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Friday, June 6, 2014

What is a Neck Fusion Surgery? Shown and Explained with Color X-Ray and Color MRI Images!

On September 9th, 2011, Denver Bronco's quarterback Peyton Manning underwent his 4th Neck Surgery, a Cervical Spine Fusion. The technical medical term is "Anterior Cervical Decompression and Fusion" (ACDF), which means "Neck Surgery performed from the front of the Neck to remove Nerve Compression and then fuse Vertebrae together".

To help us understand the medical jargon and the Anatomy of the Neck, lets first take a look at a Color MRI Image. This Image is Interactive. If you move your mouse cursor over the Image, Interactive Tags appear. Each tag displays text to explain a specific structure.

Color MRI of the Cervical Spine Anatomy including Spinal Disc, Spinal Cord.
Interactive Color MRI of the Neck (Cervical Spine) showing the Anatomy

Now that we have seen the Anatomy, lets talk about why this Surgery is performed. By all reports, Peyton Manning suffered from a combination of two Disc problems in the Neck: 1. A Herniation which was putting pressure on a Nerve traveling to his right Triceps Muscle  2. Degeneration of a Disc which means loss of elasticity and function.

Lets take a look at a Disc Herniation first. This Image is also Interactive. You can see why large Disc Herniations in the Neck cause Nerve Compression.

Sagittal Cervical Spine Color MRI Cervical Spine Disc Herniation
Interactive Color MRI of a Disc Herniation in the Neck (Cervical Spine)

Now lets compare this to Disc Degeneration. When a Disc degenerates, it loses some of its height and elasticity. As the Disc shrinks and hardens, it loses some or all of its ability to act as a "cushion" or "shock-absorber" between the Vertebrae. In addition, the loss of the height of the Disc takes away some of the space available for the Spinal Nerves which can cause Nerve compression. This Image is also Interactive.

Sagittal Cervical Spine Color MRI Cervical Spine Degenerative Disc Disease
Interactive Color MRI showing Degenerative Disc Disease (DDD)

Now that we have learned about the Neck conditions which can cause Nerve compression, lets take a look at Peyton Manning's surgery, a Neck Fusion. This Surgery is from the front of the Spine. Why? Because everything between the Skin and the Spine in the front of the Neck is soft! Also, the Spinal Nerves and Spinal Cord are located just behind the Disc. So, doing Surgery from the front means we do not have to go around the Spinal Cord to get to the Disc. On the back of the Spine our muscles are powerful and tough. If you have to remove their attachment points from the Vertebrae, they may never reattach completely, which can cause chronic muscle pain and weakness. For a football player who has to constantly scan the field, this approach to the Spine could be career ending.

Here is how the Surgery is done:
1. A small incision is made in the front of the Neck
2. All the structures between the Skin and the Spine are essentially pushed out of the way.
3. Once the Disc comes into view, it is removed in its entirety all the way down to the Spinal Cord.
4. The Nerve channels located behind and off to the side of the Disc are freed up.
5. A Bone Graft is placed into the Space which was created when the Disc was removed. This Bone
    Graft can be Synthetic Bone, Cadaver Bone, or the patient's own Bone. Peyton Manning reportedly
    had some his own Bone harvested from the Hip Bone to make the Bone Graft. This is the 
    Gold Standard", i.e. best chance to achieve a Fusion.
6. After the Bone Graft is in the ideal position, a small Titanium Plate is placed over it. This connects
   the Vertebrae above and below the Bone Graft to help it grow to the Vertebrae. Small Titanium
   Screws secure the Fusion Plate to the Vertebrae.

Here is a Color X-Ray of a Neck Fusion. Take a look at all the parts mentioned above. This Image is Interactive.

Lateral Cervical Spine Color X-Ray of an Anterior Cervical Fusion (ACDF)
Interactive Color X-Ray of a Neck Fusion (ACDF)

The final true and solid Bone Fusion usually takes 3-6 months to complete. The Titanium Plates and Screws give the Spine stability until the Bones are fully fused. During that time, a football player cannot be involved in contact sports since the Spine is still weak. Even though you would think that a Titanium Plate could absorb a lot of force and act as a good protector for contact sports, these plates are not meant for this type of force and are prone to breaking. The final bone fusion is much stronger than the Titanium Plates. What are the typical chances that a Bone Fusion actually takes place? Typically over 90%.

Here is another Interactive Color X-Ray to show you the difference between an initial Neck Fusion Surgery and a final Fusion.

Lateral Cervical Spine Color X-Rays of an initial Cervical Fusion Surgery and a completed Fusion
Interactive Color X-Rays of an Initial Neck Fusion Surgery and a Complete Fusion

So, why did Peyton Manning have a Fusion rather than either something less invasive or an Artificial Disc Replacement? First off, he did have at least one less invasive Surgery done. It was an endoscopic Surgery (small fiberoptic tube) which was done through a small hole from the back of the Spine. However, these Surgeries make it difficult to see and get access to the whole compressed Nerve. It was not successful in relieving the Nerve Compression in Peyton Manning's neck. That leave the subject of an Artificial Disc Replacement. The Artificial Discs still allow the space between the Vertebrae to move, which would be a good thing for an athlete. However, Artificial Disc Replacements were not designed for contact sports. It is generally not known how much force they can take. These Devices could potentially get dislodged with force, which could conceivably push them into the Spinal Cord and cause paralysis. This was a risk not worth taking for a football player who is exposed to some hard hits.

So what does the future hold for Peyton Manning's neck? The good news is that the fusion in his neck is solid which has earned him the endorsement of his Spine Surgeon, Dr. Robert Watkins to continue in his career. However, statistics are against Peyton from a standpoint of the long-term outcome of his Surgery. Neck Fusions have the disadvantage of causing more force and pressure on the Discs above and below the Fusion. Over time these Discs wear out faster than expected just due to aging. Statistically, this means a 3% per Year risk of needing another Surgery at one of these Discs. Chances are that he will last through his NFL career, unless he suffers a significant injury to one of the vulnerable Discs above and below the Fusion.

If you enjoyed this Blog, here are some other related subject from our recent Blogs:
1. What is a Spinal Fusion Surgery of the Low Back (Lumbar Spine)? Shown and explained with
Color X-Ray Images
2. Spinal Stenosis of the Low Back (Lumbar Spine) shown and explained with Color MRI Images
3. What is a "Spondylolisthesis" of the Low Back (Lumbar Spine)? Shown and explained with Color X-Ray and Color MRI Images.
4.  Disc Herniations of the Low Back (Lumbar Spine) shown and explained with Color MRI Images
5. What is an Epidural Injection? Shown and explained with Color MRI Images

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