C3-T1 ACDF & posterior fixation

I am scheduled for surgery March 23rd. On March 7th (after a CT scan), my surgeon gives me the dirty details, but in my initial consult, he said I need a C3-T1 ACDF & posterior fixation (7-8 hours on the table). He said this is a HUGE surgery and not normally done. He pointed out issues starting at C2-C3 and my major issue at C7-T1 and said this is a HUGE surgery, but was necessary. He added that he would offer an easier solution if possible. He did not go into any detail since he wants to talk after seeing the CT scan. I have had previous C6-C7 ACDF in 2000 with donor bone and C5-C6 ACDF in 2010 with plate & cage. The first surgery was a great success with no pain medications needed after I went home. The second one was rougher. I did have some pain and medicated a couple weeks, but a few months after surgery, I developed vocal fold paralysis and did a year of voice therapy. I am a teacher, but was doing a technology related non-classroom job that year so I managed. When back in the classroom the following year, I used a sound system. I have not needed it for the past four years.

A five level ACDF is huge and don’t know yet If the posterior part includes fusion. I studied the MRI film for months and with my chiropractor’s assistance, speculated he would want this fusion, but we did not expect the five level ACDF as well.

I am taking the last eight weeks of this school year off for this and will have 20 weeks to recover for the next school year. I know this will be a rough recovery and I am very concerned about my voice.
Has anyone had anything similar to this surgery? There is very little information about five level ACDF’s and I am very concerned. I see a benefit of ACDF vs. posterior laminectomy, but there is just no information out there I can relate to. My T1-T2 & T2-T3 discs are also herniated and will discuss that with him in 10 days.

Any advice is appreciated. I am a 50 year old male.

Thank you for the reply. I appreciate you taking time to give me some advice. My surgery will be at Christ Hospital in Cincinnati by a Neurosurgeon. I have researched everything that has been on my CT scans, MRI’s, and X-ray reports for several years now and fully expected a C3-T1 or C3-T3 posterior fusion. Knowing the 5-level ACDF is proposed, I have researched it at length. There just is not information out there for 5-level ACDF or a combo 5-level. I know every case is different and every surgery is unique; I just hope to gain some personal or medical insight to what I am in for.

Before my last ACDF, I bought a good recliner. Two months ago, I bought a lift recliner. This time around, I think I will need it.

I will look at the items you mention and give an update after my CT scan 3/7. Thanks!

Hi Abilene! Thank you for the reply. My first ACDF was done in Columbus, OH and he had retired before my second so I saw a neurosurgeon in Cincinnati I was referred to from my chiro. I liked him and thought about seeing him this time, but I was able to get into the VA system in 2011 and wanted to give them a chance. Using the Veterans Choice program, I won’t have to worry about the out of pocket expenses. I was prepared to get additional opinions, but I am close friends with my chiro and we discussed all possible ways to deal with this. He was surprised at 5 anterior levels, but said he understands why he wants this. In his opinion, the ACDF fusions are easier to recover from than a laminectomy at that many levels and fusion rates are higher. I am not certain yet if he is doing just a fixation or a fusion with the posterior portion. I am satisfied I am in good hands. I would not consider this otherwise. My surgeon is young (34), but has an impressive resume. I have researched him and he is an excellent surgeon. I know a different surgeon may offer a different solution, but that would certainly be some ACDF and posterior laminectomy. A couple people have posted comments about this surgeon stating he took their case when others would not. The VA referred my case to 8 neurosurgeons and he took my case. I do not know if that is an indication of him being willing to do this surgery or if others would not.

I have some loss of range of motion from the two previous surgeries, but not a great deal. The surgeon told me with this surgery, I would have 50% left and right, but limited up and down motion. I had major voice issues after the second surgery that appeared several months post op. I saw a voice specialist who diagnosed vocal fold paralysis and I had do voice exercises several times each day for a few months. I was lucky to have taken a technology coaching job for two years that let me recover without having to stress my voice teaching every day. When I did return to the classroom a year later, I used a sound system my Superintendent insisted they purchase for me. I still have it and use it occasionally. My voice is weaker than it used to be and I stutter from time to time. The voice part has me worried. Before my second ACDF, the surgeon said that an ACDF to T1 (which was already slightly herniated) had some risk of voice loss.

The Nurse Practitioner who we talked to for a long time was very surprised I do not have other symptoms. She said my MRI and reports indicate I should be in pain, but she seemed to think I should have leg pain or other debilitating symptoms. Maybe I have been lucky getting this far.

I am trying to do all the right things in preparation and I am not going into this with blind eyes. I have researched this endlessly and know I have a very long road ahead. It is frustrating knowing I am having a surgery that is so uncommon, there is zero information I can refer to for 5 level anterior/posterior fusions.

Sorry for the long reply. It is good receiving feedback and having dialogue about all of this.

My wife tells me to not be so worked up about this and just let things happen as they are meant to. I have no interest in changing what is suggested, but in anything I do, I research and study things until I am confident I know everything I need to know.

Abilene, I have a working document I add things to when I think of a new question for the surgeon. I am sure some of it will be answered before I need to ask, but I do not want any surprises. I have read through many of the Chronic Pain ACDF threads. I do learn things and can relate to many. I see so many people not able to work or function normally for months after 1-3 level ACDF's. After both of mine, I was up and active quick. I had my last one in November 2010 and was making maple syrup (requiring heavy lifting) four months later.

My arthritis is worse and I am older than ever (duh) so I know this is different. From what I have read, adding a level of fusion makes a big difference in recovery time.

I might add that as long as my C5-C6 & C6-C7 fusions are sound and the nerves have space, he will leave those alone so technically, the ACDF will be three additional levels to create a 5 level fusion.

I think Abilene just said it all in her post above. Being prepared as best as possible is the key & you have time to get it done. I personally think the way Abilene does, the ones with lots of issues have a bit of a more difficult time turning the corner after surgery.

Take care.

Hi Newmanmaple I've been reading your post wow sounds like your whole neck will be fuse when they're done with You! I can definitely relate to allot of the problems you've had and continue to have! I had voice problems to after my first ACDF at C6/7 back in 1985. On that one I totally lost my voice for around 3 months, they took bone out of my right front pelvis for the graft and that hurt worse than the ACDF! Took longer to heal and was in a cervical collar for over 4 months as at that time they didn't use any screws and bracket to stablelize the fusion while it healed! Anyways my voice did finally come back but is bit gravelly, and nearly 25 years later in September 2009 when I had to have my second ACDF, this time at C5/6 I found out my vocal cords on the right side was still partially paralyzed from my first fusion! Anyway with that second one they used cadaver donor bone and screws and bracket and it was allot Easier! Then in November of 2010 I had a posterior fusion at C3/4 they fused the articular joint and put in rods and pins on both sides. That surgery although easy to do according to my neurosurgeon was a real bear pain and healing Wise! I had 47 staples down the middle of the back of my neck from the base of my skull to just about the beginning of my shoulders. It was worth it in the end but it did take a long time to heal and for the pain to go away and I also had to have some PT after too! Personally I thought the posterior surgery was allot worse than the ACDF! I also can empathize with you on joint Pain! I've had surgery on both my knees and finally had a total right replacement Don in December of 2014. I've had lower back surgery done in Jan of 2013 too, but my herniated thoracic disc they won't touch !

Anyway if I can be of any help to you just let me know. Best advice I can give you right now, is be gentle with yourself and after your surgery don't over due It! Follow your surgeon's post-op orders to the Tee and just take it easy and let your body Heal!

I do wish you all the Best! Oh and Welcome to the Forum!! I think you've really came to the right place!!


White Beard

Hi newmanmaple just out of curiosity along with your voice problems do you have any problems with swallowing or laryngeal Spasms? Like in abnormal gag Reflex? The reason I'm asking besides having partial paralysis of my right vocal cords from my first ACDF I also have some swallowing problems problems and problems with gagging caused by laryngeal spasms. Over the years as I've gotten older it has become less of problem , but on occasion if I've put to much strain on my neck (cervical spine) it will come back and haunt me! Being the fact that you have the same ACDF'S that I've had, and had voice problems, I was just wondering if you have experience some of these other problems Too?

I do wish you well on your up coming Surgery! And no I don't think you can over prepare for it! I will tell you I was really surprised how rough the posterior surgery was as in comparison to the ACDF! My surgeon tried to warn me that this would be a very uncomfortable experience, but would be all worth it in the end. Well uncomfortable was an understatement but in the end he was Right! It was worth it! One thing that one of my later neurosurgeons told me that non of the other surgeons mentioned, is: That in allot of patients that have fusions (ACDF's) usually within ten years the disc above or below that fusion will go bad! Knock on wood! I got close to 25 years out of mine before the one above went bad!

Anyway Good Luck to You!

White Beard

I thought I would add my MRI findings. It is a lot to read, but you can see what I have been studying for 6 months now. I have the CT scan Tuesday and will get the surgical details.

9/16/16
COMPARISON: Cervical MRI exam dated 10/20/2010
FINDINGS: There is no evidence of abnormal marrow signal. The craniocervical junction is unremarkable and the intrinsic cord signal is normal in appearance.
C1-C2: Unremarkable
C2-C3: Left-sided degenerative hypertrophic facet arthropathy produces moderate to severe foraminal stenosis. This finding represents interval change.
C3-C4: Disc dehydration is accompanied by shallow broad-based disc displacement effacing the thecal sac without evidence of neurocompression. Degenerative facet arthropathy produces mild to moderate biforaminal stenosis.
C4-C5: Shallow broad posterior disc displacement effaces the thecal sac, noncompressive in character. Left-sided degenerative hypertrophic facet arthropathy produces moderate foraminal stenosis.
C5-C6: Anterior surgical fusion has been performed, representing interval change. Right-sided degenerative facet arthropathy produces moderate foraminal stenosis.
C6-C7: Anterior interbody fusion has been performed. Prominent right paracentral posterior vertebral body flattens the thecal sac without evidence of neurocompression.
C7-T1: Disc dehydration is accompanied by moderate loss of disc height and anterior vertebral body spondylosis. Broad-based disc displacement effaces the thecal sac and encroaches on the neural foramina effacing the left C8 nerve root. This finding was not demonstrated on the prior study.
T1-T2: Disc dehydration is accompanied by loss of disc height and anterior vertebral body spondylosis. Broad-based disc protrusion encroaches on the right neural foramen, closely approximating the right T1 exiting nerve root. Degenerative facet arthropathy produces mild biforaminal stenosis.
T2-T3: Disc dehydration is accompanied by loss of disc height and anterior vertebral body spondylosis. Broad-based disc displacement encroaches on the right neural foramen without evidence of neurocompression. Degenerative facet arthropathy is noted.

CONCLUSION:
1. C7-T1 broad disc protrusion with biforaminal encroachment, effacing the left C8 exiting nerve root. Coexisting discogenic spondylosis accompanied by degenerative facet arthropathy, contributing to biforaminal stenosis.
2. Broad disc protrusion at T1-T2 and T2-T3 encroaching on the right neural foramen at the T1-T2 level, closely approximating the right T1 exiting nerve root. Coexisting discogenic spondylosis.
3. Shallow noncompressive disc displacement at C3-C4 and C4-C5, accompanied by left-sided degenerative hypertrophic facet arthropathy, resulting in moderate to severe and moderate foraminal stenosis respectively. Coexisting left-sided foraminal of moderate severity.
4. Status post anterior surgical fusion at C5-C6 and C6C7, accompanied by posterior vertebral body prominence at the C5-C6 level, flattening the thecal sac without evidence of cord compression.

Well my CT scan was uneventful, but my consult was a surprise. My neurosurgeon said ever since we spoke last, my case has been wearing on him and he has studied things very closely. He told me I have major spurring at the T1-T2 & T2-T3 and he pointed them out on film. He said he believes some of my pain is from that level and a fusion would have to include them.

His conclusion was that I should not have any fusion. He said he understands that I am in pain and suffering, but a fusion at any level in my severely compromised spine would quickly lead to more surgery which would eventually leave me with an occipital fusion. He said this would be “a miserable existence.” He went on to tell me he does expect to see me again, but that should not be until my symptoms are too severe to live with.

I texted my chiropractor who said he wants me to see a pain management anesthesiologist to look into nerve ablation.

So that is all I know for now.

Newmanmaple:
I did not post a reply to this thread earlier, as I did not want to inject an opinion when none was being sought.

But I will admit now that I did have concerns seeing the benefits of such an invasive cervical procedure. Believe me, as a physical therapist I have worked with individuals who struggled with less than ideal post-surgical results. Many of these individuals were worse for the surgery than if they had stayed the status quo (and the status quo was less than ideal with pain, numbness, and limited fine motor control).

I applaud your surgeon with being upfront and honest with you in expressing his reservations about the proposed procedure.

I have a substantial pituitary tumor/adenoma. It has been recommended to me, on several occasions, to have it surgically excised. The technique is a trans-shenoid approach, up the nose to the brainstem. I have also been on corticosteroids for 25+ years. The risk of a cerebral vascular accident during surgery or post surgery is a real risk. I have declined the surgery and manage the day-to-day reality of living with a pituitary tumor. The deciding factor for me? I could not agree to a surgery where there was substantial risk that I could be worse in health (cerebral vascular stroke).

All to say . . . I think your surgeon was wise in taking a pause to the proposed surgery. There is every real reason to believe that you could be worse for the surgery.

Not to say that your situation is ideal. I am sure that it is not, what with cervical spurring and foraminal narrowing. But every surgery has consequences. Personally, I think you will do better staying the course.

I already live with fairly compromised health. I was not willing to compromise my health further with the proposed transphenoid surgery. Once you lose your health, it can be very difficult to reclaim.

The cervical spine is a delicate area. It should always be treated with the upmost of respect. I appreciate your surgeon's honesty in assessing your situation and possibly saving you from additional disability and hardship.
- Karen -

We do wish you the very best....whatever that may be. Please stay in touch. We care.

I am seeing a pain management anesthesiologist next Wednesday. I will report back after that visit.

Wow! Zebraplus, what a lot you have been through! I'm interested to hear more about how you are doing now. How long do you expect to be in the hard neck brace? From my own experience I agree it's a long recovery, and mine was not as extensive as what you had. What has your doctor told you about how long recovery will be. Have you read the comments in Chronic Pain 101 written by and for people like us? That's at the top of the list and our part starts 9/14.

Please start your own thread here by clicking on Post New Topic, give it a name that identifies what you are dealing with and we can follow your progress there.

Best wishes in your recovery and Think Fusion! That's been our motto.