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I have to admit I never would have thought those two terms would be in the same sentence, but as a Boston University School of Medicine Alum, hockey player and Neurosurgeon who performs both cervical fusions and cervical disc replacement I thought I would weigh in.
Disclaimer – I have no knowledge of Jack Eichel’s medical condition, his treatment to date or what his imaging reveals. However, I do perform both of the surgeries in question on a weekly basis and counsel patients on the benefits of both.
When a person herniates a disc in their neck and gets neck pain and perhaps arm pain tingling or even weakness, we generally prescribe non operative treatments such as physical therapy and even steroid injections. If those treatments fail we offer surgery.
In a cervical fusion – or ACDF ( A for anterior because the incision is in the front of the neck, C for cervical – well because it’s the neck, D for discectomy because we remove the disc, and F for fusion because we have to put you back together) the disc and usually a bone spur is removed to take pressure off a nerve. “In the old days” that would be the end of the operation and we would place the patient in a cervical collar for 6 months until their bones settled and fused together. The problem is that when the bones settle, the holes where the nerves exit the spine (neuroforamen) become smaller and can lead to chronic pain because the nerves get pinched. So surgeons evolved and put a spacer- in the beginning a wedge of bone taken from the hip- to maintain the space and keep those neuroforamen open and promote fusion. You still had to wear a collar for months until the bones healed. Not an Ideal situation.
Then technology caught up and surgeons evolved again and then we started adding a plate and screws which we call internal fixation. Now the bone graft had a more rigid internal brace to help it heal quicker and patients no longer needed to wear a brace. Surgeons and technology evolved to the degree that we no longer have to take bone from the hip, which incidentally was one of the major complaints of this operation – hip pain, and now we use a medical grade plastic filled with donated bone or donated bone that is manufactured to a specific shape.
So where does the artificial disc fit in? Well, orthopedic surgeons used to fuse arthritic hips and knees and now they replace them. Likewise, as spine surgery has evolved we now have the ability to replace rather than fuse. For a patient, the operation is essentially the same as a cervical fusion – the only difference is rather than a bone graft, plate and screws put in to reconstruct the spine, an artificial cervical disc is put in.
However, not every patient is a candidate for disc replacement. The rationale for replacement rather than fusion is that about 20-25% of patients who have a fusion will require a fusion at the level above or below their fusion. We call this adjacent segment degeneration. Cervical disc replacement was envisioned as a means to minimize adjacent segment degeneration by maintaining normal motion. However, if your spine has already degenerated then you really are not a candidate. In general, disc replacement is reserved for patients whose disc space has not decreased in height by more than 50% and do not have evidence of arthritic changes of their spine. So that restricts the procedure to the younger generations – like 24 year old hockey players.
If you are interested learning more please watch this online discussion I moderated between several world renowned spine surgeons about the benefits and pitfalls of the surgical approaches to treating cervical disc disease click HERE. If you just want to hear about disc replacement skip to 40:23.
As the Jack Eichel debate plays out in the media, I have two comments. If I have a disc herniation in my neck I want a disc replacement instead of an ACDF. Second bring Eichel back to Boston. Go Bruins!!!!