12 Posterior Cervical Plating Techniques 1. To stabilize and reduce the cervical spine 2. To maintain sagittal alignment 3. To allow for early rehabilitation 4. To increase the rate of fusion 1. Multilevel cervical laminectomy for myelopathy 2. Trauma 3. Deformity 4. Posttraumatic instability 5. Reconstruction after neoplasm excision 1. Anterior column not capable of load bearing (e.g., burst fractures). 2. Stabilization of the cervical spine after total unilateral or partial bilateral facetectomy. 3. Stabilization of the cervical spine in the absence of posterior elements (spinous process, lamina, facet). 1. Incompetence of facets 2. Anterior spinal cord compression 3. Fixed kyphotic deformity 4. Osteoporosis 5. Infection 1. Immediate rigid stabilization of cervical spine. 2. Maintenance of sagittal alignment. 3. Diminished need for postoperative immobilization. 4. Increased rate of fusion. 5. Earlier return to function. 6. Titanium implants allow for postoperative imaging. 7. Can be used if spinous processes, lamina, or facets are injured or absent. 8. Can be used for multilevel fusions. 1. Technically demanding procedure 2. Additional operative time 3. Cost Care must be taken to stabilize the neck during intubation and turning to the prone position. A Mayfield headrest is applied with one pin placed 1 inch above the pinna of the ear. The other side of the headrest has two pins that are placed 1 inch above the ear. The frame crosses in front of the forehead and attaches to the table. A horseshoe-shaped headrest may also be used, but no pressure may be placed on the eyes because retinal ischemia may result. The knees and elbows should be well padded. The reverse Trendelenburg position diminishes venous bleeding and lowers cerebrospinal fluid pressure (Fig. 12–1). The shoulders may be taped to help with caudal retraction. The incision is made in the midline of the neck over the spinous processes of the involved levels to be fused (Fig. 12–2A). The ligamentum nuchae is identified and incised in the midline. The C3-C6 spinous processes are bifid. The C2 and C7 spinous processes are more prominent. Subperiosteal dissection of the paraspinal musculature is performed down the spinous process and over the lamina. Lateral dissection at C1 should be limited to 1.5 cm from the midline as the vertebral artery is in this region. The facet capsule is excised subperiosteally at the joints to be fused. Facet capsules should be preserved above and below the fusion. Limit dissection to the involved levels to prevent formation of a “creeping fusion.” The interlaminar spaces are wide in the cervical spine. Great caution must be exercised during dissection to avoid violating the dural sac and injuring the spinal cord. Facet joint anatomy may be distorted by osteoarthritis. It is imperative to properly define the boundaries of the facet to correctly identify the starting point of the screw hole. Several systems are available including AO reconstruction plates,Y plates, and rod-screw constructs. The plates should be contoured to 105 degrees to approximate normal occipitocervical lordosis, although premolded plates are available (Fig. 12–2B
Goals of Surgical Treatment
Diagnosis
Indications for Surgery
Contraindications
Advantages of Posterior Plating in the Cervical Spine
Disadvantages
Patient Preparation and Positioning
Incision
Exposure Secrets
Procedures
Occipitocervical Fixation
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