Anterior Cervical Discectomy and Fusion

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Anterior Cervical Discectomy and Fusion

Derrick G. Sueki, Erica V. Pablo, Rick B. Delamarter and Paul D. Kim

Cervical spondylosis or degeneration presents as different clinical syndromes with the most common being degenerative disc disease, radiculopathy, and myelopathy. Cervical degenerative disc disease may present as axial neck pain, neck stiffness, or as headaches. Cervical radiculopathy classically shows symptoms of arm pain with sensory or motor deficits in the upper extremities (UEs), which is caused by disc herniation or osteophyte formation. Cervical spondylotic myelopathy (Figs. 14-1 and 14-2) may occur with gait abnormalities, hand clumsiness, or upper motor neuron signs. Studies on the natural history of degenerative disc disease demonstrate that the majority of patients suffering from axial neck pain or radiculopathy improve with conservative treatment. Cervical myelopathy, however, tends to progress with time and close clinical follow-up is warranted.

Pathophysiology And Clinical Evaluation

Cervical spondylosis is a progressive degenerative cascade that occurs with aging. Annular tears and biochemical changes in the cervical disc can lead to decreased water content, shrinking or herniation of nuclear pulposus tissue, and disc collapse. This places increased stress on associated facet and uncovertebral joints, causing them to degenerate, eventually leading to axial neck pain and stiffness. In addition, this can lead to the formation of bony spurs and disc herniations that may encroach on the neuroforamina, resulting in radiculopathy.1

The clinical presentation of cervical spondylosis can vary and must be distinguished from referred shoulder or visceral pain. A careful history and physical examination must be done to determine the exact cause of the neck pain. Nonmechanical neck pain is less likely to be related to disc disease, and other sources including tumor and infection must be considered. Radicular symptom neck pain will often be exacerbated by neck extension and rotation to the affected side (Spurling sign). In contrast, muscular neck pain is often exacerbated by neck flexion and rotation away from the more painful side. In cases of lower cervical degenerative disease, the pain often radiates to the shoulder, upper arm, or infrascapular areas, and upper cervical disease may present as temporal pain and retroorbital headaches.2

Cervical radiculopathy typically presents as pain and paresthesia in a single or multiple nerve root distribution. Spurling sign is a reproduction of radicular pain caused by extending the neck and rotating the head to the symptomatic side, which leads to narrowing of the neuroforamina. Axial compression and the Valsalva maneuver may also reproduce symptoms. The “shoulder abduction sign” is the reduction of radicular symptoms caused by placing the hand of the affected arm on top of the head, which decreases tension on the nerve roots.3

Cervical myelopathy typically has gait abnormalities, hyperreflexia, and loss of fine motor skills, which result from mechanical compression of the spinal cord in the cervical region. Motor weakness and muscle wasting may be present, as well as sensory abnormalities. Patients may also complain of neck pain and/or radicular symptoms, so careful evaluation must be done to determine the exact cause of symptoms. Typical examination findings include upper motor neuron signs and hyperreflexia manifested as a positive Hoffman reflex, clonus of deep tendon reflexes, and an upgoing Babinski reflex.

History and physical examination remain the most important processes in the diagnostic workup. Imaging and electromyography or nerve conduction studies can be used to supplement the diagnostic workup. Plain radiographs, including anteroposterior, lateral, oblique, and lateral flexion and extension views, can demonstrate developmental stenosis, disc space narrowing, abnormal alignment, dynamic instability, and osteophyte formation. Radiographic findings may occur with normal age-related degenerative changes, so radiographic findings must be correlated with clinical findings.4 Magnetic resonance imaging (MRI) is commonly used and is the most sensitive modality for demonstrating spinal cord morphology in relation to the surrounding bony and soft-tissue structures (Fig. 14-3). Computed tomography myelography is highly sensitive for detecting foraminal stenosis, but it is invasive and does have a risk of complications.5 Electromyography and nerve conduction studies can help distinguish between nerve root compression and a peripheral neuropathy and are useful in patients with unclear diagnose. In cases of mechanical neck pain without radiculopathy, several studies support the use of provocative discography to confirm discogenic origin of the pain and to clarify which disc levels are appropriate to treat.6,7

Treatment And Surgical Indications

The majority of patients with axial neck pain experience acceptable resolution of symptoms without surgical intervention. Cervical radiculopathy responds well to conservative treatment, but many patients progress to experience recurrent or persistent symptoms.8 Initially, activity modification and a brief soft collar immobilization are often recommended, but prolonged inactivity may lead to deconditioning. Early pharmacologic treatment is initiated with nonsteroidal antiinflammatory drugs or acetaminophen. With severe acute pain, narcotic analgesics may be used. Paraspinal muscle spasm may be relieved with muscle relaxants but is often improved with a soft collar immobilization alone. Some patients also may respond to oral corticosteroids.9 All medications should be prescribed only with careful regard for the potential adverse reactions and interactions with other medications that the patient is taking. Physical therapy is an essential component of conservative treatment and includes modalities, such as traction and heat or cold therapy, as well as an isometric neck and shoulder-stabilizing exercise program. The specifics of a physical therapy program are often left up to the discretion of the particular therapist.

Surgical treatment depends on the clinical entity treated and success of nonoperative treatment. Conservative treatment is the mainstay of initial treatment for cervical radiculopathy and degenerative disc disease with acceptable results.10 Surgical intervention for patients with cervical radiculopathy is indicated when the symptoms are persistent or recurrent or they are severe or debilitating enough to merit surgery.11 A prolonged conservative course is recommended for treatment of axial neck pain. If surgery is being considered for axial neck pain and diagnostic evaluation has failed, a discogram is obtained to identify the exact correct level(s) responsible for discogenic pain. As with any elective surgical procedure, appropriate patient expectations and selection must be considered before any surgical intervention (Box 14-1). In general, workers’ compensation patients and those involved in litigation can be expected to have worse outcomes even after successful fusion surgery.12,13 Cervical myelopathy must be considered separately, however, because clinical progression usually occurs even with conservative treatment. Classically, patients with cervical myelopathy have periods of clinical stability interspersed with “stepwise degeneration” and careful follow-up must be used to monitor disease progression.14

Surgical Procedure

Single-level cervical disc disease is most commonly treated with anterior cervical discectomy and fusion (ACDF). For one or more adjacent levels, some surgeons choose to perform a corpectomy of the intervening vertebral bodies instead of multilevel ACDF. After the discectomy, graft choices include an iliac crest bone graft, structural allograft, or a synthetic/metallic spacer. Currently, most surgeons use anterior cervical plating to prevent graft displacement anteriorly and to provide stability while cervical fusion occurs. In cases of severe stenosis or instability, intraoperative neuromonitoring is often used in an attempt to prevent injury and assess adequacy decompression.

Surgery begins with the induction of general endotracheal anesthesia. The patient is then placed in the supine position on a radiolucent operative table to allow imaging in both the anterior-posterior and lateral planes. A soft bump is placed beneath the scapula, and gentle traction is then applied to the cervical spine. In addition, gentle skin traction pulling toward the foot of the bed is applied with wide tape on the shoulders. Traction helps to radiographically visualize the lower cervical levels during surgery. The anterior neck is then prepped and draped, with care taken not to restrict the surgical field. Palpating the bony landmarks (or alternatively by using a radiopaque skin marker and a lateral radiograph) determines the level of the skin incision. A transverse incision is then made through the skin and subcutaneous fat, and bleeding is controlled using electrocautery. The platysma muscle is carefully cut in line with the incision to avoid cutting the large superficial veins just beneath it. Beneath the platysma muscle, the deep cervical fascia is identified and divided laterally to the anterior border of the sternocleidomastoid muscle, where it is dissected inferiorly and superiorly off of the muscle belly. A finger is then used for blunt dissection between the carotid sheath laterally and the trachea and esophagus medially down to the prevertebral fascia. Retractors are then used to retract the midline structures, allowing direct visualization of prevertebral fascia and underlying longus colli muscles and disc spaces.

Once the appropriate level is confirmed, the longus colli muscles are dissected off of the bone laterally and a self-retaining retractor is placed, exposing the disc space to the uncovertebral joints. The operating microscope, sterilely draped, is then brought into the field (Fig. 14-4). Under direct visualization using the microscope, the disc is incised with a scalpel and the anterior portion is removed using a pituitary forceps and an angled curette. A high-speed drill may be used to complete the discectomy and expose the posterior longitudinal ligament (PLL). After exposure, the PLL is elevated off of the posterior aspect of the vertebral bodies using a small 4-0 forward-angled curette; it is then excised using 1 mm and 2 mm Kerrison rongeurs. The PLL does not need to be routinely removed if no nuclear protrusion or extrusion is found, but this has to be carefully explored. The foramina can be probed with the 90° angled nerve hook to confirm adequate decompression or any remaining loose disc fragments. When the discectomy and foraminotomies are complete, the disc space is measured and an appropriately sized graft is chosen. While increased traction is applied on the halter traction device, the graft is gently impacted into position. When it is adequately positioned, all traction is removed. An appropriate-sized plate is then chosen and applied on the anterior aspect of the cervical spine. Care is taken when drilling screw holes to choose a length that will be contained in the vertebral body and be parallel with the endplate of the disc space. When the plate is in position, a lateral radiograph is obtained and graft and hardware positioning is checked (Figs. 14-5 and 14-6).

After instrumentation is complete, the wound is copiously irrigated and thoroughly checked for hemostasis. Often a drain is used even if the wound appears very dry, because a postoperative hematoma may cause significant morbidity. The platysma muscle and subcutaneous tissue are then closed with interrupted absorbable sutures. A running subcuticular layer of suture may follow this closure, followed by a sterile dressing. The patient is then placed into a rigid cervical orthosis before extubation.

Postoperatively, the head of the patient’s bed is maintained in an elevated position to decrease swelling in the neck. The patient should be able to walk, void, swallow liquids, and tolerate a diet before discharge. Most patients are discharged the day after surgery. Patients commonly complain of a sore throat and pain with swallowing a few days after surgery. If these complaints seem more severe than usual, then a single dose or short course of oral corticosteroids may be given in an attempt to minimize swelling.

Outcomes

Postoperatively, patients with radicular symptoms will often note immediate relief of pain after surgery. Most patients report a change in the quality of their axial neck pain to one more typical of postoperative pain. Generally, patients treated for radicular symptoms achieve excellent clinical results (up to 90% satisfactory results), whereas those treated for axial neck pain achieve good results.15,16 One concern in the postoperative period is overactivity before fusion is achieved. Solid consolidation of fusion often requires 6 to 12 weeks, so excessive motion and loading are discouraged during this period. Often patients are maintained in a rigid cervical collar for 6 to 12 weeks to restrict their activities, but patients frequently recover from surgery much sooner and desire to remove the orthosis and resume normal activities. This relative immobilization can result in significant patient deconditioning, which can be a challenge to the therapist. In the early period of return to activity and therapy, it is important to avoid injury caused by an overly strenuous exercise program or an overzealous patient.

Future Directions

ACDF is a generally well-tolerated and successful procedure; however, recent data has shown that cervical fusion may lead to less satisfying results than previously thought.17 Concerns about adjacent segment disease has led to the development of cervical total disc replacement.18 Recently, results of a multicenter, randomized, prospective Federal Drug Administration clinical trial of cervical disc replacement (Synthes Prodisc-C) versus ACDF has shown clinical equivalence or superiority of cervical disc replacement over fusion.19 Other clinical studies have demonstrated similar consistent evidence with other cervical disc prosthese.20,21 These treatments have the potential of offering shorter recovery times and more rapid return to activity and may help prevent the progression of adjacent-level degeneration. Our view is that cervical disc replacement is superior to fusion.

Therapy Guidelines For Rehabilitation

Rehabilitation after a surgery is a science and an art. The science of rehabilitation relies on a solid understanding of the body’s normal response to injury and trauma. The art of rehabilitation rests in the clinician’s ability to interpret the individual patient’s unique signs and symptoms. The ability to formulate a plan of care that maximizes an individual’s healing potential relies on the ability to blend the science and the art of rehabilitation. The initial portion of this chapter is designed to provide the clinician with an understanding of the role that tissue healing plays in the development of a rehabilitation program. This will serve as a scientific foundation upon which a clinician can base his or her clinical reasoning process. This tissue-healing model will then be placed in the context of ACDF. The activities and precautions of each phase of the rehabilitation process will be rooted in current understanding of the phases of tissue healing. Specific treatment options are provided throughout the chapter, but these should only serve as a guide to treatment and should not replace sound clinical reasoning or judgment when rehabilitating after ACDF.

The decision to operate on the cervical spine may be driven by localized tissue damage and subsequent focal pain, but the majority of spinal surgeries are initiated because of damage to (or threat of damage to) the neural network of the body. Myelographic computed tomography and MRI studies have all demonstrated that 20% to 30% of people who have disc herniation and stenosis do not have radicular symptoms, and many of these people do not have neck pain.22 It has also been shown that under anesthesia, only nerves that are inflamed will produce radicular symptoms when compressed or placed under traction. Therefore, although the intervertebral disc or stenosis can be the source of neck pain, it is generally injury to the nerve that drives the decision to undergo surgery. Protecting the nervous system from further damage and providing an environment in which the nerve can heal are primary goals of the surgery and rehabilitation thereafter.

Within the spine, injury or damage to the nerve often occurs at the spinal nerve root or the dorsal root ganglia. Anatomically, differences in the nerve root make it more susceptible to injury than at other regions of the peripheral nerve. The nerve root is not as well protected, less able to withstand deformation, and less able to repair itself than the remainder of the peripheral nerve. The other structure within the intervertebral foramen that is susceptible to damage is the dorsal root ganglia. The position of the dorsal root ganglia is not constant and can be found inside the foramen, outside the foramen, or in the spinal canal, which can increase the likelihood that it will be injured. In addition, unlike the spinal nerve root and peripheral nerve, the dorsal root ganglia do not have a blood-nerve barrier, which is necessary to prevent foreign substances from invading the nerve. These anatomic differences predispose the dorsal root ganglia to edema and mechanical compression.2224

Nerves must also be able to move and glide within the tissue. For this to occur, some slack in the system must exist. The spinal cord changes length by 7 cm from flexion to extension. Studies in the arm show that a 7-mm excursion occurs in the nerves with movement. In addition to compression, increased tension of the nerve can result in nerve damage.

imageMore specifically, tension in nerves causing a 20% to 30% increase in length will cause the nerve to break. Boyd and associates25 demonstrated that as little as 6% strain decreases the amplitude of action potentials by 70%, and 10% to 12% strain causes complete conduction block. They have also shown that nerve stretch of as little as 8% greater than the resting length will cause a 50% decrease in blood flow to the nerve and stretch of 15% will cause 80% to 100% reduction in blood flow. Therefore, exercises that place undue stress and tension on the nerves should be avoided.26

Neurons are incapable of dividing and migrating; therefore regeneration occurs only through existing neurons. If the connective tissue sheathing remains intact, then a potential for nerve regrowth exists. If the sheath is disrupted, then the potential for regrowth diminishes. Initially, like any tissue, an inflammatory process is seen within the nerve. Within hours after injury, the nerves start to grow back from the distal stump at 1 to 2 mm per day. In addition to transmitting nerve impulses, the axon of the nerve functions to transmit nutrients and chemicals down its lumen. These axons are filled with axoplasm, which is necessary for nerve health and survival. Axoplasm is a viscous substance and is thixotropic, which means that it needs constant agitation or it will gel.2224 imageThus care must be taken to encourage movement and gliding of the nerve, but at the same time, positions that place tension on the nerve should be avoided.

ACDF surgery affects the sternocleidomastoid, platysma, anterior scalene, middle scalene, and the longus colli muscles. It also requires the resection of the anterior longitudinal ligament, PLL, joint capsule, and synovium.2730 After the trauma incurred during surgery, the body is only capable of repairing small muscle lesions with regeneration of muscle tissue. Large lesions will fill in with dense connective scar tissue. Although dense connective scar tissue can function to reestablish tissue continuity, it lacks the contractile elements of normal muscle tissue and the tensile strength of normal ligament and tendon tissue. Therefore the ability to generate contractile forces or resist tensile loading through the region of repair is compromised.3134

Bone grafts from the iliac crest or from bone donors are often used within the disc space, between two vertebral bodies, to aid in the mineralization and fixation of the region. The iliac crest is used as the primary source of graft material because of its cancellous bone composition. Cancellous bone has a greater potential for revascularization and osteogenesis than grafts from denser cortical bone sources. Healing after a cortical bone graft can take up to two times longer than its cancellous bone graft counterpart.31,32 As will become apparent later in the chapter, the healing and mineralization of bone at the site of fusion is a major factor driving progression through the rehabilitation process.

Phase I (Inflammation)

The inflammation phase is the first phase of tissue healing. It begins with injury to the tissue, reaches its peak within the first 72 hours after injury, and is generally completed within 14 days. During these first 14 days, several events occur. Vascular structures in the immediate area constrict to prevent blood loss, and vascular tissues in the surrounding areas dilate to provide conduits through which healing materials can enter the injured site. Cells and chemical mediators are brought into the area to remove all foreign debris and dead or dying tissue and are responsible for the closure of the wound. Both of these actions are important in the prevention of infection.31,32 During the inflammation phase in bone healing, a hematoma is formed at the site of the surgery. This begins immediately after surgery and is usually completed within 7 days. The hematoma will form around the graft and fusion site, and granulation tissue will fill any open space between the graft, the vertebral bodies, and the instrumentation.3134 Clinically, rehabilitation during the inflammation phase of tissue and bone healing should focus on the prevention of blood loss, reduction of inflammation, and managing the pain that accompanies tissue damage (see Table 14-1).

Phase II (Reparative)

The reparative phase is the second phase of tissue healing. This phase begins almost immediately after injury and is completed in 21 days. The primary function of this phase is the formation of the dense connective tissue needed to repair the wound and reestablish structural continuity of the affected region. The process of repairing the tissue to its original state is a time-consuming process, and little evidence supports the notion that tendons, ligaments, or large muscle injuries heal by regenerating into their original tissue. Thus the reestablishment of structural continuity and integrity of tendons, ligaments, and large muscle lesions is completed through the creation of dense connective scar tissue. Reparation with dense connective tissue patches or scar tissue is a fast process that can allow for quicker recovery of the tissue. Angioblasts and fibroblasts begin to enter the injured region within 5 days of the injury. These cells begin the process of tissue repair and the revascularization of the region. Most of the actual dense connective tissue development is completed by day 21. During bone healing at this time, a synthesis and organization of collagen is seen in the hematoma. Once the hematoma is organized, blood vessels invade the area. This allows osteoblasts to migrate into the region and form woven bone, which is known as a soft callus.3134 Clinically, the goal of rehabilitation in this phase should be to promote the development of the new dense connective reparative tissue and woven bone (see Table 14-1).

Phase III (Remodeling)

The remodeling phase is the last phase of the tissue healing process. The purpose of this phase is to strengthen the newly formed scar tissue. Two subphase make up tissue remodeling: (1) consolidation and (2) maturation. During the consolidation subphase, tissue is undergoing conversion from a cellular type to one that is fibrous in nature. The actual size of the scar stops growing by 21 days, although the scar will continue to strengthen in response to stress. This subphase lasts from 22 to 60 days. During this phase of bone remodeling, the soft callus phase begins to mineralize and form a hard callus. Variations in mineralization time exist, but generally mineralization is completed by day 64. Mineralization of the callus is used diagnostically as a marker for when it is appropriate to begin rehabilitation. The patient will not be referred for rehabilitation until radiographic evidence indicates that the callus has mineralized.3134 Clinically, rehabilitation should address protection and prevention of excessive motion through the fusion site.

image Excessive motion at the fusion site can lead to excessive callus formation and delay of the reparative process. The goal of rehabilitation in this phase should be the strengthening of the newly formed connective tissue. Care must be taken during this phase not to exceed the mechanical limits of the newly formed tissue, because overstress of the tissue will result in tissue injury and delay healing.

The maturation subphase occurs from day 60 to 360 when the tissues are fully fibrous in nature. For this reason, a progression in the strengthening of the affected tissues may begin. For bone remodeling, the hard callus begins to adapt to the stresses placed upon it. These stressors can be internal and external and include low serum calcium levels, skeletal microdamage, and changes in mechanical stress. The bone-remodeling process generally takes 6 months from initiation to completion, but it can take up to 4 years.3134 Clinically, rehabilitation programs must provide appropriate levels of stress to the bone to encourage bone strengthening and remodeling without creating or exacerbating tissue injury (see Table 14-1).

Summary

Although guidelines can provide generalized time frames for healing and recovery, it is important to realize that a firm grasp of the factors listed previously will enable the clinician to individualize the rehabilitation program for each patient. No two patients are identical. Therefore no two rehabilitation programs should be identical. Solid clinical reasoning regarding the patient and the nature of the injury and surgery will ultimately drive the rehabilitation process.

Certain key components should be kept in mind during each phase of the rehabilitation process for ACDF.

Phase I:

The initial goal of rehabilitation should be the reduction of inflammation, closure of the wound, and reduction in pain.

Phase II:

The surgical site should be protected until dense connective tissue is formed and the bone shows evidence of mineralization.

Movement of the UEs below shoulder levels to promote nerve mobility and healing should be encouraged.

Phase III:

Gliding of the neural tissue through the surgical site to prevent the formation of adhesions should be promoted.

The clinician should begin placing stress on the soft tissue and bone in graded increments to promote proper soft tissue and bone growth and development.

Description Of Rehabilitation And Rationale For Using Instrumentation

Phase I (Inflammatory Phase)

TIME: 1 to 2 weeks after surgery (days 0 to 14)

GOALS: Protect the surgical site, decrease pain and inflammation, maintain UE flexibility, and initiate patient education regarding neutral cervical spine mechanics (Table 14-2)

During the initial phase of rehabilitation, the primary focus of physical therapy is to protect the surgical site and make sure that the patient is educated on the mechanics of maintaining a proper neutral cervical spine (Fig. 14-7). Hospitalization after ACDF in most cases will be for 1 to 2 days. During this time the patient will be given a cervical collar to wear to immobilize the neck and encourage soft tissue and bone healing. Instructions regarding the frequency of collar wear will be determined by the physician and may differ on a case-by-case basis.

Physical evaluation during this time may include wound assessment and the assessment of bed mobility and gait. imageBecause of the fragility of the wound and fusion sites, assessment of cervical range of motion (ROM) and UE strength are not appropriate in this phase. The primary physical impairments that the patient is likely to experience are pain, limited cardiovascular endurance, and limited tolerance to upright activities. During this time the injured vasculature around the wound begins to close and the noninjured vessels dilate, which may lead to increased warmth and redness around the incision site. This may be accompanied by neck pain and a sore throat. Oral analgesics may be given by the physician to manage the pain and inflammation.

The inflammatory phase lasts approximately 2 weeks. During this time activities should center on resuming normal daily activities. Ambulation to and from the restroom should begin immediately, with assistance as needed, and progress until the patient is independent. The patient should be encouraged to increase the daily sitting tolerances. Pain and fatigue should guide the progression. Once discharged from the hospital, the patient will be instructed to protect the cervical region. The cervical collar issued earlier should be worn 24 hours a day unless otherwise ordered by the physician.

imageBefore discharge from the hospital, it is important that the therapist educate the patient on proper cervical spine mechanics during activity, as well as the need to restrict large amounts of movement in the neck to prevent soft tissue and bone injury. (Refer to Box 14-2 for specific patient guidelines to follow after discharge.) Because of the many muscular attachments of the shoulder girdle to the cervical spine, the patient should be advised to refrain from heavy lifting and from activities above shoulder level. Before discharge, the need to continue a home walking program and use of the cervical collar should also be addressed.

Phase II (Reparative Phase)

TIME: 3 weeks after surgery (days 0 to 21)

GOALS: Understand neutral spine concepts, increase UE soft tissue mobility and flexibility, improve upright tolerance, improve activities of daily living (ADLs), increase cardiovascular function (Table 14-3)

TABLE 14-3

Anterior Cervical Discectomy and Fusion

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ADLs, Activities of daily living; AROM, active range of motion; ROM, range of motion; UE, upper extremity.

In many instances, phase II of the rehabilitation process will take place independently in the patient’s home. Home therapy is rarely indicated; therefore education regarding patient progression through the first month after surgery is an important aspect of hospital care. The patient will be progressed to phase III once sufficient radiographic evidence of callus formation and mineralization is seen. During the reparative phase of tissue and bone healing, the body begins to form and lay down scar tissue at the surgical site, enhancing the integrity of the musculature to withstand gradual increases in loads to the tissues. Within the bone fusion site, callus formation is nearing completion. Rehabilitation throughout this phase should be a continuation of phase I, and a broadening of the focus to include the restoration of UE ROM to shoulder level and independence with self-care skills while protecting the surgical site (Fig. 14-8). At this time in the rehabilitation process, the patient may begin active range of motion (AROM) exercises of the shoulders. Nerves and soft tissue require movement to heal properly. Movement also prevents the formation of scar tissue adhesions between the nerve and the healing tissue surrounding the surgery. Therefore movement of the arms below shoulder level should be encouraged. Exercises incorporating flexion and extension of the elbow, wrist, and fingers should also be implemented at this time. imageMotion above shoulder level should still be avoided.

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