Cervical Case Studies

22 Cervical Case Studies


Mick J. Perez-Cruet, Richard G. Fessler, and Michael Y. Wang


Abstract


This chapter reviews a number of cervical cases using a variety of minimally invasive approaches. These approaches include simple decompression, spinal fusion, and instrumentation for trauma and more complex reconstruction and tumor resection. It is hoped that these cases will spur additional interest in applying anatomy-preserving minimally invasive approaches, techniques, and technology to the cervical spine. Further refinements in instrumentation including robotics could expand indications and applications of minimally invasive approaches to the cervical spine. With proper application, these techniques and technologies can lead to faster recoveries and improved patient outcomes, ultimately leading to more cost-effective care.


Keywords: cervical, minimally invasive, degenerative disease, trauma management, tumor management, MIS instrumentation and applications


22.1 The Evolution of Cervical Minimally Invasive Spine Surgery


The cervical spine poses a unique environment for the surgeon. The biomechanics, anatomy, and function of this area are distinct from the thoracolumbar spine, and the evolution of MIS techniques has thus been quite different, as well. For most surgeons, the anterior approaches initially described by Cloward1 and Smith and Robinson2 are already minimally painful, and improvements in this arena have been challenging. Thus, most of the recent advances have been improvements in posterior cervical surgery.


This chapter highlights case studies intended to introduce the reader to some of the practical applications of topics already covered in other areas of this textbook. Case studies offer significant illumination to areas that may be more murky in topic-oriented discussions. As such, they can provide unique insight for the reader. However, they are also limited by the inherent heterogeneity seen in the practice of spinal surgery, with regard to pathology, presentation, patient factors, and responses to treatment.


22.2 Case 1: Cervical Foraminotomy


22.2.1 Patient Profile


A 47-year-old woman with a 5-year history of pain and dysesthesia located in the right anterior and lateral arm and shoulder and radiating to the right thumb and first and second finger. Increased by flexion. Improved with lying down. Failed physical therapy (PT), and epidural steroid injections. Imaging studies revealed a right C5/C6 disc/osteophyte causing foraminal stenosis (image Fig. 22.1).


22.2.2 Case Selection


Although this could be done through an anterior or posterior approach, the laterality of this disc/osteophyte complex makes it a perfect case to approach posteriorly using minimally invasive technique.


22.2.3 Preoperative Notes


The options were discussed with the patient in detail, including specific techniques, anticipated recovery and ultimate desired function, need versus no need for instrumentation, and risks.


22.2.4 Instrumentation Notes


For this approach and procedure, no instrumentation is needed.


22.2.5 Surgical Approach and Technique


Using fluoroscopy to identify the level, a 2-cm incision was made 1.5 cm right of midline. Under direct vision, dissection was performed to the facets using a Metz scissors. A medium-sized dilator was then placed onto the facets and further dilation was performed until an 18-mm working channel was positioned. Location was verified, and an endoscopic camera was placed into the channel. Alternatively, a microscope can be used for visualization. Bovie cautery was used to remove a small amount of soft tissue. A hemilaminotomy was performed using a Kerrison punch. This was extended into a foraminotomy using both a drill and the Kerrison punch. Decompression was verified from pedicle to pedicle and to the lateral aspect of each pedicle.



22.2.6 Postoperative Care


The patient was discharged in approximately 2 hours.


22.2.7 Management of Complications


The most frequent complication is most likely cerebrospinal fluid (CSF) leak from a dural breach. In the cervical spine, this requires nothing more than Gelfoam and a dural sealant.


22.2.8 Operative Nuances


Because the interlaminar space can be quite large, Kirschner wires (K-wire) should not be used here. Dissection should be performed under direct vision using a Metz scissors to create a free pathway for placement of a medium-sized dilation tube. In that way, nothing is ever pushed forcefully toward the spinal cord. Rather than using a Bovie cautery when removing soft tissue from the medial interlaminar space, the bipolar electrosurgery should be used.


22.2.9 Postoperative Results


Published series demonstrate excellent to good results in 85 to 90% of patients with a very low complication rate.3


22.3 Case 2: Cervical Decompression


22.3.1 Patient Profile


A 78-year-old man, 13 years s/p C5/C6. Anterior cervical discectomy and fusion (ACDF) with 2 years neck pain getting worse over time. It is primarily located in the posterior midline and increases with flexion. Patient has failed PT, pain medication, epidural steroid injection. Right C4 selective nerve root block significantly relieved pain. MRI demonstrates cervical stenosis at C3–C4 level (image Fig. 22.2).


22.3.2 Case Selection


This stenosis could be approached either anteriorly with an ACDF or posteriorly with laminectomy and decompression. Because this is limited to a single level, it is an easy case to perform using a minimally invasive technique and converts the operation into an outpatient procedure.


22.3.3 Preoperative Notes


The options were discussed in detail with the patient. Anterior, open posterior, and MIS posterior options were described and pros and cons of each discussed. Because of the higher incidence of swallowing difficulties in the elderly following high cervical anterior procedures, the patient did not want ACDF. He selected the minimally invasive posterior approach.


22.3.4 Instrumentation Notes


For this approach and procedure, no instrumentation is needed.


22.3.5 Surgical Approach and Technique


Using fluoroscopy to identify the level, a 2-cm incision was made, 1.5 cm right of midline. Under direct vision, dissection was performed to the facets using a Metz scissors. A medium-size dilator was then placed onto the facets and further muscle dilation was performed using serial muscle dilators until an 18-mm working channel was positioned. Location was verified, and an endoscopic camera was placed into the channel. Alternatively, an operative microscope can be used. Bovie cautery was used to remove a small amount of soft tissue. A hemilaminotomy was performed using a Kerrison punch. This was extended into a foraminotomy using both a drill and Kerrison punch.


Decompression was verified from pedicle to pedicle and to the lateral aspect of each pedicle. The tube was then angled to the contralateral side. Using a partially shielded drill, the base of the spinous process and ventral surface of the contralateral lamina were removed. Hemostasis was achieved with Surgifoam.



22.3.6 Postoperative Care


The patient was discharged in approximately 2 hours.


22.3.7 Management of Complications


The most frequent complication is most likely CSF leak from a dural breach. In the cervical spine, this requires nothing more than Gelfoam and a dural sealant.


22.3.8 Operative Nuances


Because the interlaminar space can be quite large, K-wires should not be used here. Dissection should be performed under direct vision using a Metz scissors to create a free pathway for placement of a medium-sized dilation tube. In that way, nothing is ever pushed forcefully toward the spinal cord. Rather than Bovie cautery, when removing soft tissue from the medial interlaminar space, the bipolar should be used. When drilling the contralateral side, care must be taken to drill the bone without compressing the dural sac/spinal cord. The ligamentum flavum is left in place while drilling to help protect the dura and prevent durotomy.


22.3.9 Postoperative Results


Only a few published series exist, but all report excellent to good results in 85 to 90% of patients, with a very low complication rate.3


22.4 Case 3: Tubular Access for Instrumented Fusion


22.4.1 Patient Profile


A 33-year-old man dove into a shallow pool, resulting in severe neck pain. He presented to the emergency department neurologically intact, but with axial pain 7/10. Imaging studies revealed a dislocation at the C3/C4 level (image Fig. 22.3).


22.4.2 Case Selection


With the absence of a large anterior disc herniation in a neurologically intact patient, a posterior approach with reduction, fixation, and fusion is a reasonable treatment option.


Oct 17, 2019 | Posted by in NEUROSURGERY | Comments Off on Cervical Case Studies

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