Surgery for cervical spine
disease
Patrick Statham,
Consultant Neurosurgeon,
Western General Hospital, Edinburgh
Format
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Anatomy and load bearing
Spectrum of Pathology
Clinical examination and assessment
Differential diagnosis
Special tests
Approaches
Instrumentation and prosthesies
Specific pathology
The future
Functional units:
anatomy and pathology
• Occiput C1 and C2
• C3 to C7
• Cervicothoracic junction
Longus colli
Spinal cord anatomy
Gross cervical cord anatomy
Human cervical spine
Occipital-Atlanto Complex C0 C1
• C0-C1
Flex/Ext
Lat Flex
Axial Rot
10-15°
8°
0°
13°
Atlanto-Axial Complex C1 C2
• C1-C2
Flex/Ext
10°
Lat Flex
0°
Axial Rot
47°
40% to 50% of axial Rotation
The first 45° of axial rotation
Atlanto-Axial Complex C1 C2 – Coupling
C1 C2 Biconvex cartilagenous articulation
Double threaded screw
Cervical Spine Kinematics & Anatomy
• Flexion/Extension
• Axial rotation
• Lateral flexion
• Atypical C1 C2 C7
• Typical C3-C6
145°
180°
90°
Lower cervical Spine C3-C7 – Coupling
• On lateral bending the spinous processes go to the covexity of
the curve
• C2-2° of coupled axial rot for every 3° of lateral bending
• C7-2° of coupled axial rot for every 7.5° of lateral bending
• Angle of incline of the facet joints in the sagittal plane increases
cephalocaudally
Cervical Spine instability
• Misjudgement – Death or major neurological deficit
– Un-necessary surgery with risk of
surgical complications
• Definition
“Clinical stability is defined as the ability of the spine to
limit its patterns of displacement under physiologic loads
so as not to damage the spinal cord or nerve roots.”
White and Panjabi Clin Orthopaedics 1975
Cervical Spine instability C0 C1 C2
Transverse ligament 7-8 mm
Tectorial membrane
Posterior A-O A-A membranes
Nuchal Ligament
Wolf et al. J Mt Sinai Hosp. NY. 23:283,1956
Cervical Spine instability C2-C7
Cervical Spine instability C2-C7
• Radiology
Cervical Spine instability C2-C7
A Check List
Ant elements destroyed
Post elements destroyed
Sagittal translation >3.5 mm
Sagittal angulation > 11°
Spinal cord damage
Nerve root damage
Abnormal disc narrowing
Dangerous Loading anticipated
Total of 5 or more = unstable
White et al Spine 1:15, 1976.
2
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2
1
1
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1
Spectrum of pathology
• Prolapsed discs, osteophytic compression: ‘wear
and repair’
• Inflammatory: rheumatoid, ankylosing spondylitis
• Trauma: odontoid, rotatory subluxation
• Neoplastic: meningiomas, schwannomas,
metastatic cord compression,intrinsic cord
• Congenital Klippel Feil, fused, Down’s,
enterogenous cysts
• Infection: discitis, osteomyelitis, epidural
abscess
Clinical examination
• Clothing zips, velcro
• Aids: stick, wheelchair
• Deformity OA,RhA,
AS, klippel feil,
Downs
• Other disease; cancer
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Posture
Tone
Power
Sensation
Deep tendon reflexes
Co ordination
Gait
dermatomes
Diagnosis
• MRI
• CT or CT myelogram
• Nerve conduction
studies
• Blood
• CSF
• Multiple sclerosis
• Mononeuritis
multiplex
• Peripheral n
entrapment (median,
ulnar)
• SACDC
• Brachial amyotrophy
Clinical assessment
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Natural history of condition
Risks and benefits of the intervention
Alternatives; collar halo physiotherapy
Appropriateness for this particular patient
Surgical approaches
• C1/2 anterior: trans oral
• C1/2 posterior: midline sub-occipital
• Sub-axial anterior: anterior cervical
decompression
• Sub-axial posterior: cervical laminectomy,
laminoplasty, foramenotomy
Results: NASCIS 2
6 weeks: ‘no statistical difference between
groups’
6 months: MPSS improved PP (p=0.012),
Touch (p=0.042)
1 year:(95%) ‘no significant differences in
neurological function by treatment group’
Bracken 1993: segmental and longtract
recovery in NASCIS 2
Disc prolapse C6/7
Anterior cervical approach
PATIENT POSITIONING
Plate removal, disc
decompression, solis cage
and graft
Total discectomy, iliac graft,
Anterior locking plate