combined anterior and posterior cervical spine surgery

@sksdl Hello and welcome to Connect. I am a Mayo spine surgery patient and had an ACDF 5 years ago for one level C5/C6. It took about 3 months to heal and for the fusion to begin, and after that I went through physical therapy for several months. I was in a neck brace for 3 months because by doing that, I could avoid having hardware placed on my spine, and just had a donor bone spacer. I did have spinal cord compression from a disc osteophyte complex that was pressing into my spinal cord. The frontal approach ACDF was not that bad. I found I could tolerate the after surgery pain without drugs, and since the pain meds nauseated me, that was an easy choice. I was tired a lot and slept a lot which is normal for healing from a big surgery. The posterior approach to cervical surgery hurts more because of going through the muscles that you are using to hold your head upright. The interesting thing is that as soon as the spinal cord and any nerves were decompressed, I felt better immediately and all the related pain was gone. What was left is the pain of healing the incision.

I can tell you that in my experience, the pain of surgery for a fractured ankle was much greater and for a longer period of time than anterior cervical spine surgery. I broke my ankle last year and had a few surgeries, and the last a month ago was to remove the hardware that was bothering me. My body reacts to metals, and that is why I chose spine surgery without hardware. That isn't always a choice, but it is worth asking about hardware and the problems that can come from it.

I would expect posterior surgery to cause muscle pain when you move your neck, that is when you are allowed to move your neck again. It is a long recovery, and you will have restrictions on lifting with your arms. Mine started at a ten pound limit. What does help when you are in the rehab stage is physical therapy with a PT who also does myofascial release. MFR can help loosen the scar tissue that gets tight and it helped me have a great recovery in doing this before and after surgery. C2 to T2 is going to make a long tight scar. Here is our MFR discussion with lots of links to information in the first pages. There is also a provider search at http://mfrtherapists.com/
https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/
Does your surgeon have any patients who would be willing to talk to you who have had this combined procedure? I was also wondering how they will decompress the posterior longitudinal ligament. Does this involve cutting the vertebrae to shift it to allow more room inside the canal, and does this use a hardware connection to hold it in a new position? With a big involved surgery, it is a good idea to get several opinions as there may be different ways to solve the problem with different procedures. You need to choose what is best for you if the opinions are different. Your surgeon should explain the benefits and risks and how that relates to you personally.

How did your surgeon describe the procedure?

Thank you for the information, it is very kind and very much much appreciated. I will read up on the MFR discussion.

My surgeon informed me that yes, they will cut the vertebrae and stabilize with hardware of the OPLL condition. I have had 4 other surgeries for other unrelated purposes and different broken bones on 3 occasions early in life. I have had a section of colon removed for diverticulitis, a knee, a hernia, and lastly a gall bladder removal\hernia repair combo surgery. But none have involved hardware. I have heard from friends and relatives that the fusion around metal can cause quite a bit of pain.

I plan to ask my surgeon if he has other previous combined anterior\posterior surgery patients would be willing to share experiences. That is a great suggestion. The last appt to discuss the surgery was a bit overwhelming and that was one question I just didn’t think to ask. I think I assumed I could find more patient experience stories for info on forums such as this or on youtube. But that has not proved to be so true. At least for the combined approach for a condition such as this.

One concern I have is around the anterior approach you had performed. I read that you can have trouble swallowing and that there is swelling in your throat and surrounding areas. Did you find that distressful? If so, how long did it last? And is it worse from a swelling perspective if hardware is involved.

In a previous surgery, I was under for approx 4 hours, my only lengthy time under anesthesia. When I came out of anesthesia I was extremely nauseous. My only experience like this. They were concerned I would get sick and with abdominal surgery that could be very bad. They quickly wheeled me in a room, turned out the lights, put wet rags over my head and shot anti-nausea medication into my IV. It passed a few minutes later. I guess I have this fear of this reoccurring or being worse with a 7 hour surgery. In addition, the concept of having difficulty swallowing or breathing coming out...in tandem with nausea is distressing.

The success of the surgery is obviously paramount with no issues that result in any kind of paralysis, serious infection or side effects, hardware issue, or lasting chronic pain. And of course, pain of recovery is obviously a concern. But of the things that seems to be the most top of mind...for me to understand...is those first minutes\hours after wake up.

@sksdl I also get nauseated from anesthesia, but there is a patch that the anesthesiologist can put behind your ear to stop the nausea before the surgery and it worked great for me, absolutely no nausea after surgery and it can be left in place a few days. You have to not touch it and then rub your eyes because it can damage your eyes. Perhaps that will ease your fears about waking up after surgery.

As for the sore throat with ACDF, yes that happens and I had throat pain kind of bad for 2 weeks, and then better but still painful for another. It also feels like something is stuck in your throat, and one side is worse. That is because they have to retract the trachea to get behind it to the spine. Your neck muscles can also be tight, but you can stretch that prior to surgery. My surgeon told me where his incision would be (left side) and he showed me how to put my hand on my neck and pull down. That is how myofascial release works; you make a shearing force (gentle not painful) and hold it waiting for the tissue to move and release (could be 5 to 15 minutes) and you can feel that happen. Doing this will make it easier for the surgeon during surgery and you can see a physical therapist to stretch the back of your neck and shoulders prior to surgery. There is also a risk of vocal cord paralysis from the anterior surgery. If that happens and does not come back, there is a procedure to place an implant to get the vocal cords to meet again and restore the voice. Mayo does this. I was a bit hoarse for about 2 days. If you have a vocal cord issue you would talk in a whisper.
https://www.mayoclinic.org/diseases-conditions/vocal-cord-paralysis/diagnosis-treatment/drc-20378878
Some patients always feel like there is something in their throat. The left side of my throat feels a bit different to me even 5 years later, and I am careful swallowing since this makes it easier to swallow wrong. I really don't notice it much. Right after surgery, you have to think about how to swallow correctly, don't let yourself be distracted or you can make a mistake. As for metal hardware, for me titanium plates and screws on my ankle caused pain, a low dull throbbing pain and feeling like I was getting kicked in the shins all the time and I got chronic hives, and excess phlegm in my lungs all the time. I have allergic asthma, so that was an issue for me and could cause a lung infection very easily. I had my hardware removed a month ago and that pain is now gone, I'm breathing a lot better and I don't have the throbbing pain. I still have healing pain, but it is not bad. My ankle surgeon told me about 20% of patients ask for hardware removal.

ACDF can be done without hardware (uses only a bone spacer) if your surgeon allows it and you would need to stay in a neck brace until fused. I did that and it was worth it. I would ask if hardware can be removed at a later date if it causes a problem. With spine surgery, that isn't an easy solution, but you should understand what you are getting into. Patients do have revision spine surgeries and spine hardware can be removed then such as the plates on the front of the spine. I would ask if you will be able to bend your spine after this surgery and how much motion you will loose. Fusing C5/C6 and C6/C7 does not affect head turning much at all. Most of that is done by C1 & C2 with some help from C3 and C4. My head turning is normal with a C5/C6 fusion, but I cannot touch my chin to my chest. It is close however.

When you wake up from surgery, they will be giving you ice water and the nurses need to know if you can swallow, and then that you are able to empty your bladder. Since they are talking about several days in the hospital, it sounds like you will need a lot of help in the first days. I don't remember a lot of swelling in my throat, but I can imagine you may have swelling on the back of your neck with an incision that large, and I would expect that to cause headaches from muscle tightness to the back of the head. You may want a neck wrap that chills for that, but that is a question for your surgical team as to what you can do post op. My incision was dry and did not need a drain tube; many patients do have a drain tube. They used dissolving sutures and steri-strips. I had a hard foam collar to use while showering. I was not allowed to bend or twist, so it's kind of like walking around like Humpty Dumpty. I put elastic laces in my shoes so I could just slip them on since I could not bend over to tie my shoes.

I would also ask what the hardware is for the longitudinal ligament part and the ACDF part. There are metal or PEEK (plastic) cages for the fusion that usually have a place inside where they can seed bone growth with bone spurs that they remove. My surgeon told me it heals best with natural bone instead of foreign materials. You can look the hardware up on the manufacturer's website. Will your hardware be individual pieces for each vertebrae and not rods connecting everything and preventing movement and bending?

As a precaution, my surgeon prescribed Muipiroicin which is an antibiotic ointment to put in my nose for several days before surgery. That was to prevent a staph infection, since staff can live in the sinuses. You might also be asked to shower with Hibicleans to kill germs before surgery.

There is a lot to think about. What other questions would you ask your surgeon? Are you having symptoms now from spinal cord compression?

@jennifer
****The left side of my throat feels a bit different to me even 5 years later, and I am careful swallowing since this makes it easier to swallow wrong. I really don't notice it much. Right after surgery, you have to think about how to swallow correctly, don't let yourself be distracted or you can make a mistake. ****

Can you explain this a little more, about "swallowing wrong".

@birdman518 You can choke a bit like when you swallow water and it goes down the wrong way and you have to cough it out. That is your body saying no because a drop or too was headed for the lungs causing a gag reflex. After ACDF surgery It's like you don't have complete perception of what is in your throat that you are trying to swallow and it hurts. It kind of feels like you are trying to swallow rocks. Don't try to swallow a big gulp at once. Drink slowly and swallow a little bit at a time. Make sure to keep your head level or looking down if that is permitted. Never look up while swallowing or tip your head backward because that opens the airway and you can get it in your lungs. It would be easy to do that right after ACDF surgery, so swallow carefully and slowly and do not try to talk while eating or drinking. There is also stuff to thicken liquids called Thickit. You can order that online if you are worried, but I didn't feel like I needed that. I don't think about this much anymore and I don't talk while I'm eating or drinking because the distraction can cause a mistake (and it's bad manners too.)

I have had ACDF at C4-5, C5-6, and posterior decompression with fusion C2-T2 11 months ago. I’m new to this blog. Just wanting to know if it’s normal to still have tightness in my lower neck/upper back and will that ever go away?

@rico175 Hello and welcome to Connect. I am a spine surgery patient too with a C5-C6 fusion. All surgery creates scar tissue and scar tissue in the fascia which is a cobweb like tissue that encases everything and interweaves through the muscles. It tightens up which restricts movement, traps waste products in the tissue, and can cause pain and body misalignment. On Connect, we are not medical professionals, and what we can do is share our experiences. I have worked on the tightness in my neck before and after spine surgery with my physical therapist who does myofascial release and it helps a lot. I also have thoracic outlet syndrome that makes my neck and shoulders tight and I need to do MFR and stretching on a regular basis to keep my neck moving properly and avoid being locked by muscle spasms and it has helped me a lot, and to keep the incision area on my neck from being tight. There is an emotional component to this as well because stress will just tighten everything more.

You may want to see a physical therapist. At 11 months post op, you may be able to do this, but do ask your surgeon what is best for you. I had to wait until my fusion had begun and couldn't do therapy and MFR until about 5 months postop. I have no spine hardware and was just in a neck brace until it fused. I have normal movement with only one fused level, and surely the number of levels fused will affect how much movement is lost because of spine surgery. I think MFR will help, and for a more definitive answer you can ask a MFR provider. There is a provider search at http://mfrtherapists.com/

Here is our discussion on MFR. Look at the first pages for lots of links to information and videos.
https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/
Do you think you may try myofascial release?

Thanks. I will definitely look into MFR. Given my extensive fusion from C2-T2 I realize that I am going to have limited movement but I thought that the muscles would be healed by now. Every time I pick up something over 25 pounds especially even less weight over my head I pay for it.

I had cervical discotomy and fusion on c4/c5 and c5/c6 in 2019. I have not had any pain due to the hardware at all. My neck does still bother me at times but I was told by my surgeon we can hope for 70% success rate as I had these problems for years. I am above 70%.

Your ACDF and posterior decompression with fusion C2-T2 sounds very similar to what the surgery that I am having a couple weeks from now. Only difference is I am C5-C6, C6-C7 on the ACDF. Can you give me any insight into your experience after surgery and your recovery? I am curious how long before you were able to get off meds....narcotics, never pain meds, muscle relaxers, etc...? how long before you started physical therapy? how long before you were able to return to somewhat normal activity?