Choice of Surgical Approach

and Uwe Spetzger¹

(1)

Department of Neurosurgery, Klinikum Karlsruhe, Karlsruhe, Baden-Württemberg, Germany

In most cases of degenerative diseases of the cervical spine, the neural structures are compressed from anterior; thus, the anterior approach is the mainly used surgical approach to the cervical spine. The posterior approach is suitable for findings with ligamentous hypertrophy and space-occupying facet joint arthrosis as well as for elderly patients with spontaneous bony fusion in the intervertebral spaces where as lordosis is an essential precondition for this approach. Combined approaches are indicated in cases of corpectomy of two or more vertebral bodies and generally in cases with reduced bone quality due to a metabolic diseases such as osteoporosis, diabetes mellitus or renal failure.

6.1 Anterior Approach

Anterior cervical discectomy and fusion (ACDF) is the most commonly used procedure for the surgical treatment of cervical spondylotic radiculopathy and myelopathy since most space-occupying structures originate from intervertebral discs, posterior longitudinal ligament and vertebral bodies and thus are located anteriorly to the spinal cord. A corpectomy is indicated in cases of a confluent multilevel stenosis because this kind of stenosis continues from disc space to disc space behind the vertebral body (Medow 2006; König 2013). For the surgical technique, see Sects. 8.1 and 8.2.

Especially after corpectomy the re-establishment of sagittal balance and cervical lordosis is a further goal of surgery besides decompression of neural structures (Park 2012). This is achieved by choosing an adequate vertebral body replacement and bending the anterior plate prior to implantation (see Chap. 7). Hussain et al. (2013) could show in a finite element model that range of motion and load for discs and facet joints in adjacent levels is least after anterior fusion followed by posterior and combined fusion.

These biomechanical stresses are considered as aetiological for accelerated adjacent level degeneration after fusion surgery (Kepler 2012). Thus, from a biomechanical point of view, the anterior approach for the surgical treatment of cervical radiculopathy and myelopathy should be preferred. This finding is of advantage for the clinical situation where most patients show space-occupying degenerative changes anterior to nerve roots and the spinal cord (Fig. 6.1).

Fig. 6.1

Osteoligamentous spinal stenosis from C3 to C5 in a 66-year-old female, sagittal MRI (a). Corpectomy of C4 for decompression and vertebral body replacement with an iliac crest bone graft as well as anterior plating (system: Skyline, Synthes, Umkirch, Germany), sagittal CT scan (b)

6.2 Posterior Approach

For patients with predominant dorsal spinal cord compression, the surgeon can basically choose between two different procedures: laminectomy and lateral mass fusion (Fig. 6.2) or open-door laminoplasty (Fig. 6.3). For the surgical technique, see Sects. 8.3 and 8.4.

Fig. 6.2

Osteoligamentous spinal stenosis at levels C3/C4 and C4/C5 with predominant dorsal space occupation, sagittal (a) and axial MRI (b). Indication for posterior approach with decompression and fusion (system: Synapse, DePuy/Synthes), postoperative axial CT (c)

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