joint replacement or hip joint replacement. It's usually a little steel, metal device with an intervening polyethylene structure which helps preserve motion and, theoretically—theoretically--this will decrease the chance of adjacent segment changes over multiple years, which may decrease the chance of having to have more surgery.
Bill: So, hopefully it's a…Basically, it's a longer fix, then?
Dr. Ellison: Theoretically. We are still in the long-term trials to consider this. The studies have shown very promising outcomes. There's a trend towards decreased incidence of postoperative complications with the disc replacement. Actually, there's a trend towards expedited recovery times with return to work a little bit quicker than with the neck fusion surgery. But, let me emphasize that the gold standard of this for years has been the ACDF fusion surgery. When the disc replacement was conceived, the clinical trials had to live up to the success rate of the fusion. That's how successful the ACDF procedure is and it's a very good procedure for the right reasons. The disc replacement has the theoreticals and we're still in the trials but it's been an exciting new opportunity for us to try and minimize the chance of having to have more surgery in the future.
Bill: Right. So, at this time, signs are very promising for cervical disc replacement surgery.
Dr. Ellison: That's correct.
Bill: So, what else do we need to know about it? If someone is there and is trying to learn more about cervical disc replacement surgery, what else do they need to know about it that would help them make a decision or understand what it is?
Dr. Ellison: Typically, the disc replacement surgery would be considered in a younger patient with a disc herniation or bone spur versus an elderly patient. The reason I say that is because elderly patients typically have more than one level of degenerative change that's probably related to their discomfort. So, when you have a 32-year-old with a disc herniation in their neck, or a 50-year-old, and you have that individual with a one-level problem, they're a great candidate for this. Another consideration is the fact that a significant proportion of the population smokes which is a definite risk factor for a less than optimal outcome for cervical fusion surgery. The good thing about the disc replacement , while we don't negate smoking at all, is the fact that there is no fusion necessary, so that is one thing to consider when you're wanting to consider an ACDF surgery versus the disc replacement. The disc replacement is approved for one to two level replacements but not more than that. So, typically what we're doing now is trying to place this in a one-level pathology problem. So, your typical 68 to 72-year-old who frequently comes in with a headache - like I talked earlier, a headache at the back of their neck and the pain goes into the shoulder blades, they have a difficult time turning their head in traffic to drive a car, the pain goes down their arm, they can't sleep at night, it's a debilitating problem, they don't sleep, they lose their appetite, they become frustrated and their quality of life is no good--those people tend to have more than one level pathology and the ACDF surgery is a great option for them. If they have one level pathology, then the disc replacement may be a consideration as well.
Bill: Well, that's very good information. Thanks so much for sharing. And, if the cervical disc replacement surgery does have a longer positive outcome, then I can see why in someone younger, that would be a better surgery for them at that point.
Dr. Ellison: That's correct. And, again, these studies do show a trend towards a shorter hospital stay, although I will say that one and two-level ACDF surgery and one or two-level disc replacement surgery, typically can be an outpatient procedure. So, both can be an outpatient procedure. There is a trend towards a faster return to activity, such as work or recreation with a cervical disc replacement, not statistically significant, although the trend is there towards a faster recovery. I think some of that may be due to the fact that it's a younger patient population. So, those are some of the things that we're looking at and I'll say that the studies show that at about 10 years, 20% of people with a fusion show adjacent segment degenerative changes or where the disc starts to wear out quicker than it should. So, the rate of that happening with the fusion surgery is about 3% per year. So, if you're 50 years old and you add up the statistics, the chances of having another level wear out that calls for a fusion is there. It's an unavoidable circumstance in some occasions, but we do have the theoretical advantage of the disc replacement preserving motion and potentially letting us obviate the need for more surgery in the future. It's fairly tried and I know there are some anecdotal stories of professional rugby players down in Australia that have had disc replacement in their neck and they're actually playing rugby. It's a pretty violent sport but I will say, too, that there are professional football players in the United States that have had ACDF surgery and are actually playing professional football as well. Both procedures are usually very good options for individuals with clearly identified cervical pathology.
Bill: Well, this is good news for somebody that's got chronic neck problem and it's great to see that there are more options becoming available for them. So, this is just all good and positive moving forward for someone that is suffering from a debilitating neck problem. Dr. Ellison, thank you so much for your time today. Why should someone choose Tidelands Health for their spinal care needs?
Dr. Ellison: At Tidelands Health, we have a vibrant, transforming healthcare system. We are a community friendly. We have access for the community and I think we offer the highest quality of care in our spine program, our orthopaedic program. We have a great experience with people coming to our ER and we have health grades with statuses of 5 in multiple program. We are here to serve the population in our area and try to help our population be healthier, have efficient healthcare, a quality healthcare experience and I think that's what we have to offer here better than anyone around here at Tidelands Health.
Bill: That sounds great, Dr. Ellison. Thank you so much again. For more information about Tidelands Health physicians, services and facilities, visit tidelandshealth.org. That's tidelandshealth.org. This is Better Health Radio. I'm Bill Klaproth. Thanks for listening.
Bill Klaproth (Host): Neck pain is less common than lower back pain but still, many experience neck pain which can be debilitating and quite serious, sometimes requiring surgery. Here to tell us about cervical disc replacement surgery is Dr. T Scott Ellison, a physician at Tidelands Health with a specialty in spinal surgery. Dr. Ellison, thank you so much for being on with us. Most people get the occasional stiff neck but what are the symptoms that signal something serious is going on?
Dr. T. Scott Ellison (Guest): Well, it's very common, people in the middle age- below and older middle age--to have neck problems and, typically, neck pain is due to muscle strain and improves spontaneously within a few days or a few weeks with conservative care. However, some people have bone spurs in their neck, what we call “spondylosis”, or what the lay public would term arthritis, or they can have a disc herniation in their neck and the result of that is agonizing and persistent headache, usually in the back of the neck and back of the head. Many times, these individuals will have radiating pain that goes from their shoulder blade all the way down one or both arms to the hand and fingertip areas with pain and/or numbness and tingling.
Bill: So, you mentioned conservative care--taking aspirin, standing under a hot shower, potentially, or is it ice pack? I get that confused. If you have a muscle spasm, is it ice pack or is it heat?
Dr. Ellison: Typically for an acute onset of a problem, we typically use ice or cold packs, not necessarily ice, but cold is a very, very good enemy, so to speak, of pain. It's a great analgesic. It's one of the best that we have, actually. However, some people feel better with heat and massage and, quite frankly, it comes down to someone's individual preference. With an acute injury such as an ankle sprain we typically don't start off with cold or ice or a cold pack but for a neck injury, it's not unusual that a physical therapist might give them the green light to try heat or cold and many people prefer one or the other. There’s no preponderance. There's no right answer. I just tell people to try what feels better and, typically, people fall right in the middle: half the people tend to like cool, half the people tend to like heat.
Bill: That's good to know. I guess I always get confused what is proper but I guess it comes down to an individual and what feels right to them, and I guess, eventually, what works. So, that's conservative care for those of us who wake up with the occasional stiff neck, like you said. So, headache, radiating arm pain, etc. Can you talk about that? So, the next step is, I've a stiff neck. What is the time to go to the doctor? Like a couple of weeks or really a persistent problem? Does that signal that it's time to go to the doctor and have it checked out?
Dr. Ellison: That depends on the patient's baseline of function and how it affects their activities of daily living. But, anywhere between 1, 2, 3, 4, 6 weeks with persistence of pain, many individuals will present to their primary care physician or they can present to me, either one, which is fine and which is appropriate to start investigating and trying to treat for this persistence of pain, usually over a few weeks or so.
Bill: And, how do you diagnose it? Is there an MRI or can you do that by just touch and feel and going through the range of motion? How do you typically diagnose more severe neck issues?
Dr. Ellison: Depending on the scenario, if there's been an acute traumatic event, such as a car wreck or a fall, of course, then we would typically immediately perform necessary imaging such as an MRI or CT scan to rule out any type of bony, nerve or ligament injury. However, in the absence of trauma, typically the first place we start is the history, actually, and let the patients talk to you and let you know what's wrong. Typically, by the history, you're fairly accurate in what you're going to find. We’ll do a physical exam and based on those findings and depending on the length of time of the discomfort, we may recommend someone going to physical therapy and trying an anti-inflammatory or depending on the severity of the dysfunction, we may recommend proceeding with an MRI scan. Many people in our society have had cardiac pacemakers placed or they have stents or they have some type of device in their system so they cannot undergo MRI testing. The next best test out there would be a CT scan.
Bill: Okay, then what do you look for? When is surgery necessary, then?
Dr. Ellison: Typically, surgery is a consideration when the patient fails 6 weeks of conservative care and the pain is progressive and, most notably, if they tend to have a motor deficit, if they have a particular motor group or muscle group that is weak that correlates with the MRI findings. For instance, with a C5-6 disc herniation an individual may have normal motor function except for weakness in the wrist and the reflexes at that level may be depressed. When you have an individual with those findings and you have a history of the patient that matches with the physical exam and the imaging studies, typically after having failed conservative treatment for about 6 weeks, it's reasonable to consider surgical intervention at that time, depending on the severity of dysfunction as far as it relates to the patient's activity.
Bill: So, if that is the next step, then, is cervical disc replacement surgery the traditional way to treat the neck issue?
Dr. Ellison: No, it is not. Cervical disc replacement is a newer trend. The traditional tried and true treatment for cervical disc pathology, whether it's a bone spur or a disc herniation, with appropriate indications for surgery, for years, has been called a “cervical disc discectomy and fusion”. We use the term ACDF, or anterior cervical discectomy and fusion. It is a very good operation. It is usually performed through the front of the neck because that way it's less painful, and the pathology can be approached from the front of the neck instead of having to go through the back of the neck, which has a history of causing agonizing neck pain after surgery. So, for many, many years the standard of care for this type of pathology was a one or two level, sometimes more, anterior cervical discectomy and fusion performed as an outpatient. Cervical disc replacements came about and were thought about for years and then the trials were performed in the ‘90s and 2000s, because one of the downfalls of the anterior cervical discectomy and fusion, the ACDF, is the fact that it causes a fused segment in the spine—in the neck--and it's a short segment. What happens is that you lose the motion at the affected disc and therefore that motion, the energy, is transferred to the disc above and below the fusion. And theoretically, at about a 25% rate over 10 years, there's a chance that the disc above and below can wear out, what we term as an “adjacent segment disease”. Again, there's a 25% chance that at 10 years that those adjacent segments might be considered degenerative in nature to the point where they could be symptomatic as well and be considered for more surgery.
Bill: Okay.
Dr. Ellison: Therefore, the cervical disc replacement was conceived and the purpose of that is, that instead of fusing that area in the neck - the surgery is essentially the same - the pathology is removed through the front of the neck, so we take out the bone spur and/or disc herniation that are causing the primary problem as best as we know, and then instead of placing a bone graft in a plate at that level, we put in a disc replacement device, similar to a knee joint replacement or hip joint replacement. It's usually a little steel, metal device with an intervening polyethylene structure which helps preserve motion and, theoretically—theoretically--this will decrease the chance of adjacent segment changes over multiple years, which may decrease the chance of having to have more surgery.
Bill: So, hopefully it's a…Basically, it's a longer fix, then?
Dr. Ellison: Theoretically. We are still in the long-term trials to consider this. The studies have shown very promising outcomes. There's a trend towards decreased incidence of postoperative complications with the disc replacement. Actually, there's a trend towards expedited recovery times with return to work a little bit quicker than with the neck fusion surgery. But, let me emphasize that the gold standard of this for years has been the ACDF fusion surgery. When the disc replacement was conceived, the clinical trials had to live up to the success rate of the fusion. That's how successful the ACDF procedure is and it's a very good procedure for the right reasons. The disc replacement has the theoreticals and we're still in the trials but it's been an exciting new opportunity for us to try and minimize the chance of having to have more surgery in the future.
Bill: Right. So, at this time, signs are very promising for cervical disc replacement surgery.
Dr. Ellison: That's correct.
Bill: So, what else do we need to know about it? If someone is there and is trying to learn more about cervical disc replacement surgery, what else do they need to know about it that would help them make a decision or understand what it is?
Dr. Ellison: Typically, the disc replacement surgery would be considered in a younger patient with a disc herniation or bone spur versus an elderly patient. The reason I say that is because elderly patients typically have more than one level of degenerative change that's probably related to their discomfort. So, when you have a 32-year-old with a disc herniation in their neck, or a 50-year-old, and you have that individual with a one-level problem, they're a great candidate for this. Another consideration is the fact that a significant proportion of the population smokes which is a definite risk factor for a less than optimal outcome for cervical fusion surgery. The good thing about the disc replacement , while we don't negate smoking at all, is the fact that there is no fusion necessary, so that is one thing to consider when you're wanting to consider an ACDF surgery versus the disc replacement. The disc replacement is approved for one to two level replacements but not more than that. So, typically what we're doing now is trying to place this in a one-level pathology problem. So, your typical 68 to 72-year-old who frequently comes in with a headache - like I talked earlier, a headache at the back of their neck and the pain goes into the shoulder blades, they have a difficult time turning their head in traffic to drive a car, the pain goes down their arm, they can't sleep at night, it's a debilitating problem, they don't sleep, they lose their appetite, they become frustrated and their quality of life is no good--those people tend to have more than one level pathology and the ACDF surgery is a great option for them. If they have one level pathology, then the disc replacement may be a consideration as well.
Bill: Well, that's very good information. Thanks so much for sharing. And, if the cervical disc replacement surgery does have a longer positive outcome, then I can see why in someone younger, that would be a better surgery for them at that point.
Dr. Ellison: That's correct. And, again, these studies do show a trend towards a shorter hospital stay, although I will say that one and two-level ACDF surgery and one or two-level disc replacement surgery, typically can be an outpatient procedure. So, both can be an outpatient procedure. There is a trend towards a faster return to activity, such as work or recreation with a cervical disc replacement, not statistically significant, although the trend is there towards a faster recovery. I think some of that may be due to the fact that it's a younger patient population. So, those are some of the things that we're looking at and I'll say that the studies show that at about 10 years, 20% of people with a fusion show adjacent segment degenerative changes or where the disc starts to wear out quicker than it should. So, the rate of that happening with the fusion surgery is about 3% per year. So, if you're 50 years old and you add up the statistics, the chances of having another level wear out that calls for a fusion is there. It's an unavoidable circumstance in some occasions, but we do have the theoretical advantage of the disc replacement preserving motion and potentially letting us obviate the need for more surgery in the future. It's fairly tried and I know there are some anecdotal stories of professional rugby players down in Australia that have had disc replacement in their neck and they're actually playing rugby. It's a pretty violent sport but I will say, too, that there are professional football players in the United States that have had ACDF surgery and are actually playing professional football as well. Both procedures are usually very good options for individuals with clearly identified cervical pathology.
Bill: Well, this is good news for somebody that's got chronic neck problem and it's great to see that there are more options becoming available for them. So, this is just all good and positive moving forward for someone that is suffering from a debilitating neck problem. Dr. Ellison, thank you so much for your time today. Why should someone choose Tidelands Health for their spinal care needs?
Dr. Ellison: At Tidelands Health, we have a vibrant, transforming healthcare system. We are a community friendly. We have access for the community and I think we offer the highest quality of care in our spine program, our orthopaedic program. We have a great experience with people coming to our ER and we have health grades with statuses of 5 in multiple program. We are here to serve the population in our area and try to help our population be healthier, have efficient healthcare, a quality healthcare experience and I think that's what we have to offer here better than anyone around here at Tidelands Health.
Bill: That sounds great, Dr. Ellison. Thank you so much again. For more information about Tidelands Health physicians, services and facilities, visit tidelandshealth.org. That's tidelandshealth.org. This is Better Health Radio. I'm Bill Klaproth. Thanks for listening.
