The advantages of submandibular gland resection in anterior retropharyngeal approach to the upper cervical spine

Anterior surgery to the upper cervical spine, although rare, several successful approaches were described in the literature. To avoid the risks and limitations of transoral approach, the anterior retropharyngeal approach was developed. In this study, we describe our experience with anterior retropharyngeal approach to the upper cervical spine and discuss the significance of resecting the submandibular gland. From July 2001 to July 2004, we performed six anterior prevascular retropharyngeal approaches to the upper cervical spine. The series included five males and one female, ranging in age from 26 to 60 years (mean = 46). All six patients were intubated with nasotracheal cannula. The submandibular gland was mobilized and removed in all patients allowing adequate exposure of the arch of C1, C2, and C3 vertebral bodies. The anterior retropharyngeal approach permitted an adequate access to anteriorly situated lesions from C1 to C3 in all six patients, without the risks and limitations of transmucosal surgery. This approach allowed us to perform decompression of the spinal cord and reconstruction of the anterior column of the spine with bone graft and internal fixation. Careful removal of the submandibular gland provided better visualization of the arch of C1 and C2. No facial nerve palsy was seen in any of the six patients. Anterior retropharyngeal approach to the upper cervical spine combined with removal of the submandibular gland permits exposure of the anterior spine similar to that obtained by the transmucosal route, and provides a safe simultaneous arthrodesis and instrumentation during the primary surgical procedure without the potential contamination of the oropharyngeal cavity. Removal of the submandibular gland allows better exposure with less retraction and thus avoids severe injury to the mandibular branch of the facial nerve.     

上位颈椎前路手术咽后入路“窗口”显露技术的临床应用观察

目的：探讨上颈椎前路减压经咽后入路＂窗口＂显露技术在上颈椎损伤手术中的应用。方法：2000年1月至2008年7月手术治疗上位颈椎损伤患者5例,男4例,女1例;年龄16～68岁,平均35岁。C2椎弓骨折（HangmanⅡ型）2例,C2,3椎间盘突出症2例,C2椎体结核1例。所有患者经高位前方咽后入路舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂成功获得显露。Hangman骨折复位后行C2,3椎间盘切除椎间植骨融合内固定。C2,3椎间盘突出症患者行相应椎间盘切除,减压植骨融合内固定。C2椎体结核行病灶清除并植骨等。结果：5例患者均成功在舌下神经、喉上神经、咽和颈动脉之间的＂窗口＂显露出C1前弓-C3椎体。随访5～26个月,平均13.5个月。无伤口感染,无颈部重要血管神经损伤。患者的神经症状恢复良好,所有患者植骨都获得了融合。结论：前方咽后入路的＂窗口＂显露技巧可使上颈椎获得理想的显露,创伤小,切口并发症少,有相关经验后也比较安全。     

高位颈椎的前路手术治疗

目的观察高位颈椎前路手术的临床效果,方法本组15例．男10例,女5例．年龄12—67岁。C1,2椎体结核3例．Hangman 7例,先天性齿状突不连伴难复性环椎脱位3例,齿状突骨折2例。本组经高位前方咽后入路显露C2-3,椎体结核患者行病灶清除术．先天性齿状突不连者行前路松解复位．后路环枢融合;Hangman骨折。复位后行C2,3椎间植骨融合术．放自锁钛板内固定,齿状突骨折行前路中空螺钉内固定。结果15例患者均成功地显露C1前弓至C3椎体,并完成病灶清除、复位、减压融合内固定：无颈部重要血管神经损伤,无伤口感染．9例不全瘫有部分恢复。结论高位前方咽后入路可充分显露上颈椎．高位颈椎前路术式能有效复位、减压和稳定,并可最大程度重建颈椎生理功能。     

Complications of the anterior retropharyngeal approach in cervical spine surgery: a technique and outcomes review

The retropharyngeal approach is used to avoid the risks and limitations of transmucosal surgery. The standard Smith-Robinson approach does not allow complete exposure of the C3 body/disk in patients requiring instrumentation of C3 or in patients with a short, thick neck. The anterior retropharyngeal approach provides additional exposure to the entire cervical spine in these patients. Our results in 14 cases show the anterior retropharyngeal approach to the upper and lower cervical spine to be an effective surgical technique in cases of upper cervical spine abnormalities and for multilevel abnormalities in patients with a short, thick neck. Although complications occurred as a result of the procedure, no permanent disorders were encountered. Adequate exposure to the entire cervical spine can be achieved without the high incidence of infection associated with the transoral approach.     

Aneurysmal bone cyst of the second cervical vertebrae causing multilevel upper cervical instability

OBJECTIVE: Aneurysmal bone cyst (ABC) is a rare expansile osteolytic lesion of bone comprising proliferating vascular tissue lining blood-filled cystic cavities. ABCs occur most frequently in patients under age 20 and are uncommon after 30 years of age. Three to 20% of cases occur in the spine, and upper cervical involvement is rare. Lesions may grow rapidly and attain considerable size. When involving the spine, ABCs may result in instability and neurologic compromise, making prompt diagnosis and treatment imperative. We present a report of a 6-year-old child with an ABC of the second cervical vertebrae causing atlantoaxial and C2-C3 instability, treated successfully with curettage, decompression, and anterior and posterior arthrodesis with posterior instrumentation. METHODS: The patient underwent a staged procedure consisting of posterior instrumentation from occiput to C4 and curettage of the lesion followed by anterior cervical discectomy and fusion of C2-C4. The diagnosis, surgical treatment, and outcome of the case are described and relevant literature reviewed. RESULTS: The patient sustained no lasting neurologic deficits and was disease-free at 3 years of follow-up. CONCLUSIONS: ABC is a rare but potentially devastating cause of upper cervical spine instability. Prompt detection and treatment with curettage, decompression, and fusion can produce a satisfactory result and prevent spinal cord injury.     

Two-staged operation on C2 neoplastic lesions: anterior excision and posterior stabilization

This retrospective study included eight consecutive cases with C2 vertebral body neoplastic lesions. The anterior retropharyngeal approach was used to remove the lesions and decompress the spinal cord. Spinal stabilization with occipitocervical plating in a second-stage operation makes the treatment more tolerable for patients. The object of this study was to determine the effectiveness of a two-stage operation strategy for these lesions. Eight patients were operated on via anterior retropharyngeal approach and then stabilized with occipitocervical plates posteriorly in a second sitting. All neck pain and all dysphagia problems resolved. Partial neurologic improvement was achieved in three out of four patients. No postoperative infection was seen. The retropharyngeal approach to the upper cervical spine and anterior foramen magnum lesions is an effective alternative to transoral surgery because of low complication rates. Neoplastic lesions in the upper cervical spine can safely and effectively be operated with this technique. The general medical status of patients with malignancies does not permit too long, time-consuming operations. Stabilization of the spine in a separate operation increases patient tolerability without any morbidity.     

Minimally invasive anterior approach to upper cervical spine: surgical technique

OBJECTIVE: The transoral approach of Spetzler is the classic anterior access to the upper cervical spine that provides direct exposure for anterior decompression of the spinal cord. The risks of infection, the limits in extension, and the postoperative recovery difficulties of transmucosal access suggest the use of an alternative anterior extraoral approach in upper cervical surgery. However, this approach results in complications from nerve palsy because of excessive retraction of the hypoglossal and the superior laryngeal nerves. The goal of this work was to provide anatomic data for an anterior retropharyngeal upper cervical approach through a minimally invasive window below the hypoglossal and the superior laryngeal nerves. METHODS: In two adult cadaveric cervical spines, the anterior approach using the Metrx tubular retractor system through a window between the hypoglossal nerve and the superior laryngeal nerve, as well as below these two nerves, is compared in the exposure of C1 and C2 anteriorly with the aid of an operating microscope. RESULTS: A maximum diameter of the internervous window for the tubular retractor is reached beyond which the superior laryngeal nerve will be excessively stretched. Conversely, the tubular retractor can retract the superior laryngeal nerve superiorly without undue tension. Better proximal exposure is also made possible by angling an end-beveled tubular retractor on the mandible without undue compression on the hypoglossal and superior laryngeal nerves, the marginal mandibular branch of the facial nerve, and the submandibular gland. CONCLUSION: This minimally invasive approach can replace transoral surgery, allowing direct anterior access to C1 and C2 while allowing extension to the lower cervical spine.     

Posterior transpedicular corpectomy for malignant cervical spine tumors

The goal of this study was to assess surgical clinical and radiographic outcomes of using a posterior transpedicular approach (posterolateral) for ventral malignant tumors of the cervical spine. Access to ventral lesions of the cervical spine can be challenging in patients with malignant tumors. Anterior approaches are the gold standard for ventral pathology in the cervical spine, however, there are cases, where a posterior approach is indicated due to multilevel disease, previous radiation, swallowing difficulty with difficulty in retraction of trachea and esophagus, and in cases where circumferential fusion cannot be done due to patients’ poor medical condition. A single approach could provide spinal stabilization and removal of tumor. Eight cases of ventral cervical spine malignant tumors (7 metastatic and 1 chordoma) underwent corpectomy through a posterior transpedicular (posterolateral) approach. Tumors involved C2 (5), C3 (1), C5 (1), and C7 (1). Six cases had anterior reconstruction and three column fusion, and two cases had posterior fusion alone. Gross total resection was achieved in all cases. No hardware failure or worsening of neurological condition was seen (4 patient were neurologically intact and remained intact after surgery and 4 patients improved in their Frankel grade). Pain improved in all patients, mean visual analog scale preoperative was 86 and improved to 22 after surgery. In two patients the vertebral artery was ligated without sequelae. We conclude that cervical spine transpedicular (posterolateral) approach is useful in cases where an anterior approach or a circumferential approach is not an option. It avoids the morbidity of anterior transcervical, transternal, and transoral procedures while providing decompression of neural elements and allowing three column stabilization when needed.     

Hypoglossal nerve injury as a complication of anterior surgery to the upper cervical spine

Injury to the hypoglossal nerve is a recognised complication after soft tissue surgery in the upper part of the anterior aspect of the neck, e.g. branchial cyst or carotid body tumour excision. However, this complication has been rarely reported following surgery of the upper cervical spine. We report the case of a 35-year-old woman with tuberculosis of C2–3. She underwent corpectomy and fusion from C2 to C5 using iliac crest bone graft, through a left anterior oblique incision. She developed hypoglossal nerve palsy in the immediate postoperative period, with dysphagia and dysarthria. It was thought to be due to traction neurapraxia with possible spontaneous recovery. At 18 months’ follow-up, she had a solid fusion and tuberculosis was controlled. The hypoglossal palsy persisted, although with minimal functional disability. The only other reported case of hypoglossal lesion after anterior cervical spine surgery in the literature also failed to recover. It is concluded that hypoglossal nerve palsy following anterior cervical spine surgery is unlikely to recover spontaneously and it should be carefully identified. Received: 6 March 1998 Revised: 31 July 1998 Accepted: 17 August 1998     

Surgical treatment of dysphagia after anterior cervical interbody fusion.

BACKGROUND CONTEXT: Dysphagia is a frequent complication after anterior cervical interbody fusion (ACIF). Although dysphagia usually improves over 6 months, it remains a significant and persistent problem for some patients. The etiology is poorly understood but has been reported to be associated with vocal cord paralysis, dislodgement of instrumentation and unidentified causes, such as hematoma, adhesion formation and denervation of the pharyngeal plexus. A surgical treatment of dysphagia after ACIF has not been reported. PURPOSE: We report the surgical treatment of persistent dysphagia occurring after ACIF with instrumentation. STUDY DESIGN/SETTING: A retrospective review of cervical discectomy and interbody fusion patients identified a subset of patients with symptomatic dysphagia who chose surgical treatment of the dysphagia. The hypothesis is that removal of the anterior cervical plate will release mechanical adhesions of the esophagus to the anterior spine around the plate. Outcome was graded by examination and a final telephonic interview with a dysphagia questionnaire. METHODS: Thirty-one patients who elected surgical treatment for persistent dysphagia were assessed at clinic visits after surgery at 3, 6 and 12 months for symptomatic dysphagia, and with a final telephonic questionnaire. The average time from initial surgery to time of surgical treatment for dysphagia was 18 months. Final follow-up was an average 11 months (range, 6 to 25 months) with a dysphagia questionnaire using the Bazaz-Yoo dysphagia score. Thirty-one patients responded to a phone questionnaire with the Bazaz-Yoo dysphagia score. RESULTS: The primary operative finding was extensive adhesions attaching the esophagus to the prevertebral fascia and anterior cervical spine around the periphery of the cervical plate. Seventeen patients (55%) were significantly improved to no dysphagia of solids and liquids (p < or = .0001). Ten patients (32%) reported mild dysphagia occasionally with specific foods. Three patients had persistent moderate occasional dysphagia with solid food. Two patients had persistent severe dysphagia of solids and liquids. Previous cervical surgery, particularly with pre-existing dysphagia, and unexpectedly extreme amounts of adhesions at surgery were contributing factors to the cases with persistent severe dysphagia. CONCLUSIONS: Surgical treatment of dysphagia after ACIF has not been reported. Removal of the cervical instrumentation in patients will improve the dysphagia. This improvement with surgical management, as compared with the dissatisfaction before surgical treatment, documents that this surgical treatment is a reasonable option.     

Risk factors for dysphagia after anterior cervical spine surgery: a two-year prospective cohort study.

BACKGROUND CONTEXT: Severe and disabling dysphagia is a relatively uncommon complication of anterior cervical spine surgery. However, the incidence of dysphagia ranges widely (2% to 60%). Furthermore, risk factors that contribute to the development of dysphagia have not been well identified. PURPOSE: The purpose of this study was to evaluate the prevalence of dysphagia after anterior cervical spine surgery, and to identify any risk factors associated with increased dysphagia. STUDY DESIGN: This study is a prospective cohort study designed to evaluate the prevalence of dysphagia at 1, 2, 6, 12, and 24 months. Patients were prospectively interviewed at 1, 2, 6, 12, and 24 months regarding the presence and subjective severity of dysphagia. PATIENT SAMPLE: Between the period of 1999 and 2002, 348 cervical spine surgeries were performed using the anterior Smith Robinson approach. 310 of these patients were available for 2-year follow-up. OUTCOMES MEASURE: Using the dysphagia grading system defined by Bazaz et al. (Spine 2002), we prospectively evaluated patients' postoperative dysphagia. METHODS: The presence and severity of dysphagia were reported during the telephone interviews performed at 1, 2, 6, 12, and 24 months after the procedure. Proportion analysis (chi-square or a Fisher Exact Test), prevalence ratios, and 95% confidence intervals were used to compare the prevalence of dysphagia with age, gender, type of surgery (eg, discectomy vs. corpectomy, primary vs. revision), use of instrumentation, number and location of surgical levels. RESULTS: The overall prevalences for dysphagia at 1, 2, 6, 12, and 24 months were 54.0%, 33.6%, 18.6%, 15.2%, and 13.6%. The prevalence of dysphagia was found to be significantly higher in women (18.3%) than men (9.9%) 2 years after the surgery. Revision surgery patients (27.7%) also had a significantly higher prevalence of dysphagia than primary surgery (11.3%) patients 2 years after the surgery. Patients who underwent more than two-level surgery (19.3%) also had significantly higher rates of dysphagia 2 years after their procedures than patients who had two or less levels (9.7%) operated on. CONCLUSION: Overall the incidence of dysphagia 2 years after anterior cervical spine surgery was 13.6%. Risk factors for long-term dysphagia after anterior cervical spine surgery include gender, revision surgeries, and multilevel surgeries. The use of instrumentation, higher levels, or corpectomy versus discectomy did not significantly increase the prevalence of dysphagia.     

Retropharyngeal cerebrospinal fluid collection as a cause of postoperative dysphagia after anterior cervical discectomy

BACKGROUND: Transient dysphagia after anterior cervical discectomy is not uncommon. It is usually related to esophageal edema secondary to retraction, mechanical adhesions of the esophagus to the anterior spine, and stretch injuries to nerves involved in the swallowing mechanism. Structurally induced dysphagia, secondary to laceration of the neck viscera or to the presence of retropharyngeal masses, is by far less frequent, and it does not usually improve over time. CASE DESCRIPTION: The authors present the case of a 36-year-old woman who complained of severe dysphagia both for solids and liquids after C4 through C5 anterior discectomy and fusion, complicated by a millimetric dural tear of the anterior thecal sac. Postoperative neuroimaging revealed retropharyngeal fluid collection, extending in front of the vertebral bodies of C3, C4, and C5, exerting a mass effect on the posterior wall of the pharynx. Taking into account both the MRI aspect of the collection and the dramatic improvement of symptoms after lumbar punctures, we conducted a diagnosis of CSF collection in continuity with the subarachnoid space. The dysphagia and the CSF collection resolved with conservative therapy (bed rest and 3 lumbar punctures). CONCLUSION: To the best of our knowledge, such a complication has never been described before in the literature. It should be included in the differential diagnosis of patients with postoperative dysphagia lasting more than 48 hours.     

前方经咽后入路切口治疗上颈椎病变

目的探讨颈椎前方经咽后入路切口治疗上颈椎病变的临床疗效。方法 9例上颈椎病变患者,均采用前方经咽后入路切口实施颈椎前路手术,其中包括前后路手术1例,术前JOA评分平均（8.6±1.2）分,枢椎椎弓骨折2例,颈椎肿瘤3例,颈椎结核1例,颈椎间盘突出2例,颈椎畸形1例。结果 9例患者术中均清楚显露C1~C3椎体前方,完成减压复位、病灶清除、融合内固定等操作;有脊髓压迫者术后脊髓神经功能得到一定程度的改善。全部伤口于2周后获甲级愈合,无伤口感染病例。1例术后出现口轮匝肌瘫痪,1周左右自行缓解,1例出现术后呛咳,3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。9例患者均经平均12（10~16）个月随访,JOA评分术后平均（13.4±1.6）分,与术前比较有显著差异（P〈0.01）。结论经高位前方咽后入路可充分显露上颈椎前方,进行直接有效的手术操作,创伤小,并发症少,是理想的显露途径。     

Transcervical and transoral approach to clival and upper cervical chordoma: a case report

The patient, a 48-year-old man, was first admitted in 1981 for the chief complaints of retropharyngeal tumor and anosmia. Computerized tomography scan disclosed destruction of the lower half of the clivus and retropharyngeal tumor predominantly located in the third prevertebral region. The tumor was removed partially via the transcervical approach and was histologically a typical chordoma. Two years later the tumor recurred and was operated on by the same approach. However, only partial removal of the tumor was realized due to difficulties in dissecting the fibrous adhesion. In 1986 (7 years after onset of the symptoms), the patient was readmitted due to severe dysphagia. The sagittal MRI scan demonstrated a huge oval retropharyngeal tumor with precise delineation between the tumor and clivus, clivus upper cervical spine and brain stem. The tumor was extirpated subtotally on the midline via the transoral approach. Dysphagia completely improved postoperatively and the patient regained normal smell sensation. The advantages and disadvantages of the transcervical and transoral approach to clival lesion are discussed and the advantage of the MRI imaging is stressed for preoperative information for the transoral approach.     

Recurrent laryngeal nerve injury with anterior cervical spine surgery risk with laterality of surgical approach.

STUDY DESIGN: A detailed review of anterior cervical fusion procedures from a university-based spine specialty service was completed. Noted were the laterality of approach, number of levels, discectomy or corpectomy, use of instrumentation, and cases of reoperation. OBJECTIVES: The primary purpose of the study is to determine whether there is in fact a greater risk of recurrent laryngeal nerve (RLN) injury with approach on the right or left side. Also evaluated is the risk with corpectomy, reoperative procedures, and instrumentation. BACKGROUND: Anatomic considerations have been used as justification to determine the side of surgical approach. However, few clinical studies have delineated the side of surgical approach in their results. METHODS: A total of 328 anterior cervical spine fusion procedures completed between 1989 and 1999 were reviewed. All speech changes reported were noted throughout follow-up. RESULTS: There were 187 anterior discectomy and 141 corpectomy procedures. There were 21 reoperative anterior fusions. There were 173 procedures completed from the right side and 155 from the left. There were nine patients documented to have dysphonia after surgery. Five had a left-sided approach and four had a right-sided approach. CONCLUSIONS: The incidence of RLN symptoms after surgery was 2.7% (9 of 328). The incidence of RLN symptoms was 2.1% with anterior cervical discectomy, 3.5% with corpectomy (5 of 141), 3% with instrumentation (8 of 237), and 9.5% with reoperative anterior surgery (2 of 21). There was a significant increase in the rate of injury with reoperative anterior fusion. There was no association between the side of approach and the incidence of RLN symptoms.     

Oral extrusion of a screw after anterior cervical spine plating

STUDY DESIGN: A case report of a 76-year-old woman who retched up a screw from a cervical spine locking plate 5 years after anterior cervical spine fusion. The literature relevant to this topic is reviewed. OBJECTIVES: To report the rare but potentially life-threatening complication of oral screw extrusion after anterior cervical spine plating, to review the relevant literature on the topic, and to discuss the clinical management of instrumentation failure in anterior cervical spine plating. SUMMARY OF BACKGROUND DATA: Anterior cervical spine fusion and stabilization is a well-established procedure. Complications include instrumentation failure, which can progress to extrusion through the gastrointestinal tract. Management is dependent on the severity and progression of clinical and radiologic signs and symptoms. Reoperation should be considered in certain cases. METHODS: A rare complication of anterior cervical spine plating in a 76-year-old woman 5 years after the initial operation is reported. The patient was assessed with serial physical examination and radiograph and one further follow-up 3 months after the first presentation. RESULTS: The patient was asymptomatic shortly after she retched up the screw, and at the 3-month follow-up was without evidence of progression of plate dislodgement. CONCLUSION: As reported, oral extrusion of cervical spine grafts or instrumentation is rare but potentially serious. Each case of instrumentation failure should be assessed individually to decide if conservative management is appropriate or if reoperation should be considered.     

Dysphagia and soft-tissue swelling after anterior cervical surgery: a radiographic analysis

Background contextDysphagia is common in the early postoperative period after anterior cervical discectomy and fusion (ACDF). Several mechanisms, including soft-tissue swelling, have been implicated as a cause of postoperative dysphagia.PurposeTo determine whether anterior soft-tissue swelling is greater in patients with postoperative dysphagia.Study designProspective cohort study.Patient sampleForty-three patients.Outcome measuresValidated dysphagia questionnaire, lateral cervical spine radiographs.MethodsPatients undergoing one- or two-level ACDF using allograft bone and anterior instrumentation were enrolled. Baseline patient demographic characteristics and history were recorded. A dysphagia questionnaire, including a dysphagia numeric rating scale (DNRS; range, 0–10), was administered preoperatively and 2 and 6 weeks postoperatively. Lateral cervical radiographs were obtained preoperatively and 2 and 6 weeks postoperatively. The anterior cervical soft-tissue shadow width was measured at each level. Patients were divided into groups based on the 2-week dysphagia questionnaire: Group 1 (no symptoms/mild dysphagia) and Group 2 (moderate/severe dysphagia). Anterior soft-tissue shadow width at each level was compared between groups. Correlation was used to assess the relationship between DNRS and anterior soft-tissue swelling.ResultsForty-three patients (24 females; average age, 47.9) were enrolled. Fifteen patients had one-level and 28 patients had two-level ACDF. The anterior soft-tissue shadow width increased significantly from preoperative values at all levels except C1 at 2 and 6 weeks and C2 at 6 weeks. At 2 weeks, 18 patients had no symptoms/mild dysphagia (Group 1) and 25 patients had moderate/severe dysphagia (Group 2). The average DNRS was 1.1 for Group 1 and 5.3 for Group 2 (p<.001). This difference decreased by 6 weeks but remained significant. There were no significant differences in the soft-tissue measurements between groups at any level. There was no significant correlation between the DNRS and anterior soft-tissue swelling at any time point.ConclusionsThere is a significant increase in anterior cervical soft-tissue swelling after ACDF. The width of prevertebral soft-tissue does not correlate with postoperative dysphagia.     

Zenker diverticulum: a rare complication after anterior cervical fusion

Esophageal injury is a rare but serious complication occurring after anterior cervical spine surgery. Pharyngoesophageal, or Zenker, diverticulum is an acquired outpouching of the pharyngeal musculature just proximal to a functional esophageal stricture, clinically manifesting as dysphagia, aspiration, and weight loss. We report a case in which a patient developed a pharyngoesophageal diverticulum, accompanied by retropharyngeal abscess, first identified 2 years after a 3-level anterior cervical fusion with allograft and anterior plating. The inferior portion of the cervical plate was dislodged anteriorly. In addition, the patient harbored pulmonary and mediastinal infection at the time of presentation. Despite incision and drainage of the abscess with repair of the diverticulum, the patient died in the early postoperative period. Prompt recognition and frequent follow-up, as well as patient education, may prevent this catastrophic complication.     

Dysphagia and dyspnea due to an anterior cervical osteophyte

Hypertrophic anterior cervical osteophytes have been reported as a cause of dysphagia, with about 100 cases described in the literature; on the other hand, chronic or acute dyspnea due to edema of the laryngeal inlet or bilateral vocal cord adduction-fixation is rare. We report a 57-year-old patient with a 2-year history of dysphagia and episodic dyspnea, who suffered sudden, severe respiratory distress necessitating emergency tracheotomy. A voluminous anterior cervical osteophyte at the C5 level was diagnosed by computed tomography (CT) and barium swallow test and removed by an anterior approach to the cervical spine, with clinical remission. The incidence, pathogenetic mechanisms, radiological diagnosis, and surgical indications of anterior cervical osteophytes associated with dysphagia and dyspnea are discussed. We advise examining cervical spine patients with dysphagia and/or dyspnea by radiography and CT when other investigations are not conclusive for a digestive or respiratory pathology.     

Ⅰ期前后路联合手术治疗游离齿突继发的难复性寰枢椎脱位

目的探讨颈高位咽后入路前路松解、Ⅰ期后路融合治疗游离齿突继发的难复性寰枢椎脱位的临床效果。方法本组19例均为游离齿突继发的难复性寰枢椎脱位,X线片动态位不能自行复位,且术前颅骨牵引均未获得满意复位。采用颈高位咽后入路显露C1～C3,行寰枢椎前方松解复位,Ⅰ期后路寰枢融合内固定。结果 19例患者采用颈高位前方咽后入路均成功显露C1前弓～C3椎体,前路松解后复位良好,Ⅰ期行后路寰枢融合内固定,全组无一例出现脊髓损伤加重、咽喉部阻塞或窒息。1例颈后部伤口积液感染,经换药引流后痊愈;2例出现舌下神经牵拉症状,1例出现面神经刺激症状,均在1个月后恢复正常。脊髓功能正常者无神经功能损害,不全瘫患者神经功能均有部分恢复。随访植骨均获骨性融合,无内固定松脱。结论颈高位咽后入路行前方松解能够复位游离齿突继发的难复性寰枢椎脱位患者,Ⅰ期后路寰枢融合可获良好的植骨融合。