Understanding the Combined Approach
Combined anterior and posterior cervical fusion is a complex spinal surgery that addresses severe neck conditions by operating on both the front and back of the cervical spine. It involves the permanent joining, or fusion, of two or more vertebrae in the neck to eliminate movement at that segment. This “combined” or “360-degree” approach is reserved for cases where a single anterior (front) or posterior (back) approach would not provide sufficient stability or adequately decompress spinal structures.
An anterior approach directly accesses intervertebral discs and the front of the spinal cord, while a posterior approach allows for broader decompression and robust instrumentation. The combined surgery achieves superior rigidity and stability, particularly in cases involving significant instability or multi-level spinal issues.
The anterior procedure involves removing damaged discs or bone spurs compressing nerves or the spinal cord, followed by placing a bone graft and often a plate and screws to promote fusion. The posterior approach involves placing bone graft material and using rods and screws to stabilize the back of the vertebrae. Addressing both spinal columns creates a robust construct for healing and long-term stability.
Conditions Addressed by Combined Fusion
Combined anterior and posterior cervical fusion is indicated for complex and severe cervical spine pathologies requiring extensive decompression. These include conditions causing significant instability, multi-level degeneration, or severe spinal deformities. For instance, unstable cervical trauma, such as fractures or dislocations compromising multiple columns of the spine, often requires this comprehensive approach to prevent further neurological damage and achieve stable fusion.
Severe degenerative disc disease affecting multiple cervical spine levels can also necessitate combined fusion. When widespread pressure on the spinal cord (myelopathy) or nerve roots (radiculopathy) occurs from disc herniations, bone spurs, or ossification of the posterior longitudinal ligament (OPLL), a single approach may be insufficient. Multilevel cervical spondylotic myelopathy, where the spinal canal narrows significantly, often benefits from the dual approach to ensure complete decompression and prevent post-operative instability.
Spinal deformities, such as severe cervical kyphosis (an exaggerated forward rounding of the neck), may also require a combined procedure for effective correction and stabilization. Patients with previous cervical surgeries that failed to achieve stable fusion (pseudarthrosis) or those with recurrent instability may also be candidates.
The Surgical Process
Undergoing a combined anterior and posterior cervical fusion involves a series of steps performed under general anesthesia. The procedure generally lasts several hours, depending on complexity and the number of spinal levels involved. Pre-operative medical evaluations ensure the patient is a suitable candidate.
The anterior approach is usually performed first, with the patient positioned on their back. An incision is made on the front of the neck, allowing the surgeon to access the cervical spine. Damaged discs or bone spurs are removed to decompress the spinal cord and nerve roots. A bone graft is then placed into the empty disc space to promote fusion. A plate and screws are commonly affixed to the front of the vertebrae for stabilization.
Following the anterior portion, the patient is repositioned onto their stomach for the posterior approach. A separate incision is made down the back of the neck. Through this incision, the surgeon accesses the posterior elements, performing any necessary decompression, such as laminectomy. Instrumentation is then precisely placed to stabilize the spine from the back. Bone graft material is also placed along the back surface of the vertebrae to encourage solid fusion. After both approaches are completed and stability is confirmed, incisions are closed, and the patient is moved to recovery.
Recovery and Long-Term Outlook
Recovery after combined anterior and posterior cervical fusion is a gradual process. Immediately after surgery, patients can expect neck pain and stiffness, managed with medication. A soft or rigid neck brace may be worn for several weeks to support the spine as it heals. Most patients return home within a few days.
Physical therapy plays a role in rehabilitation, often beginning a few weeks after surgery. Therapy focuses on restoring range of motion, strengthening neck and upper back muscles, and improving flexibility. Patients are advised to avoid bending, twisting, or lifting heavy objects for an initial period. Light activities, such as short walks, are encouraged early on to promote circulation and prevent stiffness.
Full fusion of the vertebrae can take several months to a year. While many patients experience a reduction in initial symptoms, some may have residual tingling or numbness as nerves heal, which can take up to a year. The long-term outlook is generally positive, aiming to provide stability and alleviate severe neurological symptoms. Although there might be some loss of neck flexibility due to fusion, the primary goal is improved function and pain relief, preventing further spinal deterioration.