1 Cervical
1.1 Trauma
1.1.1 Anterior Cervical Fusion/Posterior Cervical Fusion
Indications
Traumatic occipitoatlantal disjointment
No complete arch of C1
Bursting C1 fracture (see ▶Fig. 1.1)
Fig. 1.1 (a–c) A man suffered an incomplete cord injury after a vehicle crash. Radiology revealed that his cervical trauma was a C5 complete burst fracture. Diagnostic Features. In: Vialle L, ed. AOSpine Masters Series, Volume 5: Cervical Spine Trauma. 1st ed. Thieme; 2015
Congenital abnormalities
Odontoid movement into foramen magnum
Vertebral shifts
Symptoms and Signs
Stiff neck
Sharp pinpoint pain in neck
Soreness lasting >7 days
Weakness in neck muscle
Tingling/Numbness in general neck area
Trouble gripping objects
Tingling in finger tips
Frequent tension headaches (~4+ days per week)
Surgical Pathology
Traumatic brain injury (TBI)
Traumatic injury to general neck region
Fracture/Displacement/Compression
Surgical Procedure
Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 12 days
Appropriate intubation and sedation
Horizontal skin incision 1 to 2 inches on either side of the spine
Split thin muscle underlying skin
Enter plane between sternocleidomastoid muscle and strap muscle
(Anterior) Enter into the plane between trachea/esophagus and carotid sheath
Dissect away thin fascia
Locate disk (preoperative imaging match/intraoperative fluoroscopy)
Remove disk by cutting annulus fibrosis and nucleus pulposus
Remove entire disk including cartilage endplates to reveal cortical bone
Remove ligamentous tissue front to back to allow access to spinal canal
Insert bone graft and implant cage into evacuated space
Attach small plate to front of spine with screws in each vertebral bone (see ▶Fig. 1.2 to ▶Fig. 1.4)
Fig. 1.2 (a, b) Cord decompression, corpectomy (C5), and fusion (C4–C6) were performed. The fusion healed within one year. Diagnostic Features. In: Vialle L, ed. AOSpine Masters Series, Volume 5: Cervical Spine Trauma. 1st ed. Thieme; 2015 
Fig. 1.3 (a–d) A patient suffered cervical trauma resulting in C3/C4 dislocation. Fusion (C3–C4) was performed and lateral mass screw placement was verified using X-ray and CT scan. Cervical case studies. In: Perez-Cruet M, Fessler R, Wang M, eds. An Anatomic Approach to Minimally Invasive Spine Surgery. 2nd ed. Thieme; 2018 
Fig. 1.4 A man suffered cervical trauma after a bicycle accident, resulting in traumatic disk herniation. Radiology revealed associated cord contusion and C3–C4 instability. Fusion (C3–C4) was performed and after therapy, his paresis reduced. Brembilla C, Lanterna L, Gritti P, et al. The use of a stand-alone interbody fusion cage in subaxial cervical spine trauma: a preliminary report. J Neurol Surg A Cent Eur Neurosurg 2015;76(01):13–19
Clean surgical site, exit, and suture
If posterior approach is needed, place the patient prone with Mayfield head pins with all pressure points padded
Dissect to lamina over affected levels and confirm levels on X-ray
Perform laminectomy and foraminotomies over affected levels that are stenotic and place lateral mass screws with rods and bone graft if needed over affected levels for fusion
Obtain hemostasis, place drain, and close wound in multiple layers
Pitfalls
Loss of neck mobility by ~30%
Intraoperative cerebrospinal fluid (CSF) leak
Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
Damage to spinal nerves and/or cord
Postoperative weakness or numbness or continued pain
Postoperative wound infection
Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
Prognosis
Most patient are hospitalized for 1 to 2 days, then return home with strict orders of minimal sudden head/neck movement
Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities
Full fusion (formation of hard bone) may take 12 to 18 months
Physical therapy (PT) and occupational therapy (OT) should strongly be considered
1.2 Elective
1.2.1 Anterior Cervical Fusion/Posterior Cervical Fusion
Indications
No complete arch of C1
Bursting C1 fracture
Congenital abnormalities
Odontoid movement into foramen magnum
Vertebral shifts
Symptoms and Signs
Stiff neck
Sharp pinpoint pain in neck
Soreness lasting >7 days
Weakness in neck muscle
Tingling/Numbness in general neck area
Trouble gripping objects
Tingling in finger tips
Frequent tension headaches (~4+ days per week)
Surgical Pathology
Spondylosis
Spondylosis
Adjacent segment pathology (ASP)
Radiculopathy (see ▶Fig. 1.5)
Fig. 1.5 (a, b) An elderly woman with neck pain and deformity from myelopathy received posterior decompression (C3–C6), anterior diskectomy and fusion (C4–C5), and posterior fusion (C2–T2). A transition rod was added for stabilization. Radiographic considerations. In: Ames C, Riew K, Abumi K, eds. Cervical Spine Deformity Surgery. 1st ed. Thieme; 2019
Osteomyelitis
Vertebral body tumors
Myelopathy (see ▶Fig. 1.6 and ▶Fig. 1.7)
Fig. 1.6 (a, b) An elderly man with chin-on-chest deformity (kyphosis) received anterior and posterior cervical osteotomies. Posterior fusion (C2–T10) was performed and resulted in significant correction of the kyphosis. Radiographic considerations. In: Ames C, Riew K, Abumi K, eds. Cervical Spine Deformity Surgery. 1st ed. Thieme; 2019 
Fig. 1.7 (a, b) An elderly woman with neck pain from myelopathy received posterior decompression and fusion (C3–C6). This was followed by a diskectomy and osteotomy (C6–C7), posterior fusion (C2–T2), and laminectomy (C6/7 and C7/T1) for decompression. Radiographic considerations. In: Ames C, Riew K, Abumi K, eds. Cervical Spine Deformity Surgery. 1st ed. Thieme; 2019
Postlaminectomy kyphosis (see ▶Fig. 1.8)
Fig. 1.8 (a, b) Landmarks for posterior cervical tubular decompression via foraminotomy. After identifying the lamina–facet junction and other bony landmarks, commence laminar resection. Minimally invasive tubular posterior cervical decompressive techniques. In: Vaccaro A, Albert T, eds. Spine Surgery: Tricks of the Trade. 3rd ed. Thieme; 2016
Opacified posterior longitudinal ligament
Surgical Procedure
Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 12 days
Appropriate intubation and sedation
Horizontal skin incision 1 to 2 inches on either side of spine
Split thin muscle underlying skin
Enter the plane between sternocleidomastoid muscle and strap muscle
(Anterior) Enter into the plane between trachea/esophagus and carotid sheath
Disect away thin fascia
Locate disk (preoperative imaging match/intraoperative fluoroscopy)
Remove disk by cutting annulus fibrosis and nucleus pulposus
Remove entire disk including cartilage endplates to reveal cortical bone
Remove ligamentous tissue front to back to allow access to spinal canal
(Posterior) Incision on midline, behind neck
Elevate paraspinal muscles
Confirm correct level (discussed above)
Remove small portion of facet joint with burr drill, expose nerve root, gently move to side to expose disk herniation
Insert bone graft and implant cage into evacuated space
Attach small plate to spine with screws in each vertebral bone
Clean surgical site, exit, and suture
Pitfalls
Loss of neck mobility by ~30%
Instrumentation failure
Bone graft failure
Intraoperative CSF leak
Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
Damage to spinal nerves and/or cord
Postoperative weakness or numbness or continued pain
Postoperative wound infection
Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
Prognosis
Most patient are hospitalized for 1 to 2 days, then return home with strict orders of minimal sudden head/neck movement
Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities
Full fusion (formation of hard bone) may take 12 to 18 months
PT and OT
1.2.2 Posterior Cervical Foraminotomy/Posterior Cervical Decompression
Symptoms and Signs
Mild to moderate neck pain
Radicular sensory loss in arm(s)
Radicular pain in arm(s)
Myotomal weakness in arm(s)
Myelopathy (dropping objects, cannot button shirt, gait imbalance, and urinary incontinence)
Surgical Pathology
Cervical herniated nucleus pulposus
Foraminal stenosis
Cord compression
Diagnostic Modalities
X-ray of cervical spine to assess for alignment, fracture, and degenerative disease
CT of cervical spine to assess for bony anatomy regarding alignment, fracture, and degenerative disease
MRI of cervical spine to assess for nerve root or cord compression
Dynamic X-ray of cervical spine to look for instability (in patients without severe cord compression)
Differential Diagnosis
Degenerative disease
Traumatic nerve root compression
Treatment Options
Exhaust all conservative routes with PT, aqua therapy, chiropractic, acupuncture, epidural steroid injections, and medical management (if possible, prior to surgical intervention)
Surgical decompression with or without stabilization via posterior decompression and foraminotomy (at appropriate indicated levels based on imaging studies)
Indications for Surgical Intervention
Intractable radicular arm pain
Intractable weakness and/or numbness in arms in radicular fashion
Cord compression with or without myelopathy
Surgical Procedure for Posterior Cervical Spine
Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 2 weeks preoperatively
Appropriate intubation and sedation
Place the patient prone in neutral position with Mayfield head holder
Time out performed
Incision along posterior cervical spine midline
Subperiosteal dissection of muscles down to bone performed at appropriate level (see ▶Fig. 1.9)
Fig. 1.9 Fluoroscopy reveals trajectory of tube for cervical decompression. Identify the facet joint before placing parallel to disk space at that level. Minimally invasive tubular posterior cervical decompressive techniques. In: Vaccaro A, Albert T, eds. Spine Surgery: Tricks of the Trade. 3rd ed. Thieme; 2016
X-ray/fluoroscopic confirmation with two people for appropriate level (see ▶Fig. 1.10)
Fig. 1.10 Guide for patient selection considering between anterior cervical diskectomy and fusion (ACDF) and posterior foraminotomy (PF). Patients selected for PF will have mediolateral or lateral disk herniation and are without relevant osseous component. Scholz T, Geiger M, Mainz V, et al. Anterior cervical decompression and fusion or posterior foraminotomy for cervical radiculopathy: results of a single-center series. J Neurol Surg A Cent Eur Neurosurg 2018;79(03):211–217
Laminectomy and foraminotomy unilaterally or bilaterally, if needed, depending on diagnosis and indication for surgery (see ▶Fig. 1.11)
Fig. 1.11 A spinal needle marks entrance site for a lower cervical (C6–C7) foraminotomy. It is recommended to enter the skin rostral to the foramen. Operative procedure. In: Wolfla C, Resnick D, eds. Neurosurgical Operative Atlas: Spine and Peripheral Nerves. 3rd ed. Thieme; 2016
Use pituitary rongeur/Kerrison rongeur and high-speed drill
Once spinal cord and/or nerve roots are decompressed, obtain X-ray confirming appropriate levels decompressed
If stabilization is planned, then instrumentation and fusion can be performed
Muscle and skin closure with drain placed (if necessary)
Pitfalls
Intraoperative CSF leak
Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
Damage to spinal nerves and/or cord
Postoperative weakness or numbness or continued pain
Postoperative wound infection
Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
Prognosis
Most patient are discharged home the same day for single level foraminotomy
Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities
PT/OT can be performed as outpatient to regain strength
Most patients do very well and are happy with the results
1.3 Tumor/Vascular
1.3.1 Cervical Tumor Resection (Vertebral Pathology)
Symptoms and Signs
Incidental with symptoms (depending on size and location)
Moderate/Severe numbness in upper extremities
Paresthesias in upper body extremities
Neck pain and loss of mobility due to neck pain
Radiating pain down the arms
Pain in moving shoulders
Muscle weakness in arms
Inability to conduct fine motor skills with hands
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