Cervical Total Disc Replacement (CTDR)
CTDR is increasing in popularity for certain neck problems. It similar in success to anterior cervical fusion procedures. If there is significant degeneration of the vertebral segments, cervical disc replacement is contraindicated and fusion is the treatment of choice, but for patients without significant degeneration, CTDR is a viable alternative. Currently CTDR is only FDA approved for up to 2 levels.
Cervical disc replacement involves going through the front of the neck to access the spine. The benefit of this approach is that it is unnecessary to split or cut any major muscles – unlike most posterior approaches to the spine. This makes recovery quicker and less painful compared to a posterior approach.
Once the spine has been exposed, the disc material and bone spurs which may be causing pressure on the nerves or spinal cord are removed. A mobile prosthesis is then placed between the vertebrae. Final x-rays are taken to confirm good alignment of the prosthesis. The surgical site is washed out with antibiotic solution and closed with stitches in multiple layers under the skin. A layer of sealant material is placed to seal the skin. Bandages are rarely required.
Hospital Stay and Recovery
Most patients are allowed to return home the same day of the procedure. Occasionally, someone will remain overnight, and very rarely does one need to stay longer.
The postoperative course is as follows:
- Follow up appointments at 3 weeks and 2 months. X-rays are taken if there are problems, otherwise they are not needed.
- Activity restrictions are mostly unnecessary after CTDR. Common recommendations include avoiding contact sports and excessive twisting of the neck. Most daily activities are fine.
- By 3 months, all activities are generally allowed.
Risks of Surgery
No surgery is without risk, but fortunately the risks associated with CTDR are rare. The most common risks are:
- Swallowing discomfort – Since the esophagus gets moved during the
surgery, there can be some soreness. Usually this is not too bad, but occasionally swallowing can be very difficult requiring a longer stay in the
hospital or even a feeding tube for a short time. - Infection – Although this is very rare with anterior neck surgery, an infection can mean repeated wash out surgeries and as a worst case scenario, can be life threatening.
- Soreness (usually in the back of the neck) – This is due to stretching of the
ligaments in the neck and generally resolves within a few days to a few weeks. Shrugging and rowing exercises can help minimize this discomfort and are appropriate to start right after surgery. - Hardware failure – Sometimes the prosthesis can loosen or migrate. If this happens and is symptomatic, revision to fusion surgery may be required. Minor movements of the implants are common in the first few months as the device settles somewhat. Fortunately these are rarely symptomatic.
- Fusion – Although disc replacement is done to preserve motion in the cervical region, some will go on to fusion regardless. Generally this does not change the outcome of surgery.
Other risks which are more serious but very rare can include:
- Nerve injury – Can result in weakness, numbness and/or continued pain.
Some of these will recover over time, but it generally takes many months. - Paralysis – Since the surgery involved removing disc material and/or spurs
which sometimes are in direct contact with the spinal cord, this is a possible complication. Fortunately, surgeons who perform this procedure regularly know how to minimize risk to the spinal cord during this procedure making this extremely rare. - Esophageal injury – Although very rare, can lead to deep infection and need for major surgery. Great care is taken with the esophagus during the surgery to avoid this.
- Laryngeal nerve injury – May result in permanent hoarseness. Temporary
hoarseness is common, and generally resolves in a few weeks to a few months. - Horner’s syndrome – Notable for a droopy eyelid on one side. Usually caused by abnormal anatomy in the area of surgery. Most will resolve with time.
It is important to remember that although CTDR is highly successful in decreasing the primary symptoms, it does increase mobility of the neck at the surgical level(s). This is rarely problematic. However, some individuals will not tolerate the increased motion and will require revision to fusion.
Most individuals state that they have such improvement in their shoulder, arm and/or hand symptoms that the surgery is well worth it even if they have some residual symptoms.
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