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.     

经椎管椎间盘切吸术在颈椎管狭窄合并椎间盘突出症治疗中的应用

目的　讨论后路椎间盘切吸术在颈椎管狭窄合并椎间盘突出症治疗中应用的方法和疗效。方法　在单开门椎管扩大成形术或半椎板成形术的基础上 ,行后路颈椎间盘穿刺切吸 ,本组共治疗 17例 ,男 13例 ,女 4例。结果　随访 6个月～ 3年 ,根据神经系统检查和功能状况评定 ,优 8例 ,良 7例 ,可 2例 ,无症状加重或病情恶化者。结论　该术式可以通过一次手术达到颈椎管前、后方同时减压的目的 ,手术方法易于掌握 ,安全性高 ,对颈椎稳定性无明显影响     

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.     

Impact of preoperative neurological status on perioperative morbidity associated with anterior and posterior cervical fusion

OBJECT: Cervical spine fusion is performed for various indications in patient populations ranging from young and healthy to aged and frail. Whereas disease pathoanatomy dictates the surgical approach, preoperative neurological status does not necessarily implicate a specific technique. Although one expects anterior decompression to be performed over fewer segments in healthier patients who experience fewer complications and faster recovery, the impact of pre-operative myelopathy on perioperative complications remains unclear. No large-scale study has evaluated rates of common complications for cervical fusion or their association with surgical approach and neurological status. METHODS: Data for 96,773 patients who underwent cervical fusion for degenerative disease between 1988 and 2003 were collected from the Nationwide Inpatient Sample database. Patients were grouped according to surgical approach (anterior versus posterior) and preoperative neurological status (myelopathic versus nonmyelopathic). Multivariate regression was used to evaluate group effects on selected postoperative complications, length of stay, and disposition at the time of hospital discharge. Although this technique can control for the observed covariates, the absence of key information such as the number of fused levels precludes statistical comparison between patients who underwent anterior or posterior approaches. RESULTS: In this study the authors confirmed that preoperative neurological status impacts perioperative morbidity. For example, patients who were nonmyelopathic and underwent an anterior approach were 7 years younger than the rest of the cohort, and they had a mortality rate of 0.05%. Transfusion was required in 0.34%, and venous thromboembolism occurred in 0.04%. Conversely, these rates were > 13-fold higher in patients with myelopathy who underwent a posterior approach. Furthermore, independent of approach, preoperative myelopathy is highly prognostic of death, pneumonia, transfusion, infection, length of stay, and posthospital disposition. These outcomes at least doubled, with some increasing > 10-fold. CONCLUSIONS: This nationwide study clarifies the frequency and associations of inpatient complications encountered when treating cervical spine disease. Whereas immediate complications due to anterior approaches are limited, patients with myelopathy who undergo a posterior approach have a more sobering outlook. This study shows that clinical myelopathy augments rates of complication during cervical fusion, regardless of the approach. The exclusion of pathoanatomical data from the Nationwide Inpatient Sample database, of key importance in guiding the surgical approach, prevents any conclusions being drawn about the merits and disadvantages of anterior versus posterior surgery.     

单纯前路手术治疗无明显后方压迫的陈旧性颈椎半脱位

目的 探讨无明显后方压迫的陈旧性颈椎半脱位行单纯前路手术减压内固定的可行性及手术方法.方法 2004年5月至2006年7月收治陈旧性颈椎半脱位患者16例,受伤至手术时间均超过2个月,行前路减压,术中试图通过撑开螺钉及钛网钢板同定的运用,以获得减压固定、恢复正常序列.结果 16例患者术后均恢复正常颈椎序列及椎间隙高度,随访6-11个月,平均8.5个月,无植骨未融合及钛板螺钉松动、断裂病例.所有患者症状均得到改善,JOA评分由术前的平均13.4分恢复为最后随访时平均15.9分,改善率为69.4%.结论 对于陈旧性颈椎半脱位,后方结构已纤维愈合稳定,而且无明显后方脊髓压迫,前路减压技术完全能达到减压融合重建颈椎序列的目的 .     

局部麻醉在颈椎后路手术中的应用价值

目的：针对颈后路手术中的各种麻醉方法,并发症,探讨局麻在颈后路手术中的应用价值。方法：回顾分析了局麻下行颈后路手术病例５８例。结果：通过对５８例病人的术中局部麻醉观察,优：５２例,良：５例,优良率９８３％,无严重并发症。结论：局麻下行颈后路手术,病人保持清醒,并发症较少,可尽最大可能避免脊髓、神经根损伤,且简便易行,是一种理想的麻醉方法。     

Cervical spine surgery: Complications and considerations

Surgery is a successful treatment option for traumatic or degenerative mechanical pathologies of the cervical spine. These surgeries can be performed from either an anterior or posterior approach. Each approach has its own indications and associated potential complication profile. The anterior approach is the work horse of degenerative spinal pathologies but is associated with unique proximity related visceral complications like dysphagia, dysphonia, esophageal or oropharyngeal injury, and sympathetic chain injuries. The posterior approach to the cervical spine has fewer indications relative to the anterior approach but again has its own unique complication profile including C5 palsies and epidural hematomas.     

Modified prone position using lateral brace attachments for cervico-dorsal spine surgeries

Purpose

The purpose of the study was to propose a method of prone positioning for posterior cervico-dorsal spine surgeries that is easy to achieve without additional equipment and may reduce complications associated with prone positioning in patients.

Methods

41 patients underwent posterior spine surgeries using our method of prone positioning on a fluoroscopy compatible conventional operation table, and the technical difficulties and complications associated were noted. After induction under general anaesthesia in supine position, cervical tongs were applied. An assembly of two adequately padded cylindrical bolsters and two lateral brace attachments was set on a conventional operating table. The patient was then positioned prone so that the tongs as well as insertion pins of the tongs rest on the lateral brace attachments, with the face and head suspended freely in between. A neutralisation weight was then applied suspended from the tongs to stabilize the head.

Results

The time required for patient positioning was noted and was found to be nearly the same as that required for traditional prone positioning. No problems were noted during patient positioning and with anaesthesia tubing management. All surgeries went well without position related complications except for one patient who developed post-operative macroglossia. All cervical tong pin sites healed without any complications. The fluoroscope easily gained access to the operative areas.

Conclusions

Our modification appears simple, versatile and reproducible for posterior approach procedures of the cervical and upper dorsal spine in prone position. Also, the method can be easily implemented in most conventional operating room facilities with minimal surgeon effort and without the need for any additional inventory.     

前后路联合手术治疗陈旧性颈椎骨折脱位

目的：探讨同期前后路联合手术治疗陈旧性下颈椎骨折脱位的应用价值。方法：15例采取同期前后路联合手术治疗，颅骨牵引下切开复位。手术在全麻下进行，先采用俯卧位，充分松解后方关节突交锁与脊髓后方压迫。然后置平卧位，行前路椎体复位、减压、植骨及安放钢板固定。结果：15例全部获得随访，平均随访时间34个月，脱位均完全复位，平均融合时间3．3个月，无植骨不愈合及内固定断裂、松动、脱出。无术中血管、神经系统损伤，颈椎生理曲度、脱位椎间高度、颈椎的稳定性维持良好。12例脊髓不全损伤神经功能改善。结论：前后路联合手术，可解除后方关节突的交锁及椎管的压迫，经前侧入路复位、植骨与固定，可完全恢复颈椎的序列，使椎管前后方压迫得到彻底解除，植骨块与上下椎体间接触面积增大，融合率较高，安放钢板操作容易，颈椎术后即刻得到稳定，减少了卧床并发症。     

Surgical stabilization of the cervical spine. A comparative analysis of anterior and posterior spine fusions

Two hundred twenty-two cervical spine stabilization procedures in 212 patients are reviewed. In 114 posterior cervical fusions, 88 anterior fusions, and ten combined procedures, no deaths occurred. Surgical complication rates were similar, but more severe complications were noted with anterior cervical fusions, including tracheoesophageal problems and transient neurologic loss. Six cases of graft dislodgement requiring reoperation also occurred. In long-term follow-up evaluations, 36 anterior fusion patients developed progressive kyphotic deformity averaging 22 degrees between surgery and the time solid fusion was obtained. Degenerative changes above and below the fusion mass were detected in 36 of 59 patients treated by anterior surgery. Posterior cervical fusion patients were noted to have no significant late change in alignment, and degenerative changes were infrequent. However, 73 of 98 patients had significant extension of fusion mass beyond the originally intended levels of stabilization. Because anterior cervical spine fusion was associated with significant complications of graft dislodgement and tracheoesophageal trauma, as well as postsurgical progressive deformity, the authors recommend posterior wiring and fusion as the procedure of choice to treat cervical spine instability and permit halo-free postsurgical rehabilitation. When anterior neural decompression and fusion is necessary, concomitant posterior wiring and fusion or halo vest immobilization may be necessary to maintain reduction and prevent kyphotic angulation, because posterior ligamentous disruption is not always grossly evident on radiographic examination.     

Cervical spine lateral approach for myeloradiculopathy: technique and pitfalls

BackgroundThe authors describe the rationale of cervical spine lateral approach technique to manage spondylotic myeloradiculopathy with its advantages, disadvantages, complications, and pitfalls.MethodsThe cervical lateral approach could be indicated to treat spondylotic myeloradiculopathy where anterior compression is predominant and the spine is straight or kyphotic without instability.ResultsUsing the present approach the lateral aspect of the cervical spine is easily reached and the vertebral artery is well controlled. The lateral part of the pathological intervertebral discs, uncovertebral joints, vertebral bodies and posterior longitudinal ligament are removed as necessary and decompression tailored to each patient to completely free the nerve roots and/or spinal cord.ConclusionThe cervical lateral multilevel corpectomy/foraminotomy technique allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression preserving spinal stability and physiological spinal motion.     

Management of cervical spinal fractures in ankylosing spondylitis with posterior fixation

STUDY DESIGN: Introduction of a posterior approach for internal fixation of fractures of the ankylosed cervical spine. OBJECTIVES: To evaluate the clinical outcome of patients with ankylosing spondylitis and cervical spinal fractures treated with posterior instrumentation and a collar orthosis. SUMMARY OF BACKGROUND DATA: Cervical spinal fractures in patients with ankylosing spondylitis almost always extend completely across the vertebral segment to include both anterior and posterior elements. Treatment with immobilization alone is often inadequate. Generalized spinal rigidity and exaggerated thoracic kyphosis may hinder anterior exposure. Posterior approaches have been described but generally require postoperative halo immobilization. In the authors' technique for patients whose spinal alignment is relatively well preserved, a posterior exposure is used that achieves three-point internal fixation along multiple segments. The complications associated with halo immobilization are avoided. METHODS: Seven patients with ankylosing spondylitis and fractures of the cervical spine were stabilized with posterior instrumentation. Patients were immobilized after surgery with either a cervical collar or a sternal occipital mandibular immobilizing brace and observed for neurologic outcome, radiographic evidence of bony fusion, and complications. RESULTS: No patient experienced neurologic deterioration with surgery. Two patients died at acute rehabilitative facilities after discharge. Radiographic evidence of fusion was observed in the five patients available for follow-up. CONCLUSIONS: Patients with ankylosing spondylitis and cervical spinal fractures can be adequately treated with lateral mass plating and interspinous wiring of autologous rib graft. Adequate postoperative immobilization can be attained with a cervical collar and does not require a halo vest.     

Vertebragenic dysphagia

Dysphagia due to external compression by anterior hyperostosis of the cervical spine is rare. The diagnosis may be established by conventional X-ray of the spine, oesophagogram, CT or MRI. CASES: We operated on one patient with an exostosis on the axis and another patient with large anterior osteophytes from C3 to C7 in Forestiers's disease. Postoperatively the patients were asymptomatic. CONCLUSIONS: Painful dysphagia due to anterior hyperostosis of the cervical spine is an indication for surgery. The anterolateral extrapharyngeal approach from C3 to C7 and the transoral intrapharyngeal approach to the vertebra C2 are preferred. In cooperation between orthopaedics and ENT the surgical treatment has no major complications and gives good functional results.     

Vertebral artery (V2) pseudo-aneurysm after surgery for cervical schwannoma. How to prevent it and a review of the literature

Study designCase report and review of the literature.ObjectiveTo prevent and manage a suspected iatrogenic vertebral artery injury during a cervical spine anterior approach.Summary of background dataThe anterior spine approach is a common surgery with few complications. One of the rare but significant risks is vertebral artery injury. Consequences of vertebral artery injuries are often delayed. Therefore, it is essential to prevent this complication and to know how when exploring after a suspected vertebral artery injury.MethodsReport of a case and review of the literature. A 61-year-old woman presented with a cervical schwannoma involving the C5–C6 foramen. She had undergone surgery 22 years before by the posterior approach. We performed an anterior cervical approach. After 12 days, a vertebral artery pseudo-aneurysm occurred. Our review of the literature is focalized on vertebral artery injuries during cervical surgery by the anterior approach.ResultsThe patient was treated by coil embolization with a good outcome. To our knowledge, only 6 cases of vertebral artery pseudo-aneurysm after surgery have been reported in the literature.ConclusionAccording to the literature, vertebral artery pseudo-aneurysms resulting in anterior cervical approach are rare but their consequences could be severe. Prevention begins by detailed surgical planning. Peroperative imaging is helpful. Any suspected vertebral artery injury should postpone a contralateral approach before angiographic imaging.     

颈椎后纵韧带骨化症手术并发症探讨

[目的]探讨颈椎后纵韧带骨化症（OPLL）手术主要并发症的原因及对策。[方法]对2002年3月~2006年5月85例颈椎后纵韧带骨化症手术治疗病例进行回顾性分析。其中连续长节段骨化行颈后路全椎板切除减压内固定68例,发生并发症13例;孤立型或短节段骨化行颈前路椎体次全切减压植骨内固定17例,发生并发症3例。[结果]术后获得随访66例,随访期3~25个月,平均13个月。颈后路并发症：颈肩痛8例,给予消炎止痛药、脱水、理疗等保守治疗,术后2~20周患者疼痛缓解,恢复基本满意,其主要原因与减压后脊髓漂移神经根受牵拉或手术操作导致神经根受刺激或损伤有关。2周内缓解者可能与手术创伤局部组织水肿肌肉痉挛所致。术后不全瘫或症状加重4例,经药物及高压氧等治疗,3例恢复理想,1例恢复欠佳,不全瘫发生主要与手术减压后脊髓再灌注损伤有关。术后血肿2例,均经及时发现即刻手术探查血肿清除、激素冲击治疗而获得恢复,术中止血不彻底或手术创面渗血、引流管引流失败是其主要原因。脑脊液漏1例,经脱水、局部适当包扎及颈部制动,于术后3d脑脊液漏停止,切口愈合良好。手术切口感染2例,经抗感染、局部清创缝合等治疗术后20d左右获得愈合。前路并发症：术后不全瘫2例,经甲强龙冲击,神经营养药（弥可保）、高压氧治疗,术后20~30d完全恢复;脑脊液漏1例。内置物相关并发症：前路钛网下沉1例,后路内固定螺钉脱落1例（单枚）。[结论]颈椎后纵韧带骨化无论行后路或前路手术可发生多种并发症,有些是难以避免的,而有些则是可以经过努力预防或杜绝的,术前准备充分,术中小心操作,术后加强管理,是减少后纵韧带骨化手术并发症的关键。     

Complications in cervical spine surgeries

Complications in cervical spine surgeries can occur infrequently; however, these adverse events can be catastrophic. Each approach to the cervical spine has its own unique set of complications that can occur. Pre-operative planning, vigilance intraoperatively, and careful postoperative care can help avoid complications and allow early detection of adverse events that can prevent long-term sequelae. Both anterior and posterior surgical approaches consistently offer great results, each approach can be technically demanding, and surgeons should be familiar with the appropriate techniques and possible complications.     

The management of neglected spondylitis tuberculosis with dislocated C1 and C2 odontoid destruction: A case report

Introduction and importanceSpinal tuberculosis was the most common TB infection in human body. Musculoskeletal tuberculosis (TB) mostly affected lower thoracal or upper lumbar spine. However, TB infection can also occurs along vertebral spine. We reported a rare case about TB infection in cervical spine. We provided the clinical manifestation and therapeutic method for the patient. Cervical TB infection is a very rare case. Especially, when it involves in C1 and C2 like we provided on this case.Case presentationA 24 years-old male came to the orthopaedic clinic with neck pain that aggravated by neck movement. He previously diagnosed with TB infection on his lung within 3 months. We performed x-ray data to determine the source of neck pain. Examination revealed anterior collapse of C1, destruction of odontoid process, and soft tissue swelling. We also performed MRI cervical to assess the destruction of anterior corpus C1.Clinical discussionWe decided to operate the patient with reposition and posterior stabilization of C1 using occipital plate from posterior approach and added some synthetic bone graft. The medical treatment is anti-tuberculosis drugs, usually conducted conservatively in mild-to-moderate cases. But, if there is deterioration in neurological deficit or persisting deficit with spinal cord compression, such as C1 and C2 involvement, surgery can be considered. There are two types of surgery; posterior fixation and fusion and anterior release and posterior stabilization.ConclusionTB musculoskeletal infection must be evaluated regularly to consider the perfect time for additional surgical treatment. The good decision to operate the moderate to severe case could improve the patient’s functional outcome.     

陈旧性下颈椎骨折脱位的手术治疗（附42例报告）

目的探讨陈旧性下颈椎骨折脱位的发生原因、手术方法及临床疗效。方法2005年6月～2008年12月,借助椎体间撑开器经颈前路整复脱位椎体、椎体间植骨融合钢板内固定术以及颈后路整复脱位椎体联合应用前路椎体间植骨融合钢板内固定术治疗陈旧性下颈椎骨折伴脱位42例患者。其中,18例患者单纯经颈前路完成脱位颈椎椎体复位,24例前路整复失败病例联合颈后路整复脱位椎体并前路椎体间植骨融合钢板内固定术。观察术后颈椎的稳定性、植骨融合率及神经功能恢复情况。结果全部病例均获得解剖复位,颈椎生理弧度及椎间隙高度恢复正常,术中无神经损害加重及血管损伤等并发症发生,术后颈椎获得即刻稳定性。经6～48个月随访,椎间植骨均获得骨性愈合,螺钉无松动、退出或断裂,颈椎脱位矫正度无丢失,神经功能均有不同程度恢复。结论陈旧性下颈椎骨折脱位应先行前路整复,如失败再行后路手术整复脱位椎体并前路椎体间植骨融合内固定术,对于颈椎陈旧性骨折脱位仍强调恢复颈椎解剖对位的重要性。     

Komplikationen bei operativen Eingriffen an der Wirbelsäule

The number of surgical interventions for spinal diseases has greatly increased due to rapid improvements in surgical techniques. The close anatomical relationship between neural and bony structures and the various anatomical approaches to the spinal column lead to a large variety of possible surgical complications. Therefore, it seems helpful to differentiate the complications with respect to their origin. An incorrect positioning of the patient can result in palsy or even blindness. Surgical access to the spine depends on the pathology and the surgical target. Typical complications can be explained by the anatomical situation, such as the vicinity of the esophagus in the anterior approach to the cervical spine or the great vessels in anterior procedures to the lumbar spine. Complication during the surgical manipulation of the spine can be related to either decompression procedures of neural structures or spinal implants. The correction of spinal deformities can result in very specific complications.