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Cervical Fusion
Anterior cervical spinal fusion surgeries are commonly done in conjunction with an anterior cervical discectomy. For many patients, cervical spinal fusion surgery (fusing one vertebra to another) is often done to eliminate motion at a vertebral segment. Decreasing the motion at a painful motion segment should decrease the pain at that segment. Achieving the fusion also serves to maintain adequate space for the decompressed spinal cord and/or nerve roots. The fusion may also prevent the spine from falling into a collapsed deformity (kyphosis).
Additionally, anterior cervical spinal fusions are also done to treat cervical instability due to:
- Trauma (fractures or dislocations)
- Tumor
- Infection
Bone grafts for spinal fusion surgery
To achieve a spinal fusion, a bone graft is used to promote two bones growing together into one. The patient’s own bone will grow into and around the bone graft and incorporate the graft bone as its own. This process creates one continuous bone surface and eliminates motion at the fused joint. A small piece of bone is used to fuse a disc space, and a longer so-called ‘strut graft’ is used to bridge across multiple disc spaces if a ‘corpectomy’ has been performed.
There are several options available to patients and surgeons for bone grafts in anterior cervical spine surgery:
1.) Autograft bone for spinal fusion Autograft bone (patient’s own bone) is harvested from the iliac crest (hip). This technique has been the gold standard since the 1950’s. Autograft bone usually achieves a fusion in 90%-95% of patients.
The principal disadvantage with using autograft bone is that another incision needs to be made over the hip to harvest the bone graft. Possible complications associated with taking out bone graft include:
- Graft site chronic pain (which happens 10% to 25% of the time)
- Infection
- Bleeding
- Damage to the lateral femoral cutaneous nerve (a sensory nerve that supplies sensation to the front of the thigh)
- Pelvis bone fracture
The chances of a complication increase with the size of the bone graft and patient obesity. For those who opt to use an autograft, many patients find the bone graft harvest site to be more painful than the cervical surgery site itself.
2.) Allograft bone for spinal fusion
Allograft bone (a.k.a. ‘bank’ bone or donor bone from a cadaver) eliminates the need to harvest the patient’s own bone. Basically, the donor graft acts as a bone scaffolding onto which the patient’s own bone grows and eventually replaces over years. There are no living cells in the bone graft, so there is little chance of a graft ‘rejection’ like with an organ transplant. However, bone graft healing remains an issue, as there is a somewhat greater likelihood of bone graft failure with allograft compared to autograft.
With allografts, the speed of healing may be slower than an autograft bone fusion.
In addition:
In one-level spinal fusions, it yields nearly equivalent fusion rates as autograft bone.
Anterior cervical instrumentation (plates & screws) are commonly employed with allografts to increase fusion rates.
With increasing numbers of levels to be grafted/fused, the differences in fusion rates between allograft and autograft become more significant.
There is a theoretical risk of transmission of an infection from a donor. The risk of contracting a disease such as HIV or hepatitis from an allograft has been estimated to be between 1 in 200,000 to 1 in 1 million. However, with modern procurement and sterilization methods for bone tissue, the risk is essentially moot.
Potential risks and complications of a spinal fusion surgery include:
The principal risk from a spine fusion is that the graft does not heal. In general, allograft bone does not heal quite as well as autograft bone, but both yield good results when used in the anterior cervical spine.
If a graft is used without instrumentation, there is a small chance (1% to 2%) of a graft dislodgment or extrusion. If this happens, another operation is necessary to reinsert the bone graft, and instrumentation (plates) can then be used to hold it in place.
Controversies about spine fusion surgery While physicians agree on many things about spine fusion surgery, there are some areas that lack consensus. Two such areas are the type of bone used (autograft vs. allograft) and how many levels should be fused. Type of bone used with fusion surgery
Whether an autograft or allograft is used is based mostly on a combination of the surgeon’s and patient’s preference. Some surgeons still feel most comfortable with autograft as it yields the best fusion rates. Other surgeons have had good results with allograft bone and wish to avoid the postoperative pain and possible complications associated with harvesting a bone graft.
In some instances, it may be more compelling to use a patient’s own bone. There are some situations where it is more difficult to get a solid fusion and using a better bone graft is reasonable. Factors that may make obtaining a solid fusion difficult include:
- Revision surgery (previously failed grafts)
- Smokers/smokeless tobacco product users