Artificial disc replacement surgery recommended vs fusion

Hello Sb4ca, this was a choice that I had to make myself....fusion or disc replacement for cervical stenosis.

I chose fusion for several reasons. I was able to have a fusion with no hardware on a single level C5/C6 and stay in a hard collar until fusion began which was 3 months. That may sound impossible, but it went by quickly and I was making the choice because I wanted to avoid metals and foreign substances in my body. I had allergic reactions to my pierced earrings and had to give them up completely. My surgeon told me it heals best with just a bone spacer. Anything that is screwed into bone can become loose or pull out and that is an even greater risk if there is poor bone quality. With aging, osteopenia and osteoporosis can become an issue, and the fusion would be stronger than any hardware attached by screws that the body does not attach to on its own. Sometimes, the spine will grow bone around a disc replacement implant attempting to stabilize it which then requires re-operation and a fusion. The loss of spine motion with a fusion depends on what level it is. At C5/C6, it does not affect my ability to turn my head at all and most of that is done by C1 & C2 with lesser help from C3 & C4. I can no longer touch my chin to my chest in forward flexion, but it is pretty close. Bone also has some spring to it and hardware attached will make it stiffer which would transfer a bit more stress to adjacent discs. I asked my surgeon about adjacent disc disease in relation to fusions and number of levels fused. The risk goes up when more levels are fused which makes sense because it puts more pressure on the discs at the top and bottom end of the fusion because it is doing the job of more levels that no longer move. A fusion shrinks as the bone heals, and with a metal plate attached to the front of the spine, if the plate is too long, it can start to rub on the discs at the ends affecting them. Adjacent segment disease also happens with disc replacement implants, and also to patients who have had no spine surgery. I am 5 years post op from my fusion and there is no adjacent segment disease as confirmed by a recent MRI. I have been doing everything I can to maintain good posture and build core strength because that is what my surgeon advised to prevent future spine problems. I work with a physical therapist who also does myofascial release to get my body back in proper alignment and relieve the stresses caused by tight fascial tissue. That pressure can also affect the spine. Your surgeon can give you statistics on adjacent segment disease. It is true that the risk is a bit higher with fusions, but there are other factors that affect it also. I had one damaged level from an auto accident years ago, and the other discs were fairly normal. With aging, discs dry a bit and shrink and that can open up a crack that may be there from an earlier injury like a traffic accident. For me that took about 20 years for the disc to rupture.

There is a lot of information about myofascial release in this discussion with lots of links on the first pages.
https://connect.mayoclinic.org/discussion/myofascial-release-therapy-mfr-for-treating-compression-and-pain/

Here is a very important topic to add to your discussion. The symptoms you describe can also be attributed to thoracic outlet syndrome. That is not to say they are not spine related, but you can have both problems at the same time and your doctor may be missing the TOS if you have it. It is a common problem, but is often misunderstood by doctors because it is complex and is glossed over in med schools (according to my neurologist). I was told it was rare by a doctor who missed my diagnosis, and he had no explanation for why my circulation changed in my arms with a change of position in Doppler imaging studies. That is what TOS does. It causes pinching of nerves and blood vessels traveling to the arms. This bundle of nerves (and vessels) leaves the spinal cord and passes through scalene muscles and under the collar bone and under the Pec Minor muscles. These are all tight spaces that can get smaller with TOS. Whiplashes can cause spine injures and TOS, so the injury that caused a spine problem may have caused TOS as well, and add to that stressful jobs, poor slouching posture, and some people who have less space under the collar bone because of their physical build. As you may have guessed, I had both TOS and a ruptured C5/C6 disc with compression of my spinal cord at the same time. My TOS was missed entirely by the hand surgeon who a few years earlier operated on my carpal tunnel (another condition that causes similar overlapping symptoms) and he didn't know why my hands were turning bluish and purple and getting cold to the touch. It was TOS cutting off the blood supply and causing weakness and tingling in my arms. I also had muscle atrophy on the back of my arms and shoulders caused by spinal cord compression that affected the Deltoids and Triceps. I had been working with a physical therapist for TOS at the time the disc ruptured and I stopped progressing. The ruptured disc caused bone spurs to grow next to it and it started pressing into my spinal cord.

This is a good technical article about TOS.
https://mskneurology.com/how-truly-treat-thoracic-outlet-syndrome/

My comments will continue in the next post. (see below)

It is the job of doctors such as a neurologist to figure out the source or sources of the pain, so the surgeon addresses the correct problem. Spinal cord compression can cause pain anywhere in the body which can seem pretty random. That was confusing to several spine surgeons who evaluated me, and now there is more medical literature available that describes this issue which is called "funicular pain."
I did not have any problems at the nerve roots inside the foramen, so all of my pain was caused by the cord compression or the TOS. Compression of nerve roots is very specific as to which nerves will cause pain and it follows something called a Dermatome map. That is a map of the body surface divided into sections showing which nerves service those areas.

Dermatomes
https://www.physio-pedia.com/Dermatomes

Here are some considerations. Get some more opinions from different surgeons at facilities that have good reputations for their outcomes. your insurance company can help because they rate the success of surgeons and their procedures. Get an evaluation for thoracic outlet syndrome because your symptoms suggest it. Not all places understand TOS, so look for a teaching medical center at a major university that lists TOS as a condition they treat. You will find TOS specialists there who are often thoracic surgeons. The best course of treatment for TOS is often physical therapy with myofascial release (according to my thoracic surgeon.) There is surgery for it, but it can make a patient worse because all surgery creates scar tissue that gets tight and it can just add to the problem. I came to Mayo Clinic for evaluation because I had been diagnosed with both TOS and cervical stenosis in the central canal.

I found a study that concludes: https://pubmed.ncbi.nlm.nih.gov/28816821/ ASD is adjacent segment disease, ACDF is a fusion

"Surgery for ASD was performed after a mean period of 32 months from the primary ACDF. ASD occurred after single level ACDF in 54% of cases, most commonly after C5/6 fusion (28%). Risk factors for ASD were found to be preexisting radiological signs of degeneration at the primary surgery (74%) and bad sagittal profile after the primary ACDF (90%). "

" ASD occurred predominantly in the middle cervical region (C4-6); especially in patients with preexisting evidence of radiological degeneration in the adjacent segment at the time of primary cervical fusion, notably when this surgery failed to restore or maintain the cervical lordosis. "

The bad sagittal profile is talking about poor posture. The neck should have a normal curve of the spine called lordoisis. I know that I have a good lordotic curve now that my spine has been corrected, and I have good core strength because of the chores I do in caring for horses and riding my horse. Riding a horse at a walk works all of my back muscles and I sit up straight with good posture. That just makes my spine stronger because it is properly aligned while working. I make sure that if I am lifting hay bales or gates to get them to open or closed, I am doing this with good straight posture. This has helped me progress much better that just physical therapy alone and reduces my symptoms even through I have and am still treating TOS with physical therapy and myofascial release. MFR also helped make my spine surgery easier by loosening up tissue and relieving tight scar tissue afterward.

This study discusses a hybrid strategy using both ADR (disk replacement) and ACDF (fusion) together when 2 levels are involved and shows different combinations.

I know being a spine patient can be shocking and stressful, and you just want a solution to the problem, but make sure you chose the very best surgeon that you can and the procedure that you want. there may be different procedures with different risks, and you need to understand them all somewhat to make an informed choice. If the surgeon does not fully understand the issues, you will need another opinion. If you can do that at a multidisciplinary medical center where different specialties work together (like they do at Mayo) , that would be an advantage.

Do you have other thoughts or concerns now about disk replacement vs fusion? What questions can you ask your specialist to find answers?

I can see what looks like complete pinching off of cord at 3/4 & 5/6 but of course that’s not the case but does have severe compression My entire cervical spine has horrible degeneration and that’s the issue I brought up with surgeon My 4/5 has issues too and I wouldn’t want that used as an anchor That’s when he brought up artificial disc replacement and I’m more confident with that approach Funny you brought up TOS I’ve previously had brachial neuritis but that really affected ability to lift arm on affected side

@sb4ca It was that confident comment by your doctor that it was your neck that made me think that they were so sure and confident about it that they were not looking for other issues that may also be involved. Since this is all new from your description of the MRIs, something like TOS would be very easy to miss and then you could go through surgery and a long recovery and may still have issues with the same symptoms. I had to get 6 spine surgical opinions before one of them (at Mayo) got it right. All of them could see that my spinal cord was compressed, but only one understood why that was giving me what seemed like random pain and muscle contractions all over my body. The others refused surgery because they didn't understand the connection of the symptoms with imaging, and didn't want a patient who might have some other big problem with a potential poor outcome affecting their success rate. One suggested I could have MS, and that was completely wrong and he didn't want to make my problems worse, so he bailed. The doctors who recognized that I had TOS were neurologists and thoracic surgeons and my spine neurosurgeon at Mayo who was collaborating with the thoracic surgeon to figure out what was causing the major issues and they agreed it was the cervical stenosis, and they they also authorized PT to treat the TOS and the recovery from spine surgery. My TOS was missed by 2 orthopedic hand surgeons.

If you do have TOS, spine surgery will probably affect it when the scar tissue tightens. That was true for me with a spine surgery incision pretty close to the area involved with TOS. PT and myofacial release helps a lot.

Are you planning to get other surgical opinions before you decide on your treatment?

That was a good article and I sent it to my nephew whose many many doctors have now said they believe he has TOS. He's been dealing with neurological issues for months now and they've ruled out many other conditions, like spine compression. Your symptoms that you described sound very similar to his and next step is meeting a neurologist to rule out other causes. If that's a clean bill of health, he goes back to the vascular surgeon for treatment of TOS. Would you mind if I gave him your call name here so he could post and find you, or how does that work? In terms of myself, its mainly been my right side mostly affected, with numbness and nerve pain traveling across shoulder and back of neck and the collarbone along with unusual symptoms on left. I didn't mention this before because its not specific to spine surgery, but the second opinion doc and his PA found hard lymph nodes on my left side when I brought up the epidural hadn't helped that area. They ordered a stat CT of my chest and I'll get the results from 1st doctor after hours tomorrow. So in the end this could be two different conditions, but praying no nodes found in thoracic area.

@sb4ca Thank you for your update. You can send the link to this discussion to your nephew. Here are a few other discussions that also discuss thoracic outlet syndrome (TOS). Your nephew can read these, but it he wants to post, he needs to join Connect. I will see his posts since I watch these and spine posts to help out where I can. Often TOS is a diagnosis of elimination. There is surgery for TOS which can be a bit extreme like taking out the first rib or some of the scalene muscles on the side of the neck. Hopefully the doctor will want to try long term physical therapy, and hopefully they will be familiar with myofascial release because it helps TOS a lot without causing further scar tissue from surgery. To call my attention in a discussion, if he posts @jenniferhunter, it will send me a separate e mail about the post. I'm happy to help.

There are lymph nodes all over the body which is normal, and the question is why are they hard? I'm wondering if they are swollen and blocked with fluid. There are physical therapists and massage therapists that do lymphatic drainage massage which is very similar to myofascial release. The doctors may have other concerns as lymph nodes can become involved if a person has cancer and it spreads through the lymphatic system and gets trapped in a lymph node. I'm not saying that to scare you, but your doctors may be thinking something along those lines. My husband had melanoma on his hand, and they mapped the lymph nodes in his arm pit with blue dye they injected in his hand right before they did surgery to remove the cancer from his hand so they knew which were the closest ones. They biopsied those during surgery, and luckily they were clear because the cancer had not spread, otherwise, treatment and outcomes could be very different because melanoma is very difficult to treat if it has spread. The question needs to be answered for you. Sometimes diagnosing issues is like a big jig saw puzzle to be figured out. If they do not find a problem, physical therapy may be able to help with MFR to get tissue and body fluids moving again.

If you do also have TOS, hopefully your orthopedic surgeon will collaborate with a TOS specialist in your care. TOS just takes a long time to try to fix, maybe years, and you need to change habits and posture that affects it. Stress is also a big factor, and is also for me. It will make my body brace and tighten up, yanking up the first rib and affecting my ability to breathe normally. Some recovery is physical and some is emotional to get past the things that are triggers for stress and learn coping methods.

With a complex multilevel spine problem, you may find differing opinions on ways to fix this from different surgeons. Are you also considering other spine specialist opinions or neurosurgery opinions or specialists at another facility?