Posterior Cervical Fusion

Overview and Indications

Posterior Cervical Fusion (PCF) is the general term used to describe the technique of surgically mending two (or more) cervical spine bones together along the sides of the bone using a posterior (back of the neck) incision. Bone graft is placed along the sides the spine bones, which over time, fuses (mends) together. PCF may be performed in conjunction with or without a posterior decompression (laminectomy) and/or instrumentation (use of metal screws/rods). Nowadays, metal screws and rods are almost always used, which adds immediate stability and increases the fusion rate (percentage of patients where the bone successfully mends together).

PCF is most commonly performed for patients with cervical fractures or instability, but is also performed for a variety of other spinal conditions, such as tumors, infections, and deformity. PCF may also be performed in conjunction with anterior cervical surgery, especially when multiple levels are involved.

Surgical Technique

The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes with the assistance of a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the prone (lying on the stomach) position, generally using a special operating table/bed with special padding and supports. The surgical region (neck area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.

A 3-6 inch (depending on the number of levels) posterior (back of the neck) longitudinal incision is made in the midline, directly over the involved spinal level(s). The fascia and muscle is gently divided, exposing the spinous processes and spine bones. An x-ray is obtained to confirm the appropriate spinal levels to be fused. A laminectomy (removal of lamina portion of bone) and foraminotomy (removal of bone spurs near where the nerve comes through the hole of the spine bone) can be performed if necessary. Two small metal screws can be affixed to each spine bone, one on each side, which are then connected together with a titanium metal rod on each side of the spine. The bony surfaces and facet joints are then decorticated and bone graft is placed, which mends together over time (weeks and months).

The wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with strong sutures. The skin can usually be closed using sutures or staples. A sterile bandage is applied.

The total surgery time is approximately 2-4 hours, depending on the number of spinal levels involved.

Post-Operative Care

Most patients are able to go home 3-5 days after surgery. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid excessive bending and twisting of the neck in the acute postoperative period (first 1-2 months). Patients can gradually begin to bend and twist their neck after 2-3 months after the fusion solidifies and the pain subsides. Patients are also instructed to avoid heavy lifting in the postoperative period (first 2-4 months).

Brace

Most patients are required to wear a neck brace after surgery. This reduces the stress on the neck area and helps improve bone healing and decrease pain in the postoperative period.

Wound Care

The wound area should remain covered with a gauze bandage secured in place with tape. The area should be kept clean and dry. The bandage should generally be changed every 1-2 days, especially after showering.

Showering/Bathing

Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should change the bandage, and dry off the surgical area. The dressing should otherwise be changed every 2-3 days when at home. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.

Driving

Patients may begin driving when the pain has decreased to a mild level and neck range-of-motion is improved, which usually is between 2-6 weeks after surgery. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.

Return to Work and Sports

Patients may return to light work duties as early as 2-4 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 3 months after surgery, if the surgical pain has subsided and the neck strength and mobility has returned appropriately with physical therapy. Patients who have undergone cervical fusion at only one level may return to heavy lifting and sports activities if the surgical pain has subsided and the neck strength and mobility has returned appropriately with physical therapy. Patients who have undergone cervical fusion at two or more levels are generally recommended to avoid heavy lifting, laborious work, and impact sports.

Doctor's Visits and Follow-Up

Patients will return for a follow-up visit to see the doctor approximately 12-14 days after surgery. Medications will be refilled if necessary. The incision will be inspected and the stitches or staples will be removed. Patients will usually return to see Dr. Spoonamore or Dr. Smith every 4-6 weeks thereafter, and an x-ray will be taken to confirm the fusion area is stable and healing appropriately. At 8-12 weeks after surgery, patients will be given a prescription to begin physical therapy for gentle neck exercises.

Results and Outcome Studies

The results of posterior cervical fusion (PCF) surgery in the treatment of symptomatic unstable spinal fractures, tumors, infections, and deformity are generally excellent. Numerous research studies in medical journals demonstrate greater than 75-95% good or excellent results from PCF surgery. Most patients are noted to have a significant improvement of their neck pain and instability, and return to many, if not all, of their normal daily and recreational activities.

Selected Bibliography

Anderson PA, Henley MB, Grady MS, Montesano PX, Winn HR. Posterior cervical arthrodesis with AO reconstruction plates and bone graft. Spine. 1991;16:S72-S79.

Brodke DS, Anderson PA, Newell DW, Grady MS, Chapman JR. Comparison of anterior and po

sterior approaches in cervical spinal cord injuries. J Spinal Disord Tech. 2003;16:229-235.

Carreon L, Glassman S, Dimar J, Campbell M. Treatment of anterior cervical pseudoarthrosis outcomes of posterior fusion vs. anterior revision. Spine J 2004;4S18.

Das K, Hillard V, Nwagwu C, Anant A, Murali R, Chiles B. Posterior cervical stabilization/fusion using segmental screw-rod fixation: technique analysis and results in 52 patients. Spine J 2003;3125.

Fehlings MG, Cooper PR, Errico TJ. Posterior plates in the management of cervical instability: long-term results in 44 patients. J Neurosurg. 1994;81:341-49.

Levine AM, Mazel C, Roy-Camille R. Management of fracture separations of the articular mass using posterior cervical plating. Spine. 1992;17:S447-54.

Xu R, Haman SP, Ebraheim NA, Yeasting RA. The anatomic relation of lateral mass screws to the spinal nerves. A comparison of the Magerl, Anderson, and An techniques. Spine1999;24:2057-61.