Extrapharyngeal (anterolateral) approach to the cervical spine

The extrapharyngeal approach to the anterior cervical spine is a safe, rapid surgical exposure. Other surgical exposures such as the posterior, lateral, and intraoral (transpharyngeal) have inherent limitations that this approach avoids. By going anterior to the sternocleidomastoid muscle and great vessels, the surgical exposure of the anterior cervical spine is wide and the vital structures of the neck are visualized and not injured. We have used this extrapharyngeal approach to treat various disease states of the anterior cervical spine, such as trauma, osteomyelitis, neoplasia, and degenerative disease. Major complications have been neural injury, and pharyngeal fistula.     

Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine

The sympathetic trunk is sometimes damaged during the anterior and anterolateral approach to the cervical spine, resulting in Horner’s syndrome. No quantitative regional anatomy in fresh human cadavers describing the course and location of the cervical sympathetic trunk (CST) and its relation to the longus colli muscle (LCM) is available in the literature. The aims of this study are to clearly delineate the surgical anatomy and the anatomical variations of CST with respect to the structures around it and to develop a safer surgical method that will diminish the potential risk of CST injury. In this study, 30 cadavers from the Department of Forensic Medicine were dissected to observe the surgical anatomy of the CST. The cadavers used in this study were fresh cadavers chosen at 12–24 h postmortem. The levels of superior and intermediate ganglions of cervical sympathetic chain were determined. The distance of the sympathetic trunk from the medial border of LCM at C6, the diameter of the CST at C6 and the length and width of the superior and intermediate (middle) cervical ganglion were measured. Cervical sympathetic chain is located posteromedial to carotid sheath and just anterior to the longus muscles. It extends longitudinally from the longus capitis to the longus colli over the muscles and under the prevertebral fascia. The average distance between the CST and medial border of the LCM at C6 is 11.6 ± 1.6 mm. The average diameter of the CST at C6 is 3.3 ± 0.6 mm. Superior ganglion of CSC in all dissections was located at the level of C4 vertebra. The length and width of the superior cervical ganglion were 12.5 ± 1.5 and 5.3 ± 0.6 mm, respectively. The location of the intermediate (middle) ganglion of CST showed some variations. The length and width of the middle cervical ganglion were 10.5 ± 1.3 and 6.3 ± 0.6 mm, respectively. The CST’s are at high risk when the LC muscle is cut transversely, or when dissection of the prevertebral fascia is performed. Awareness of the CST’s regional anatomy may help the surgeon to identify and preserve it during anterior cervical surgeries.     

Value of the bilateral anterolateral approach for the treatment, by corporectomy and prosthesis, of metastases of the lower cervical spine. Apropos of 20 cases

The authors report their experience of the antero-lateral bilateral approach for the treatment of inferior spinal cervical metastasis. They underline the effect of osseous posterior wall compression.     

Results of percutaneous cervical vertebroplasty using an anterolateral approach for cervical spine tumors

Objective:The aim of this study was to report the results of percutaneous vertebroplasty in managing symptomatic osteolytic cervical spine tumors.Methods:This study comprised a retrospective examination of patients who received percutaneous vertebroplasty between 2008 and 2020 for the treatment of tumor-induced symptomatic cervical vertebra involvement. The study summarized the demographics, vertebral levels, pain control rates, clinical results, and complications of percutaneous vertebroplasty using an anterolateral approach.Results:The study sample consisted of 6 female and 2 male patients aged between 20 and 56 (mean = 41.37) years. Tumors were located at C2 in 6 cases, at C3 in 1 case, and at C5 in another. The mean volume of poly (methyl methacrylate) injected was 1.5 mL (range: 1-2 mL). Biopsy results showed the presence of metastasis in 5 cases and plasmacytoma in 3. No postoperative complications or mortality were observed after the procedure. Preoperative mean 7.75 visual analog scale score decreased to 2.62. Pain control was reported to be 66.2%.Conclusion:Anterolateral cervical vertebroplasty seems to be a safe, effective, and helpful therapeutic alternative for the treatment of cervical spine tumors. It reduces the risk of infection compared to the transoral method.Level of Evidence:Level IV, Therapeutic Study     

Reduction-stabilization of a vicious callus of the lower cervical spine by bilateral anterior approach

The authors report a new technique which allows reduction and stabilization of cervical fractures healed in a vicious position. The procedure allows total removal of bony and discal protrusions, a correction of the pathological kyphosis by osteotomy of posterior facets. Advantages and drawbacks of this technique are discussed.     

Ventral approach to the cervical spine

Since they were introduced in 1950, ventral approaches for surgical operations on the cervical spine have become widely used. The most frequently used is the anteromedian approach, passing along the anterior border of the sternocleidomastoideus muscle and then between the upper gastrointestinal tract and the vascular bundle to give access to the spine. This approach allows access to practically every segment of the cervical spine. The significance of the transoral approach is stressed in the literature, and we ourselves are also convinced of its importance. In this paper, however, the combined anteroposterior procedures and the cervicothoracic methods used for the transitional zone are also described. Complications affecting the upper gastrointestinal tract, the vessels or the nerves are always possible, and to reduce their likelihood to a minimum it is essential to make a detailed study of the complicated anatomy of the neck region.     

颈前外侧改良L形切口治疗上颈椎病变

目的 改进上颈椎颈前外侧手术入路的切口显露方式.方法 采用颈前外侧改良L形切口为7例上颈椎病变患者实施颈前路手术.包括联合后路手术1例.男5例,女2例;枢椎椎弓骨折2例,颈椎肿瘤4例,后纵韧带骨化1例;术后第1、3,6个月对患者进行随访.观察伤口部位生长变化情况和有无吞咽困难、颈髓损伤出现.结果 7例患者均经6个月随访.全部伤口于2周后获Ⅰ级甲愈合.1例术后出现呛咳,4周左右自行缓解.其余病例未出现颈部重要神经血管损伤与相应节段的颈髓损伤.所有病例无伤口感染,伤口显露及愈合效果满意.结论 颈前外侧改良L形切口可为上颈椎前方手术入路有效的切口显露方式之一.     

High anterior cervical approach to the upper cervical spine

BACKGROUND: Surgical exposure of the upper cervical spine is challenging, and optima approaches are subjects of debate. The high anterior cervical approach to the upper cervical spine is a favorable method that provides direct and wide exposure for fusion and anterior decompression of the upper cervical spine. The authors present their experiences with 15 patients in whom fusion and instrumentation on the upper cervical spine were performed via the prevascular extraoral retropharyngeal approach. METHODS: A series of 15 patients who were surgically treated using the high anterior cervical retropharyngeal approach was reviewed. These cases involved a C2 hangman's fracture with significant angulation and translation (11 patients), C2 EDH (1 patient), C2 chordoma (1 patient), C3-4 metastasis (1 patient), and C2-3-4 OPLL (1 patient). RESULTS: Twelve patients underwent C2-3 fusion followed by instrumentation. C2-5 fusion with instrumentation was performed in 2 patients. One patient experienced occipitocervical fusion after anterior removal of a C2 chordoma. A solid fusion was achieved in 13 patients. However, 1 patient needed additional posterior fusion because of fusion failure, and the other died due to ischemic heart disease. There was 1 patient who developed permanent dysphagia related to the hypoglossal nerve and 2 who had transient dysphagia. No complications occurred related to the marginal branch of the facial nerve or submandibular gland. CONCLUSIONS: The high anterior cervical approach is a useful surgical technique for an upper cervical lesion without severe morbidity, which allows direct anterior access to C2 and C3 while allowing extension to the lower cervical spine.     

Approach to lesions of the clivus and upper cervical spine by the retropharyngeal intermaxillo-hyoid route

The authors report the intermaxillo-hyoido-retropharyngeal approach for cranio-cervical junction's pathology. They underline its advantages. It's indications are discussed by six personal cases.     

Management of bilateral locked facets of the cervical spine

A total of 28 cases of cervical spine dislocation with bilateral locking of facets treated between 1976 and 1984 were analyzed to determine whether treatment modality had any effect on outcome based on cord or root function. Motor vehicle accidents were responsible for 19 cases; the most common levels of dislocation were C-5, C-6 and C-6, C-7, with 10 each. Twenty patients were admitted with complete myelopathies. Ten patients whose dislocations were successfully reduced with traction had no neurological changes, but 1 reduced elsewhere deteriorated from a C-5 to C-2 level. Eleven of these patients underwent posterior cervical fusions after delays of 1 to 17 days (mean = 6.3); 2 died, and 1 patient achieved slight root return. Seven underwent anterior decompression and fusion or combined anterior and posterior approaches after delays of 9 to 120 days. One patient died in the postoperative period, 1 had substantial recovery of cord function, and 5 had recovery of root function. There was no operation or improvement in 2 patients. Eight patients had incomplete myelopathies; 4 were initially reduced, with 2 improving slightly as a result. Three patients underwent posterior fusions with foraminotomies with minimal improvement. Five had anterior or combined approaches; these patients improved at least one neurological grade each, including 3 who became newly ambulatory. All 24 surviving patients achieved spinal stability, although it occurred slightly earlier in the anterior fusion groups. Surgical approaches designed to provide spinal stability and restore the normal anatomy of the spinal canal and neural foramina may be of functional benefit in the management of these dislocations.     

Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications.     

Anterior approach to the cervical spine: surgical anatomy

While performing the anterior approach to the cervical vertebral bodies, injury to important anatomic structures in the vicinity of the dissection represents a serious risk. The midportion of the recurrent laryngeal nerve and the external branch of the superior laryngeal nerve are encountered in the anterior approach to the lower cervical spine. The recurrent laryngeal nerve is vulnerable to injury on the right side, especially if ligation of inferior thyroid vessels is performed without paying sufficient attention to the course and position of the nerve, and the external branch of the superior laryngeal nerve is vulnerable to injury during ligature and division of the superior thyroid artery. Avoiding injury to the recurrent laryngeal nerve (especially on the right side) and superior laryngeal nerve is a major consideration in the anterior approach to the lower cervical spine. The sympathetic trunk is situated in close proximity to the medial border of the longus colli at the C6 level (the longus colli diverge laterally, whereas the sympathetic trunk converges medially). The damage leads to the development of Horner's syndrome with its associated ptosis, meiosis, and anhydrosis. Awareness of the regional anatomy of the sympathetic trunk may help in identifying and preserving this important structure while performing anterior cervical surgery or during exposure of the transverse foramen or uncovertebral joint at the lower cervical levels. Finally, the spinal accessory nerve (embedded in fibroadipose tissue in the posterior triangle of the neck) is prone to injury. Its damage will result in an obvious shoulder droop, loss of shoulder elevation, and pain. Prevention of inadvertant injury to the accessory nerve is critical in the neck dissection.     

Perforation of the cervical esophagus and hypopharynx complicating surgery by an anterior approach to the cervical spine

Difficult diagnostic and therapeutic problems are raised by perforations of the cervical oesophagus or hypopharynx in patients undergoing surgery to the cervical spine via an anterior approach. Based on their experience of three recent cases, the authors review the diagnostic approach, based on clinical examination and diatrizoate sodium oesophageal series, and propose conservative treatment consisting of surgical drainage with or without suture of the perforation and without removal of the osteosynthesis material, appropriate antibiotic therapy and hypercaloric enteral nutrition via nasogastric tube. The prevention of this complication is based on correct use of surgical retractors.     

Bilateral anterolateral approach in primary tumors of the cervical vertebrae

The author reports on his experience with the bilateral anterolateral approach to the cervical spine for primary tumors of the cervical spine. It has a threefold objective: Neurological: aiming at the decompression of the spinal cord and the roots as much as possible without making any radicular or vascular sacrifice. Anatomic: the bilateral control of the foraminal segment and the vertebral arteries ensures absolute safety for the approach to the lateral parts of the vertebral body, the pedicles, and if necessary, the articular surfaces and the isthmi. Static: the anterior reconstruction graft and osteosynthesis with a plate or an acrylic prothesis ensure stability. Compared with the classic anterior approach, the bilateral anterolateral approach offers the following advantage: it allows more extensive surgery on tumors. However, the posterior segment of the spine appears to be difficult to control by this approach. An anterior support is necessary because of the removal of the stabilizing elements of the vertebra. Computed tomography provides great help in determining the exact indications for this surgical procedure.     

改进的侧前方手术径路在胸腰椎爆裂性骨折中的应用

目的 探讨改进的侧前方手术径路减压内固定治疗胸腰椎爆裂性骨折的疗效. 方法 2003年4月至2006年9月利用胸腰段的解剖关系,改进成"L"形肌间隙经椎间孔入路行骨折减压内固定治疗胸腰椎爆裂性骨折,临床应用16例(改进径路组),并将11例经传统胸腹膜外入路(传统径路组)作为对照组,比较两组住皮肤切口到完全显露椎体出血量、手术时间及总出血量、疗效等方面的差异,并观察术中、术后并发症情况. 结果 27例患者于术均获成功.所有患者获得6～26个月(平均13个月)随访.改进径路组从皮肤切口到完全显露椎体的出血量平均为(80.0±56.5)mL,总出血量平均为(450.0±273.1)mL,手术时间平均为(119.0±35.5)min;传统径路组从皮肤切口到完全显露椎体的出血量平均为(350.0±145.5)mL,总出血量平均为(900.1±421.3)mL,手术时间平均为(193.2±48.3)min,两组上述指标比较差异均有统计学意义(P<0.05).两组在Cobb角改善、伤椎前缘高度比值及神经功能恢复差异均无统计学意义(P>0.05).两组术中均无严重并发症发生,无截瘫加重、植骨块塌陷及高度丢火现象,无假关节肜成和内固定失败. 结论改进的"L"形肌间隙经椎间孔径路行胸腰椎爆裂性骨折侧前方减压入路简捷,出血少.既能充分减压,又能最大限度保持脊柱的稳定性,还可避免加重脊髓损伤、胸腹膜损伤等并发症.     

Transclival transcervical approach to the upper cervical spine and clivus

The transclival-transcervical approach to lesions of the craniocervical junction is described. It gives reasonable access to the lower part of the clivus and to C1 and C2 for removal to tumours and stabilization of fractures and otherwise caused dislocations of this region. Because an opening of the pharynx can be avoided, reconstruction work can be done using bone graft or reinforced methyl-methacrylate without risk of infectious contamination. The results obtained in 6 cases are presented.