Anterior Cervical Approach Research Articles

The clinical effect and disquisition of anterior cervical approach surgery with posterior longitudinal ligament hook pliers and posterior longitudinal ligament nip pliers

To study the clinical effect of anterior cervical approach surgery to removal posterior longitudinal ligament (PLL) with posterior longitudinal ligament hook pliers and posterior longitudinal ligament nip pliers. To retrospectively analyzed anterior cervical approach surgery treatment 73 patients who were cervical spondylosis myelopathy. All patients removal PLL with self-make instrument, According to JOA grade to evaluate effect of operations. Full patients removal PLL were in succeed, in shape of extradural has renew, the JOA grade were increase, (12.8 ± 3.2) vs (8.3 ± 1.9). Removal PLL were increase effect of downright decompress in anterior cervical approach surgery, Operations become safety agile and reduce the complications with self-make instrument.

Surgical resection of neoplastic cervical spine lesions in relation to the vertebral artery V2 segment.

Neoplastic cervical spine lesions are seen infrequently by the spinal surgeon. The surgical management of these tumors, particularly with associated neurovascular compromise, is challenging in terms of achieving proper resection and spinal stabilization and ensuring no subsequent recurrence or failure of fixation. In this report we highlight some of the problems encountered in the surgical management of tumors involving the cervical spine with techniques applied for gross total resection of the tumor without compromising the vertebral arteries. Ten patients with neoplastic cervical spine lesions were managed in our study. The common cardinal presentation was neck and arm pain with progressive cervical radiculo-myelopathy. All patients had plain X-rays, computer tomography scans, and magnetic resonance imaging of the cervical spine. Digital subtraction or magnetic resonance angiograms were performed on both vertebral arteries when the pathology was found to be in proximity to the vertebral artery. When a tumor blush with feeders was evident, endovascular embolization to minimize intraoperative bleeding was also considered. A single approach or a combined anterior cervical approach for corpectomy and cage-with-plate fixation and posterior decompression for resection of the rest of the tumor with spinal fixation was then accomplished as indicated. All cases made a good neurological recovery and had no neural or vascular complications. On the long-term follow-up of the survivors there was no local recurrence or surgical failure. Only three patients died: two from the primary malignancy and one from pulmonary embolism. This report documents a safe and reliable way to deal with neoplastic cervical spine lesions in proximity to vertebral arteries with preservation of both arteries.

Leprotic cervical spondylodiscitis

Leprosy is a chronic infectious disease caused by the Mycobacterium leprae that leads to leprotic neuropathy involving the peripheral nerve and several characteristic skin lesions. Skeletal involvement can occur in peripheral joints, such as the wrist and the ankle. However, there is no report of an axial leprotic lesion involving the spine or paraspinal soft tissue. The authors report the first case of a leprotic cervical lesion involving the axial skeletal system. A 48-year-old male presented with neck pain and severe pain in the right suprascapular area and left arm. Preoperative MRI of the cervical spine revealed signal changes in the prevertebral soft tissue at the level of the C3, 4, 5 vertebral bodies. There were a lower signal intensity on T1-weighted image and high signal intensity on T2WI of the bone marrow at the level of the C5 and C6 vertebral bodies, and a C5/6 segmental ossification of the posterior longitudinal ligament. There were herniated cervical disc on the left C5/6 with C6 root and the right side of C6/7 with a C7 root compression. He was previously diagnosed with leprosy when he was 14 years old and received treatment intermittently over the course of 7 years. But patient did not disclose his past history. Surgical intervention was conducted using an anterior cervical approach. An incision was made in the anterior longitudinal ligament at C5/6, and a pinkish gray friable gelatinous material was observed on the C5/6 disc and on the anterior lower one-third surface of the C5 vertebral body. Specimens were obtained and subjected to pathological evaluation and microbiological culture. After C5/6 and C6/7 discectomies, nerve root decompression and autologous iliac bone grafting were performed at the C5/6 and C6/7 levels. The C5-6-7 vertebrae were fixed with an Atlantis cervical locking plate and a screw system. The pathological report indicated chronic inflammation with heavy plasma cell infiltration on the specimen. We sent the specimens to the Institute of Hansen's Disease, and polymerase chain reaction for leprosy tested positive. After surgery, his pain disappeared and he was given a prescription for antileprotic drugs. The authors describe the first case of leprotic cervical spondylodiscitis that was operatively treated in a 48-year-old patient with known leprosy history since his 14 years old.

Ventral Surgical Approaches to Craniovertebral Junction Chordomas

Chordomas are primarily malignant tumors encountered at either end of the neural axis; the craniovertebral junction and the sacrococcygeal junction. In this article, we discuss the surgical management of craniovertebral junction chordomas. In this paper, we discuss the surgical management of craniovertebral junction chordomas. The following approaches are illustrated: transoral-transpalatopharyngeal approach, high anterior cervical retropharyngeal approach, endoscopic transoral approach, and endoscopic transnasal approach. No single operative approach can be used for all craniovertebral chordomas. Therefore, the location of the tumor dictates which approach or approaches should be used.

Outcome of 132 Operations in 97 Patients With Chordomas of the Craniocervical Junction and Upper Cervical Spine

To study the outcomes of surgery for chordomas of the craniocervical junction and upper cervical spine as well as complication rates, survival, and associated adverse factors. Retrospective review of patients (1982-2007) at 2 European centers who underwent transoral, transfacial, transmandibular, and anterior cervical approaches for excision of chordomas of the craniocervical junction and cervical spine. The chi test and Fisher exact test were used to determine significant adverse factors (P < .05), and log-rank survival analysis was used to compare outcome in different groups. One hundred thirty-two operations were performed in 97 patients. The most common operations were transoral surgeries and maxillotomies. After surgery, neck pain was the same or better in 98.1% of patients. Of the 18.6% of patients who presented with myelopathy, 27.8% improved, 44.4% remained unchanged, and 27.8% deteriorated. Major complication rates were velopharyngeal incompetence, 3.1%; vertebral artery stroke, 1%; wound infection, 3.1%; dysphagia, 3.1%; failure of fixation, 2.1%; sepsis, 3.1%; meningitis, 3.1%; and cerebrospinal fluid leakage, 6.2%. Five- and 10-year overall survivals were 55% and 36%, respectively. Patients who presented to our units for revision surgery, after prior attempts at resection elsewhere, were associated with a worse survival than patients who underwent de novo surgery. We present, to our knowledge, the largest published series of chordomas at the craniocervical junction. Complication rates for these major operations can be minimized at specialist centers, with careful patient selection and counseling. As complete or as radical an operation as possible should be performed at first presentation; the best chance for the patient is the first chance.

Significance and cost-effectiveness of somatosensory evoked potential monitoring in cervical spine surgery

Intraoperative somatosensory evoked potential (SSEP) monitoring during cervical spine surgery is not a universally accepted standard of care. Our retrospective study evaluated the efficacy and cost-effectiveness of intraoperative SSEP in a single surgeon's practice. Intraoperative SSEP monitoring was performed on 210 consecutive patients who had cervical spine surgery: anterior cervical approach 140 and posterior approach 70. They were screened for degradation or loss of SSEP data. A cost analysis included annual medical costs for health and human services, durable goods and expendable commodities. Temporary loss of the electrical wave during cauterization resolved upon discontinuation of the cautery. We had no loss of cortical wave with preservation of the popliteal potential. A drop in the amplitude of the cortical wave was observed in three patients. This drop was resolved after hemodynamic stabilization in the first patient, readjusting the bone graft in the second patient, and interrupting the surgery in the third patient. The additional cost for SSEP monitoring was $835 per case and the total cost of the surgery was $13,835 per case. By spending $31,546 per year on SSEP, our institution is saving a total cost ranging from $64,074 to $102,192 per patient injured per year. Intraoperative SSEP monitoring is a reliable and cost-effective method for preventing postoperative neurological deficit by the early detection of vascular or mechanical compromise, and the immediate alteration of the anesthetic or surgical technique.

SIMPLE METHOD FOR DETERMINING THE NEED FOR STERNOTOMY/MANUBRIOTOMY WITH THE ANTERIOR APPROACH TO THE CERVICOTHORACIC JUNCTION

Frequently, the cervicothoracic junction can be reached through a simple anterior approach. In some cases, access to this region requires a much more aggressive surgical intervention, such as manubriotomy or sternotomy. Information regarding the need for such interventions is particularly useful to have preoperatively to guide surgical planning as well as discussions regarding surgical risks and expected morbidities. Whereas methods utilizing magnetic resonance imaging have been proposed for determining the lowest level that can be accessed through a simple low cervical approach, we describe a simple technique using sagittal computed tomographic imaging. Our technique does not require any complex geometry and has given us very consistent results. Computed tomographic sagittal reconstruction of the cervical and upper thoracic spine that includes the entire sternum is obtained. The lowest accessible disc space is determined by a straight line passing through and parallel to the disc space that also passes above the manubrium (the intervertebral disc line). Sagittal computed tomographic reconstructions obtained from 50 adult patients were reviewed, and the lowest disc space accessible from an anterior low cervical approach was determined. The most common accessible level was T1-T2 (23 patients), followed by C7-T1 (13 patients), T2-T3 (10 patients), and C6-C7 (4 patients). A 35-year-old man with T2-T3 compression fractures with kyphotic deformity was treated with T2 and T3 vertebrectomies and T1-T4 fusion through an anterior approach. We propose a simple and consistent method for determining the need for manubriotomy or sternotomy for anterior approaches to the cervicothoracic junction.

Treatment of upper cervical spine injuries via the high anterior cervical retropharyngeal approach

Objective To study the indications and clinical outcome of the upper cervical spine via the high anterior cervical retropharyngeal approach in treatment of upper cervical spine injuries. Methods There were 41 patients including 32 males and 9 females, at age of 12-67 years. Of all patients, there were 21 patients with Hangman fractures, two with fracture of C2 vertebral body, 12 with irreducible atlantoaxial dislocation secondary to os odontoideum, four with C1,2 tuberculosis and two with C2 gaint cell tumor. All patients underwent the high anterior cervical retropharyngeal approach to expose C1C3. C2,3 fusion followed by self-locking plate was performed for Hangman fractures and C2 fractures. Ventral reduction plud posterior aflantoaxial fusion was done for irreducible atlantoaxial dislocation secondary to os odontoideum. Lesion was cleared for tuberculosis and the tumor was resected and reconstructed. The neurological funcation was evaluated according to the ASIA criteria, the JOA score and Odom' s criteria. Results Successful exposure of arch of atlas to C3 was achived in all 41 patients, with satisfactory reducation, decompression, fusion, lesion resection and reconstruction. The trauma patients with normal neurological function showed no neurological deficit postoperatively, but those with quadriparesis had partial recovery. While the patients with illness obtained marked recovery of neurological function, with the JOA score from preoperative 8.9 to 12.5 at final follow-up. The clinical success rate (excellent/good/fair) reached 94. % according to Odom' s Criteria. Hypoglossal symptom was found in three patients and facial nerve symptom in two, without wound infection. Conclusions Via the high anterior cervical retropharyngeal approach, the upper cervical spine can be thoroughly exposed to facilitate reduction, decompression and reconstruction and maximally restore physiological function of the cervical spine in treatment of the upper cervical spine injuries. Key words: Spinal fractures; Cervical vertebrae; Dislocations; Fracture fixation; internal; Anterior cervical retropharyngeal approach

Cervicothoracic Giant Cell Tumor Expanding Into the Superior Mediastinum: Total Excision by Combined Anterior-Posterior Approach

This article describes a case of cervicothoracic giant cell tumor expanding into the superior mediastinum treated by total spondylectomy. A 42-year-old-man presented with back pain and paraparesis. Magnetic resonance imaging revealed the collapse of the T2 vertebral body. The spinal cord was severely compressed by the tumor mass. The tumor had spread from T2 to the mediastinum, so that the tumor was in contact with many vital structures. To resect the tumor completely, total spondylectomy from T1 to T3 was performed through a combined anterior-posterior approach. The tumor was dissected from the vital structures using an anterior low cervical approach and splitting one-third of the sternum. En bloc vertebral resection from Th1 to Th3, including the tumor pseudocapsule, was possible through a posterior approach. The tumor around the nerve roots or dura was resected piece by piece since it was possible to separate the capsulated tumor from the dura. Splitting one-third of the sternum allowed separation of the tumor from the anterior vital structures, under direct vision. This allowed en bloc vertebral resection of the tumor that had spread to the mediastinum from T2 and in the craniocaudal direction from T1 to T3. Although giant cell tumor is benign, it can be locally aggressive. Complete excision of a giant cell tumor is the best treatment option even for the cervicothoracic spine, to protect the vital structures or neural function.

Single Anterior Procedure for Stabilization of a Three-Part Fracture of the Axis (Odontoid Dens and Hangman Fracture)

A case of a 3-part fracture of the axis combining an odontoid dens and a hangman fracture is reported. To describe a single anterior procedure allowing stabilization with an odontoid screw fixation and a C2-C3 fusion in a case of complex fracture of the axis. Even if fractures of the axis are common, multiples fractures of the axis are rare and their management is still challenging for surgeons who have to achieve primary stability, early mobilization, preserved cervical range of motion, and favorable outcome. A 79-year-old man was referred in our neurosurgical department 3 weeks after a bicycle accident. He had persistent neck pain without radicular pain. Neurologic examination was normal. The initial CT scan showed a rare and complex fracture of the axis consisting of a fracture of the dens and a traumatic spondylolisthesis of C2-C3. The surgical procedure was performed using an anterior cervical approach under fluoroscopic guidance. First, a C2-C3 fusion was performed using an iliac crest graft. Then an anterior odontoid screw was placed under fluoroscopic guidance. Finally, an anterior plating of C2-C3 covering the odontoid screw was achieved. Postoperative course was uneventful and patient was discharged at day 6. This single time procedure was able to achieve primary stability of the fractures of the axis and offers the possibility of an early mobilization of the patient with a good outcome. This approach allowed a better preservation of the cervical range of motion compared with a classic posterior fusion.

Upper cervical spine chordoma of C2–C3

Chordoma is a rare low-grade malignant neoplasm derived from the remnants of the embryonic notochord. This locally invasive neoplasm is subject to recurrence after treatment. The median survival time is estimated to be 6.3 years. Various treatment approaches have been attempted, including radical excision, radiotherapy and chemotherapy. Treatment outcome is significantly influenced by the size and site of the chordoma. Recently, Imatinib, a molecular-targeted agent, has been shown to have antitumor activity in chordoma. Proton radiotherapy, stereotactic radiotherapy and intensity-modulated radiotherapy have also been used. Surgical treatment is still the primary choice for chordoma. It has become more aggressive in recent years, evolving from intralesional or partial excision to en bloc resection. However, upper cervical localizations make such en bloc resection in most cases not possible. We present and discuss the therapeutic challenges of a young female with large retropharyngeal chordoma who presented to our institution after conventional photon beam radiotherapy. This C2/3 tumor was classified IB according to the Enneking classification. It distributed to layers A-D and sectors 1-6 according to the Weinstein Boriani Biagini Classification. The left vertebral artery (VA) was encapsulated and displaced. One stage intralesional extracapsular tumor excision and reconstruction was achieved by combined bilateral high anterior cervical approaches and posterior approach. No recurrence or metastasis was observed 3 years after the operation. She returned to her previous occupation as office worker.

Airway Obstruction Caused by Soft Tissue Edema during an Anterior Cervical Approach - A Case Report -

Anterior approaches to the cervical spine for performing decompression, fusion and/or instrumentation are common and useful methods for treating many conditions, including degenerative diseases. One of the rare, but serious complications of an anterior cervical approach is respiratory insufficiency as a result of upper airway obstruction, which is due to airway narrowing and prevertebral soft tissue swelling. We experienced a case of serious airway obstruction that was caused by soft tissue edema combined with postoperative hematoma after an anterior cervical spine approach. We report here on this case and include a review of the relevant literature.

Partial median corpectomy for C2-C3 intradural arachnoid cyst: Case report and review of the literature

Anterior cervical location of arachnoid cyst is a rare and only 22 cases have been reported in the literature. The surgical approach was quite varied and mostly these cysts were accessed via dorsal laminectomy, with few patients developing postoperative neurological deficit. We report a 51-year-old male with a cervical arachnoid cyst extending from the dens to the inferior border of the C3 body, which was successfully decompressed via an anterior cervical approach through the partial corpectomy of C2. This is probably the first case report demonstrating the safety of anterior partial median corpectomy of the C2 body with micro discectomy of C2-C3 space for excision of the anterior cervical archnoid cyst. The additional advantage of this procedure is that it may not result in spinal instability.

An Anatomical Variant : Low-Lying Bifurcation of the Common Carotid Artery, and Its Surgical Implications in Anterior Cervical Discectomy

The common carotid artery generally bifurcates into the internal and external carotid arteries at the level of C3-4. Injury to the common carotid artery during anterior cervical discectomy is a complication that is very much feared but encountered rarely. Knowing the anatomic variations of the common carotid artery and using an operating microscope during the anterior cervical approach for cases with low-lying bifurcation of the common carotid artery would prevent injuries to this artery. We present a 42-year-old female who has successfully undergone anterior cervical discectomy at the level of C5-6 and C6-7. She had a low-lying bifurcation of the common carotid artery.

Diffuse idiopathic skeletal hyperostosis as a cause of progressive dysphagia: a case report

BackgroundForestier's disease, also known as diffuse idiopathic skeletal hyperostosis (DISH), is an idiopathic rheumatological abnormality in which exuberant ossification occurs along throughout the body, but most notably the anterior longitudinal ligament of the spine.Case presentationWe report on a 75-year-old white patient with progressive difficulty in swallowing and dysphagia, resulting in weight loss over the last two years. Radiological evaluation, (x-rays and Magnetic resonance imaging), confirmed the diagnosis of DISH, and revealed marked compression of the esophagus at the C5-6 level, due to excessive ossification of the anterior longitudinal ligament of the cervical spine.The patient was treated with anterior cervical approach for removal of the hyperostosis without fusion. He had marked improvement in swallowing function and was able to resume a normal diet after one month.ConclusionDiffuse idiopathic skeletal hyperostosis or Forestier's disease is an uncommon etiology of difficulty in swallowing and progressive dysphagia. Surgical excision of the cervical osteophytes typically leads to excellent symptomatic results.

Preoperative Laryngeal Nerve Screening for Revision Anterior Cervical Spine Procedures

Anterior cervical spine procedures carry an inherent risk of recurrent laryngeal nerve (RLN) injury. Patients with persistent RLN paresis may be asymptomatic because of compensation from the opposite side. If such patients undergo an opposite-side anterior approach for revision surgery, they are at risk for a second RLN injury, creating the potential for bilateral vocal fold paresis and possible need for tracheotomy. A program of routine screening for laryngeal paresis was implemented for these patients. This retrospective study reviews the results of this screening process. Patients referred for preoperative laryngeal nerve screening were identified. Their charts were reviewed for the results of the videolaryngoscopic examination, and for any recommendations made based on the findings. Relevant history and other physical findings were recorded. Fifty screening laryngeal examinations were performed in 47 patients, of whom 31 (66%) had previously undergone a single anterior cervical approach procedure, and 16 (34%) had undergone more than one. Thirteen of the examinations (26%) revealed abnormal laryngeal findings, including paresis or paralysis in 11 cases (22%), of which 5 were asymptomatic. The findings resulted in a recommendation of a cervical approach from the already-involved side. None of the revision procedures resulted in bilateral vocal fold paralysis. The risk of laryngeal nerve injury appears to increase as higher cervical levels are approached. Minimally symptomatic injuries of the laryngeal nerves from prior neck surgery create a potential serious risk of bilateral vocal fold paralysis with subsequent procedures. Preoperative laryngeal screening is a simple and effective method for reducing this risk.

Long-Term Follow-Up Results in Patients With Cervical Disk Disease Treated by Cervical Anterior Fusion Using Titanium Cage Implants

This study is a retrospective analysis of 146 patients, 85 males and 61 females aged 21-80 years (mean 52 years), with cervical disk disease who underwent anterior fusion and titanium cage implantation with follow-up periods of no less than 72 months after surgery. All patients underwent the conventional anterior cervical approach. After removing the protruded disk and osteophyte, cylindrical titanium cages were placed. Single, two, and three level fusion was performed in 76 (52%), 64 (44%), and 6 (4%) patients, respectively. Functional assessment used the Neurosurgical Cervical Spine Scale (NCSS). The curvature index and range of motion were evaluated pre- and postoperatively. The clinical outcomes were satisfactory and there were no significant complications. The mean NCSS was 9.7 before and 12.7 at 1 year after the operation, and 12.1 at final examination. No postoperative cage extrusion or pseudoarthrosis occurred, but the cages descended in 10 patients (7%) although alignment was satisfactory. At 5 years after the operation, 140 of the 146 patients (96%) had solid fusion. The long-term results of anterior fusion with titanium cage implantation in patients with cervical disk disease were satisfactory. Titanium cage placement is a highly useful alternative to the conventional treatment method in these patients.

Surgical treatment of upper cervical vertebra disease from high anterior cervical retropharyngeal approach

目的 探讨经高位前方咽后入路手术治疗上颈椎疾病的临床效果.方法 本组14例,C2、3椎间盘突出伴C2、3脱位7例,Hangman骨折3例,齿状突骨折2例,C3椎体肿瘤2例.采用高位前方咽后入路,10例行C2～3椎间盘切除或C3椎体病灶清除+自体髂骨或钛网融合器植入+颈前路钢板内固定术,2例行齿状突中空螺钉内固定术.结果 14例患者术中均清楚显露c1前弓～C3、4椎体前方,完成减压复位、病灶清除、融合内固定等操作;无颈部重要血管神经损伤;有脊髓压迫者术后脊髓神经功能得到一定程度的改善.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。

Anterior Approach to the Cervicothoracic Junction Without Sternotomy

Description of a new anterior approach to the cervicothoracic junction and retrospective study of results. To propose a less invasive anterior approach and report the preliminary results of this technique. Different partial sternotomies with or without associated clavicular resection have been proposed but expose patients to the risk of pseudarthrosis. A less invasive technique should reduce the morbidity of this surgery. From 2000 to 2004, 37 patients were operated between T1 and T4. Whenever possible, access was limited to a left standard cervical approach anterior to the carotid sheath extended caudally. If necessary, partial manubrial resection preserving the sternoclavicular joints was performed to extend the exposure. In the majority of cases, metastatic spinal cord compression was involved. The average duration of surgery was 114 minutes; the average blood loss was 760 mL. For access to the vertebral body of T2, a standard anterior cervical approach alone was always sufficient. For exposure of T3 and T4, median manubrial resection was performed in roughly 1 case out of 2. This was used in every case for T5. There were 4 severe and 3 mild complications. This approach provides satisfactory access to the anterior aspect of the spine down to T5 while preserving the sternoclavicular joints.

Intraoperative facet joint injury during anterior cervical discectomy and fusion: an experimental study

Object Disorders of the cervical spine can be successfully addressed by surgical intervention when the choice of such intervention takes into account the possible complications in the treated and adjacent structures. The aim of this study was to investigate the potential for intraoperative trauma in cervical zygapophysial joints and to describe possible pathological changes that may occur during cervical spine surgery. Methods Fifteen sheep underwent surgical intervention via an anterior cervical approach; discectomy at the C5–6 level was performed. In 10 animals, the discectomy was accompanied by titanium cage fusion. The sheep were killed immediately after completion of the operation. Radiological examination of the isolated cervical spines followed. Furthermore, the cervical spines were submitted to decalcification and incised using a microtome, and tissue sections were then studied using light microscopy. Results Radiological examination was used to assess vertebral alignment, vertebral body (VB) morphology, implant position, and endplate and facet joint gross morphology. Histological examination of the endplate and VB demonstrated degenerative lesions as well as cellular necrosis. The study of the facet joints at the treated as well as at adjacent segments (both above and below) revealed in some cases edema between the collagen fibers of the joint capsules, congestion, and microhemorrhages. Injuries were evident in animals in which the Caspar device was used. Conclusions Histopathologically confirmed lesions occurred in facet joints while anterior cervical spine surgery was being performed in sheep. The findings were indicative of trauma and, in the case of human spine surgery, could possibly account for several postoperative complications and patient complaints.