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  • Anterior Cervical fusion or posterior foraminotomy?

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    Old 01-07-2014, 04:48 AM   #1
    CT06405
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    Anterior Cervical fusion or posterior foraminotomy?

    My MRI states that I have mild to moderate central canal stenosis at C4-C6. Surgeons who have seen the MRI say that my disc bulges are typical of my age (59), not too impressive, and there is still spinal fluid around them. Some are hesitant to operate on the discs, as they say my neck is not that bad.

    I also have moderate foraminal stenosis at C4-C6. I only have symptoms on the left side causing frequent nerve pain down into the scapula area and occasionally across the left shoulder down into the left arm, corresponding with the C6 dermatome.

    I think a foraminotomy through a posterior approach would be a good procedure for me, but most surgeons seem to want to go through the front of the neck, remove the discs, and address everything at once. I just wonder if that's overkill and could cause other problems.

    I would like to hear if anyone who has had either of these operations has an opinion on which is less risky, easier to go through, more effective, etc. The scapula pain is really annoying and very limiting as far as activities or even driving.

     
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    Old 01-07-2014, 08:49 AM   #2
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    If you had a foraminotomy done, you could always get ACDF's later, if necessary. I just don't know if a foraminotomy could sufficiently address the disks that are bulging into your foramina. When I had a C5 foraminotomy done, it was, as I recall, to address facet hypertrophy. As the facets are behind the foramina, the posterior foraminotomy could access them more easily that it could a disk bulge. My understanding is that a foraminotomy that's going after disk-related problems has to remove some bone (parts of the facets?) to even get at the problem. This may mean disturbing neck muscles more than they were disturbed in my operation.

    I don't know how many opinions you have gotten, but you need at least three, and from different practices. If all three agree, then I guess you may have to go along with whatever they say. If they say that you don't need ACDF's yet, but that you probably will at some time, then it might be worth it just so you don't suffer for years first.

    Last edited by WebDozer; 01-07-2014 at 08:52 AM.

     
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    Old 01-07-2014, 10:17 AM   #3
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    If you had a foraminotomy done, you could always get ACDF's later, if necessary. I just don't know if a foraminotomy could sufficiently address the disks that are bulging into your foramina. When I had a C5 foraminotomy done, it was, as I recall, to address facet hypertrophy. As the facets are behind the foramina, the posterior foraminotomy could access them more easily that it could a disk bulge. My understanding is that a foraminotomy that's going after disk-related problems has to remove some bone (parts of the facets?) to even get at the problem. This may mean disturbing neck muscles more than they were disturbed in my operation.

    I don't know how many opinions you have gotten, but you need at least three, and from different practices. If all three agree, then I guess you may have to go along with whatever they say. If they say that you don't need ACDF's yet, but that you probably will at some time, then it might be worth it just so you don't suffer for years first.
    My problem is more facet hypertrophy than disc bulge, so if we do a foraminotomy it would only be to open the foramen and not do anything at all with the discs. My discs are not that bad, I hear, so some doctors think they should not be operated on, vs. some who recommend it. I 've seen 5 surgeons.

    However, as you say, ACDF prevents a future operation. Which operation, in your case, was easier to recover from and more successful?

     
    Old 01-07-2014, 10:34 AM   #4
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    What does your MRI report say about the cause of your foraminal stenosis? What about the canal stenosis?

     
    Old 01-07-2014, 11:36 AM   #5
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    What does your MRI report say about the cause of your foraminal stenosis? What about the canal stenosis?
    It says, "Bilateral uncovertebral hypertrophy causes moderate bilateral neural foraminal narrowing, left greater than the right. " In other words, it's caused by facet joint hypertrophy. It repeats this for C4-C5 and C5-C6.

    Of the canal stenosis, at C4 - C6, it says, "there is posterior disc osteophyte complex which cause mild to moderate central canal stenosis."

    Doctors who have looked at it have said the disc herniations are "not very impressive" as one put it. Several have flat out refused to operate at all.

    I am afraid if I let someone do a fusion and remove the discs, they will ignore the enlarged facet joints, which compress the nerve at the foramen and may be causing my problem.

    My symptoms seem to be more what I have heard is typical of foraminal stenosis rather than central canal stenosis. The only pain I have is on the left side, mostly behind the upper edge of the scapula, which gets a lot of muscle guarding after activity with the left arm. After activity like tennis, pain can go across the shoulder and into the arm but not very severely.

     
    Old 01-07-2014, 11:54 AM   #6
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Uncovertebrals are not facets. The uncovertebral "joints" are ridges on the top/back of the vertebrae (and in FRONT of the foramina). When disks wear out, they get more stress and lay on extra bone. The facets are the bones on the side of the spinal cage, and BEHIND the foramina.

    It's my slightly-educated-but-still-amateur opinion that uncovertebrals are harder to reach in a foraminotmy than are facets.

    I can see why surgeons don't want to do ACDF's. Are these same surgeons also unwilling to try a foraminotomy?

     
    Old 01-07-2014, 12:08 PM   #7
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    Uncovertebrals are not facets. The uncovertebral "joints" are ridges on the top/back of the vertebrae (and in FRONT of the foramina). When disks wear out, they get more stress and lay on extra bone. The facets are the bones on the side of the spinal cage, and BEHIND the foramina.

    It's my slightly-educated-but-still-amateur opinion that uncovertebrals are harder to reach in a foraminotmy than are facets.

    I can see why surgeons don't want to do ACDF's. Are these same surgeons also unwilling to try a foraminotomy?
    One surgeon is willing to do a foraminotomy if I get some diagnostic injections establishing that the neck is the source of my scapular pain, but he does not think I need an ACDF. The catch; this one does not take my insurance, so I'd have to pay for it and can't go there.

    Another will do a foraminotomy, but would prefer to do an ACDF and address the facet joint at that time through the anterior approach, while also removing at least one disc. But I'm afraid this approach would not adequately address the foraminal stenosis mentioned in the MRI, while exposing me to all the downside risks of a fusion that I may not need.

    How did your operations work out? Would you do it again, and are you pain free?

    Last edited by CT06405; 01-07-2014 at 02:12 PM.

     
    Old 01-07-2014, 12:11 PM   #8
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Uncovertebrals are not facets. The uncovertebral "joints" are ridges on the top/back of the vertebrae (and in FRONT of the foramina). When disks wear out, they get more stress and lay on extra bone. The facets are the bones on the side of the spinal cage, and BEHIND the foramina.

    It's my slightly-educated-but-still-amateur opinion that uncovertebrals are harder to reach in a foraminotmy than are facets.

    I can see why surgeons don't want to do ACDF's. Are these same surgeons also unwilling to try a foraminotomy?

     
    Old 01-07-2014, 01:38 PM   #9
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    Uncovertebrals are not facets. The uncovertebral "joints" are ridges on the top/back of the vertebrae (and in FRONT of the foramina). When disks wear out, they get more stress and lay on extra bone. The facets are the bones on the side of the spinal cage, and BEHIND the foramina.

    It's my slightly-educated-but-still-amateur opinion that uncovertebrals are harder to reach in a foraminotmy than are facets.

    I can see why surgeons don't want to do ACDF's. Are these same surgeons also unwilling to try a foraminotomy?
    One surgeon is willing to do a foraminotomy if I get some diagnostic injections establishing that the neck is the source of my scapular pain, but he does not think I need an ACDF. The catch; this one does not take my insurance, so I'd have to pay for it and can't go there.

    Another will do a foraminotomy, but would prefer to do an ACDF and address the facet joint at that time through the anterior approach, while also removing at least one disc. But I'm afraid this approach would not adequately address the foraminal stenosis mentioned in the MRI, while exposing me to all the downside risks of a fusion that I may not need.

    How did your operations work out? Would you do it again, and are you pain free?

    Last edited by CT06405; 01-07-2014 at 02:12 PM. Reason: added something

     
    Old 01-07-2014, 03:02 PM   #10
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    All three of my ops (ACDF, foraminotomy and laminoplasty) worked fine. I think I had three pretty good surgeons. Two of them I had to pay out of pocket, but I'd do that to get a good surgeon. My insurance paid for the hospital and anesthesiologist, which is most of the cost, anyway.

     
    Old 01-07-2014, 03:45 PM   #11
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    All three of my ops (ACDF, foraminotomy and laminoplasty) worked fine. I think I had three pretty good surgeons. Two of them I had to pay out of pocket, but I'd do that to get a good surgeon. My insurance paid for the hospital and anesthesiologist, which is most of the cost, anyway.
    It's too bad that it took 3 operations to take care of the problem! And it sounds like you had the more serious operation - the fusion - done first. Was it much worse to recover from than the other two operations?

     
    Old 01-07-2014, 04:05 PM   #12
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    I had three separate problems. A severely herniated C3-4 disk in 1997, facet arthropathy blocking the left C5 foramen in 2004, and multiple stenosis/obstructions in 2011. These were addressed, respectively, by an ACDF, a foraminotomy and a C4-5-6 laminoplasty.

    The ACDF was so long ago that I don't remember the recovery well. As I had hardware put in, the surgeon said I had no need for a collar. Even so, I think I was quite tentative for a couple of months. I believe that ACDF's have gotten better since then, in terms of recovery. The foraminotomy essentially had no recovery period, and the laminoplasty wasn't much fun for a month, but I was as good as new in about ten weeks.

    Last edited by WebDozer; 01-07-2014 at 04:07 PM.

     
    Old 01-07-2014, 05:15 PM   #13
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Luckily they all worked out for you, so hopefully you are set!

    I think the least risky operation for me would be the foraminotomy, if it would work, so I may try that first. I'm getting a new cervical spine MRI this week and have a couple more consults set up, so I'll see what they say. Most are pushing fusion or nothing, but that could just be the trend now, as fusion technology has improved.

     
    Old 01-18-2014, 06:23 AM   #14
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    Quote:
    Originally Posted by WebDozer View Post
    I had three separate problems. A severely herniated C3-4 disk in 1997, facet arthropathy blocking the left C5 foramen in 2004, and multiple stenosis/obstructions in 2011. These were addressed, respectively, by an ACDF, a foraminotomy and a C4-5-6 laminoplasty.

    The ACDF was so long ago that I don't remember the recovery well. As I had hardware put in, the surgeon said I had no need for a collar. Even so, I think I was quite tentative for a couple of months. I believe that ACDF's have gotten better since then, in terms of recovery. The foraminotomy essentially had no recovery period, and the laminoplasty wasn't much fun for a month, but I was as good as new in about ten weeks.
    Thanks Webdozer - my issues are with the C5 and C6 nerve, although doctors describe my foraminal and cervical canal stenosis as minimal to moderate. So I have not rushed into surgery, as I want to make sure this nerve compression is actually coming from my neck. When you had your C5 or C6 issues, did you have any pain or stiffness in the upper back near the scapula? That is mostly what bothers me, rather than hand or arm pain, which is only occasional after activity.

     
    Old 01-18-2014, 04:25 PM   #15
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    Re: Anterior Cervical fusion or posterior foraminotomy?

    No upper back stiffness. Just bicep and deltoid weakness...

     
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