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Cervical spine surgical approaches

Anterior versus posterior cervical approaches and comparison of their indications

13 questions 3 source pages

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13 questions
Q1Describe the position for an anterior approach to the cervical spine.▸
  • GA + reverse Trendelenburg
  • Radiolucent table + head ring
  • Sandbag between scapulae, slight neck extension to evade the jaw
Q2Describe the incision and dissection of the anterior cervical approach.▸
  • Left side incision (predictable recurrent laryngeal nerve course)
  • Insert RT for easy identification of oesophagus; LA + adrenaline along planned incision
  • Split platysma; deep investing cervical fascia just anterior to SCM; retract strap muscle medially
  • Blunt dissection then incise pretracheal fascia medial to the carotid sheath
  • Retract carotid sheath laterally, larynx and oesophagus medially
Q3Which structures may be ligated and which planes are incised?▸
  • +/- superior thyroid vessels (superior thyroid artery close to SLN at C3/4, superior thyroid vein at C6/7)
  • +/- omohyoid
  • Incise the prevertebral fascia
Q4What are the dangers during subperiosteal dissection?▸
  • Subperiosteal dissection of longus colli, retracted laterally
  • Protect the sympathetic trunk and recurrent laryngeal nerve below C6
  • Spine level time out; mount self-retaining retractor to bed
Q5What are the complications of the anterior cervical approach?▸
  • Vertebral artery injury: single = 3-5% stroke, bilateral = potentially fatal
  • Haematoma
  • Oesophageal injury 0.2-0.4%
  • Dysphagia
  • Vocal cord palsy (usually lower level C6-7)
Q6What are the advantages of an anterior approach to the cervical spine?▸
  • Shorter fusion segment
  • More deformity correction
  • Directly addresses pathology (most pathology is anterior)
  • Addresses axial neck pain with fusion
  • Avoids violation of the posterior tension band
Q7What are the disadvantages of an anterior approach?▸
  • Approach complications (nerve, vessel, oesophagus, trachea)
  • Fusion complications (pseudarthrosis, hardware failure)
  • Graft complications (migration, donor site)
  • Not for congenital / multilevel compression
  • ASD in ACDF (adjacent segment disease in anterior cervical discectomy and fusion)
Q8What are the advantages of a posterior approach?▸
  • Deals with posterior pathology
  • Addresses multilevel pathology
  • More familiar to most surgeons
  • Enlarge canal/ volume expansion (enlarges the canal)
Q9What are the disadvantages of a posterior approach?▸
  • Unable to deal with kyphosis >10 deg
  • C5 palsy
  • Instability (post-laminectomy kyphosis)
  • Hinge fracture in laminoplasty
Q10How is the patient positioned for a posterior approach to the cervical spine?▸
  • GA, prone reverse trendelenberg tilt (reverse Trendelenburg)
  • OSI table, hands by side of body
  • Mayfield skull clamp
  • Neck slight flexion to open interlaminar space; strap to pull shoulders inferiorly
Q11How are levels checked before surgery?▸
  • By surface landmark
  • By X-ray
Q12How is the dissection performed?▸
  • Posterior midline incision
  • Cervical fascia along the nuchal ligament
  • Subperiosteal dissection laterally to the facet
  • Avoid dissecting muscle attachments at C2 and C7 to prevent kyphosis
Q13Describe the laminoplasty technique.▸
  • Locate the groove between lamina and facet
  • Create a trough just medial to the groove
  • Split the spinous process with a T saw / 1mm burr
  • Plastic deformity of the anterior cortex
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