Stabilization of the Cervical Spine by Anterior Fusion

Abstract

This paper recounts chronologically the development and application of an original procedure for anterior fusion of the cervical spine. Twenty patients with various pathological lesions of the cervical spine were treated by this operation. No complications specifically related to this technique occurred. Fusion was achieved in all but two patients whose operations were performed less than six months prior to the time of writing. Table I summarizes our experience. The value of posterior spine fusion as a means of re-establishing stability of the cervical spine has been proved. Since 1952 we have been exploring anterior fusion as an alternative to posterior spine fusion in instances where the posterior approach would be difficult, hazardous, or unsuited to the pathological condition at hand. With increasing experience the indications for anterior fusion have become broader, and the advantages of this procedure have become more clearly recognized. In destructive lesions of the cervical vertebral bodies, anterior fusion is particularly useful. By this procedure it is possible to obtain biopsy material, to remove the lesion, to decompress the spine, and to restore stability. In fracture-dislocations of the cervical spine anterior fusion is useful under the following circumstances: 1 . After extensive laminectomies performed to decompress the spinal cord in acute disturbances, stability can be restored most effectively by anterior fusion; 2. In the presence of associated severe maxillofacial injuries that have caused or may cause impairment of respiratory function, anterior fusion can be performed with the patient supine, thus facilitating the maintenance of an adequate airway; 3. When pre-existing moderately severe or severe osteo-arthritic lipping indicates that disturbances in the function of the cord or nerve roots may occur in the future as the result of enlargement of the osteophytes and increasing foraminal encroachment, anterior fusion seems advantageous; once stability is established by anterior fusion the way is open for laminectomy, decompression, and foraminotomy should the need arise; 4. When the integrity of the intervertebral disc has been altered, and recurrence of the dislocation is a distinct possibility—a complication that has occurred in three of our cases—anterior fusion is a useful method of restoring stability. Fusion of all fractures and fracture-dislocations that occur between the occiput and the first thoracic vertebra is not necessary; however, when fusion is indicated the relative ease of access to the involved vertebrae through the anterior approach, the lack of complication encountered in this series, and the rapidity with which fusion has occurred suggest that anterior fusion may be superior to the posterior procedure in many persons. Spontaneous dislocations may occur early or many years after extensive laminectomy for the removal of a cord tumor, a ruptured intervertebral disc, or other lesion, especially if portions of the facets have been removed. These dislocations may cause disturbances in the function of the spinal cord or nerve roots, which are apparently produced by a traction phenomenon secondary to the deformity of the spinal canal created by the dislocation. Posterior spine fusion under these circumstances is tedious and hazardous. The value of anterior fusion in restoring stability in these instances is clear. In lesions of the intervertebral discs in the cervical spine we have limited use of the anterior approach to removal of the disc and fusion in two patients up to the time of writing. Finally, we should like to emphasize that fusion of the cervical spine from an anterior approach has proved to be an excellent means of establishing stability. It is an excellent adjunct to posterior fusion. Both techniques are of extreme value, and the selection of which procedure to use must be based on the nature of the individual problem. Each patient reported here was treated according to his individual problems. As new problems arise, we believe that anterior fusion of the cervical spine will find wider applications.