19.1 Case Presentation and Preoperative Imaging

A 61-year-old woman presents to your office with chronic neck pain and numbness in her right hand. The numbness is exacerbated by turning her head to the right, looking up, and overhead reaching. She has 5/5 strength and intact reflexes in the upper extremities bilaterally, with no clonus or spasticity. Hoffman’s sign is positive bilaterally. Conservative therapy with heat and ice packs, and physical therapy have provided minimal pain relief. Magnetic resonance imaging (MRI) scan of the cervical spine was recommended ( Fig. 19.1 ).

19.2 Indications

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  Degenerative cervical disk disease with central stenosis, neuroforaminal stenosis, or myelopathy.

  
  
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  Tumor.

  
  
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  Epidural abscess.

  
  
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  Ossification of the posterior longitudinal ligament with stenosis.

19.3 Positioning

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  Prone.

  
  
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  Landmarks:

  
  
  
  
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    Spinous processes:

    
    
    
    
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      C2, C7–T1 are the most prominent.

19.4 Approach

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  Superficial dissection:

  
  
  
  
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    Straight incision is made in the midline:

    
    
    
    
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      Internervous plane is in the midline; paracervical muscles are segmentally innervated by the left and right posterior rami.

      
      
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      Minimal bleeding may emanate from the venous plexuses.

    
    
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    Dissection is performed through the ligamentum nuchae:

    
    
    
    
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      Continuous with the supraspinous ligament.

  
  
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  Deep dissection:

  
  
  
  
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    Remove paracervical muscles subperiosteally ( Fig. 19.2 ):

    
    
    
    
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      Excessive bleeding may occur from the segmental arterial vessels.

    
    
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    Perform laminectomy at the junction between the lamina and lateral mass of each side:

    
    
    
    
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      The epidural veins are thin and may bleed copiously.