Anterior Cervical Approach Research Articles

Preliminary clinical application of anterior pedicle screw fixation of lower cervical spine

Objective To discuss the feasibility and safety of anterior pedicle screw (APS) fixation in treatment of lower cervical spine injuries. Methods A total of 10 patients with lower cervical spine injuries were treated with APS fixation.All the patients received preoperative cervical CT scans,and then three-dimensional model was reconstructed by using Mimics software to measure the screw placement parameters (insertion point,screw placement angle,screw length and diameter).All APS fixations were performed through anterior cervical approach,and then centrums antetheca and bilateral outer edges were exposed to distinguish the vertebral end plates.Screw insertion was strictly operated under the fluoroscopic assistance and preoperative screw placement parameters.The postoperative efficacy of APS fixation was evaluated by radiologist and other orthopedist via anteroposterior and lateral radiation,CT scan,three-dimensional model reconstruction and MRI.A follow-up was carried out at 1,3,6 and 12 months after operation. Results Except for one screw for C4 and one for C7,another 24 crews for C3-C7 were successfully inserted.Postoperative CT scan demonstrated four screws breaking the outer vertebral wall.Except for one patient suddenly died from acute myocardial infarction one week after operation,the other nine patients received follow-up.Of three trauma patients,one patient at Grade A did not get improvement but with no aggravation and two achieved improvement for 2-3 grades according to Frankel grade.Among six non-trauma patients,spinal function score by JOA was averagely elevated to 13.4 points,with improvement rate of 60.7％ according to Hirabayashi method.There were no serious complications except for two patients of dysphagia among the patients who were followed up. Conclusions APS fixation is feasible for lower cervical spine injuries.The keys to successful screw insertion are preoperative measurement of individualized screw insertion parameters and appropriate application of intraoperative fluoroscope technique. Key words: Cervical vertebrae; Internal fixators; Pedicle screw

Anterior Cervical Reconstruction With Pedicle Screws After a 4-Level Corpectomy

Case report. To describe a new method of anterior cervical reconstruction with pedicle screws. Anterior reconstruction after multilevel corpectomy is a challenging technique, and there are many reports on its complications. Graft dislodgement is one of the major complications after long cervical fusion. The main cause of failure seems to be a lack of stability in the conventional reconstruction technique. However, pedicle screws for posterior cervical reconstruction show remarkable stability. We describe a new technique of anterior cervical reconstruction with pedicle screws and fibular strut grafting. Seven patients with multilevel cervical myelopathy were treated with this new reconstruction technique after a 4-level corpectomy. We describe this new technique and review the patients' clinical history, results of radiographical imaging, and outcomes. Clinical outcomes were assessed preoperatively and at 3 months postoperatively. Postoperative radiographs were assessed 3 months and 6 months postoperatively. The mean operative time was 182 minutes and the mean blood loss was 271 mL. The average Japanese Orthopaedic Association score for cervical myelopathy improved from 11.5 points preoperatively to 14.5 points 3 months postoperatively. No patients experienced major complications, such as neurological deterioration, infection, or massive blood loss. There was no case of reconstruction failure, graft dislodgement, migration, or screw displacement. To our knowledge, this is the first description of an anterior cervical reconstruction approach, using pedicle screws and fibular strut grafting after a 4-level corpectomy. It is likely that this technique will result in better clinical outcomes with fewer complications in the treatment of patients with multilevel cervical myelopathy.

Complications of the anterior retropharyngeal surgical approach to the degenerative cervical spine

Anterior cervical retropharyngeal approach for decompression of neural structures is well known and considered as an effective surgical procedure. Opportunities for segment fusion or discoarthroplasty for motion preservation are granted. Both conceptions have their advantages and disadvantages separately from risks of the surgical approach. The aim of this study is to present and analyze the complications of the anterior retropharyngeal surgical approach to the degenerative cervical spine.

A Non-Fusion Technique for Removal of Cervical Disk Prolapse using Minimally Invasive Anterior Cervical Transoseous Approach

Introduction In Acute cervical disk prolapse, root compression is the source of pain. In all established techniques, the removal of cervical disk prolapse is performed either through the disk space or through the foramen or joint (microforaminotomy, Frykholm's procedure). So as a result of these techniques, either bradytrophic tissue with little healing potential is disturbed, or bone structures involved in weight bearing or movement are partiallly resected. Consequently, most of these decompression procedures have to be combined with fusion or disk replacement. Materials and Methods This prospective study included P114 patients (54 females and 46 males) with a mean age of 46.4 years and was operated from 2005 to 2010. Indications were cervical soft disk herniations causing symptomatic root compression. Contraindications included instability of the affected segment, central spine compression, fractures or advanced degeneration. A modified version of Oswestry index and the neck disability index (NDI) for neck and arm pain was recorded preoperatively as well as, 3 m and 1 year postoperatively. Also the visual analog scale (VAS) was recorded before and after the procedure. The approach via a 15 mm skin incision is performed by removing a bone cylinder of 6 mm in diameter from the cranial vertebra temporarily. The sequester is removed under direct visual control of the operating microscope. After decompression the bone cylinder is repositioned. Results The mean operation time per 1 segment was 64.4 minutes and mean blood loss was 82.04 mL. Hospitalization period ranged from 2 to 3 days and patients were mobilized in the same day of operation. Total 98 (98%) patients showed complete recovery of neurological deficits postoperatively. The postoperative mean NDI was improved from 34 (preoperative) to 4.6 (postoperative). Also the mean Oswestry score was improved from 16.4 to 1.6. Corresponding improvement of the VAS for neck and arm pain was also recorded and was improved from 6 to 1.3. All 3 scores were statistically significant ( p = 0.05). The 1-year postoperative functional radiographic assessment showed that there was no significant impairment of the stability of the operated segment according to the criteria of White and Panjabi. Complications: one patient (2%) suffered from recurrence after 4 weeks, that was resolved after reoperation with the same method. There was no dural or root sleeve injury. There was no neurological dificit. Neither an approach related postoperative problem nor an infection did occur. Conclusion Removal of a lateral or foraminal disk prolapse through a bony channel proved to be possible and safe. Since the bone cylinder is put back in situ and proved to be incorporated in the vertebral body there is no permanent lesion of the approach. Short-term reduction of the corpus mechanical strength did not lead to any adverse side effect. Since no significant loss of disk height, kyphosis, or segmental instability did occur, this minimal invasive procedure may be a valuable additional option in the operative treatment of the cervical disk prolapse. I confirm having declared any potential conflict of interest for all authors listed on this abstract No Disclosure of Interest None declared Böhm H, Greiner-Perth R, et al. A new minimally invasive posterior approach for the treatment of cervical radiculopathy and myelopathy. Surgical technique and preliminary results. European Spine Journal 2003;12:268–273 Brunaeu M, Cornelius Jf, George B., et al. Microsurgical cervical nerve root decompression by anterolateral approach. Operative Neurosurgery 2006;2:108–113 Cloward RB: The anterior approach for removal of ruptured cervical discs. Journal of Neurosurgery 1958;15:602–617 Fontanella A. Endoscopy microsurgery in herniated cervical discs. Int Intradiscal Therapy Soc Inc Tenth Ann Meet, Naples, Florida, 1997 (Neurological Research 01 (1999) 21:31–38) Fontanella A. Minimally invasive neurosurgery. A convincing alternative to open surgery. Rivista di Neuroradiologia 1997; 10:541 Fritsch EW, Pitzen T. Zervikale Bandscheibenprothesen. Der Orthopäde 3 2006;35:347–361 Heidecke V., Vogel S., Beurkert W. et al. Ergebnisse nach ventraler Fusion mittels Carbon-bzw. Titancage bei zervikalen Bandscheibenvorfällen. Dissertation zur Erlangung des akademischen Grades Doktor der Medizin. (2004) Hilton L. Minimally invasive tubular access for posterior cervical foraminotomy with three dimensional microscopic visualizationand localization with anterior/posterior imaging. The Spine Journal 2007;7:154–158

A Non-Fusion Technique for Removal of Cervical Disk Prolapse using Minimally Invasive Anterior Cervical Transoseous Approach

IntroductionIn Acute cervical disk prolapse, root compression is the source of pain. In all established techniques, the removal of cervical disk prolapse is performed either through the disk space or through the foramen or joint (microforaminotomy, Frykholm's procedure). So as a result of these techniques, either bradytrophic tissue with little healing potential is disturbed, or bone structures involved in weight bearing or movement are partiallly resected. Consequently, most of these decompression procedures have to be combined with fusion or disk replacement.Materials and MethodsThis prospective study included P114 patients (54 females and 46 males) with a mean age of 46.4 years and was operated from 2005 to 2010. Indications were cervical soft disk herniations causing symptomatic root compression. Contraindications included instability of the affected segment, central spine compression, fractures or advanced degeneration. A modified version of Oswestry index and the neck disability index (NDI) for neck and arm pain was recorded preoperatively as well as, 3 m and 1 year postoperatively. Also the visual analog scale (VAS) was recorded before and after the procedure. The approach via a 15 mm skin incision is performed by removing a bone cylinder of 6 mm in diameter from the cranial vertebra temporarily. The sequester is removed under direct visual control of the operating microscope. After decompression the bone cylinder is repositioned.ResultsThe mean operation time per 1 segment was 64.4 minutes and mean blood loss was 82.04 mL. Hospitalization period ranged from 2 to 3 days and patients were mobilized in the same day of operation. Total 98 (98%) patients showed complete recovery of neurological deficits postoperatively. The postoperative mean NDI was improved from 34 (preoperative) to 4.6 (postoperative). Also the mean Oswestry score was improved from 16.4 to 1.6. Corresponding improvement of the VAS for neck and arm pain was also recorded and was improved from 6 to 1.3. All 3 scores were statistically significant (p = 0.05). The 1-year postoperative functional radiographic assessment showed that there was no significant impairment of the stability of the operated segment according to the criteria of White and Panjabi. Complications: one patient (2%) suffered from recurrence after 4 weeks, that was resolved after reoperation with the same method. There was no dural or root sleeve injury. There was no neurological dificit. Neither an approach related postoperative problem nor an infection did occur.ConclusionRemoval of a lateral or foraminal disk prolapse through a bony channel proved to be possible and safe. Since the bone cylinder is put back in situ and proved to be incorporated in the vertebral body there is no permanent lesion of the approach. Short-term reduction of the corpus mechanical strength did not lead to any adverse side effect. Since no significant loss of disk height, kyphosis, or segmental instability did occur, this minimal invasive procedure may be a valuable additional option in the operative treatment of the cervical disk prolapse.I confirm having declared any potential conflict of interest for all authors listed on this abstractNoDisclosure of InterestNone declaredBöhm H, Greiner-Perth R, et al. A new minimally invasive posterior approach for the treatment of cervical radiculopathy and myelopathy. Surgical technique and preliminary results. European Spine Journal 2003;12:268–273Brunaeu M, Cornelius Jf, George B., et al. Microsurgical cervical nerve root decompression by anterolateral approach. Operative Neurosurgery 2006;2:108–113Cloward RB: The anterior approach for removal of ruptured cervical discs. Journal of Neurosurgery 1958;15:602–617Fontanella A. Endoscopy microsurgery in herniated cervical discs. Int Intradiscal Therapy Soc Inc Tenth Ann Meet, Naples, Florida, 1997 (Neurological Research 01 (1999) 21:31–38)Fontanella A. Minimally invasive neurosurgery. A convincing alternative to open surgery. Rivista di Neuroradiologia 1997; 10:541Fritsch EW, Pitzen T. Zervikale Bandscheibenprothesen. Der Orthopäde 3 2006;35:347–361Heidecke V., Vogel S., Beurkert W. et al. Ergebnisse nach ventraler Fusion mittels Carbon-bzw. Titancage bei zervikalen Bandscheibenvorfällen. Dissertation zur Erlangung des akademischen Grades Doktor der Medizin. (2004)Hilton L. Minimally invasive tubular access for posterior cervical foraminotomy with three dimensional microscopic visualizationand localization with anterior/posterior imaging. The Spine Journal 2007;7:154–158

Does the Third Cervical Vertebra Need to be Rimmed for Odontoid Screwing? A Hypothetical Study of Anatomic Landmarks

The superoanterior portion of the third cervical vertebra may need to be rimmed during anterior odontoid screw fixation procedures. We, therefore, retrospectively evaluated radiological data to analyze the anatomical relation between the second and third cervical vertebra of the patients who were operated by an anterior cervical approach with respect to the question if odontoid screw fixation would have been possible without rimming or not. Patients in whom the anterior approach for cervical disc prolapse and/or cervical stenosis was used between 2008 and 2010 were included in this study. The odontoid screw angle, and the angle between the lower second and the upper third cervical vertebral endplate were measured on intraoperative cervical lateral radiographs. If the screw line passed through the superior anterior portion of the third vertebral body, it was determined that the third cervical vertebra would have been needed to be rimmed if odontoid screwing would have been planned. 100 patients were included. There were 50 males and 50 females with a mean age of 47.9 years (mean ± SD: 47.9 ± 12.6 years). The mean odontoid screw angle, and the angle between the lower second and the upper third cervical vertebral endplate were 65.61° ± 3.75° and 15.24° ± 4.85° (nonparallel vertebral endplates only), respectively. The odontoid screw angle, in which the third cervical vertebra would not have been needed to be rimmed, was 63.87° ± 2.84°. In addition, the odontoid screw angle in which the third cervical vertebra would have been needed to be rimmed was 67.28° ± 3.77°. The odontoid screw angle may be easily measured on lateral radiographs. In cases in which the odontoid screw angle is 67.28° ± 3.77° or higher, the superoanterior portion of the third cervical vertebra would be needed to be rimmed for proper screw fixation of odontoid fractures.

Morbid Obesity Increases Cost and Complication Rates in Spinal Arthrodesis

A retrospective cross-sectional study of all spinal fusions in California from 2003 to 2007. This study analyzes whether morbid obesity alters rates of complications and charges in patients undergoing spinal fusion. Prior studies of obesity have focused on lumbar fusion; some identified increases in wound complications. However, these studies typically do not account for comorbidities, do not examine nonlumbar fusions, and usually are small single institution series. Our study used the Healthcare Cost and Utilization Project's California State Inpatient Databases (CA-SID) to identify normal weight and morbidly obese patients admitted in California between 2003 and 2007 for 4 types of spinal fusion: anterior cervical fusion (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] procedure code 810.2), posterior cervical fusion (810.3), anterior lumbar fusion (810.6), and posterior lumbar fusion (810.8). Demographic, comorbidity, and complications data were collected. Primary outcome was in-hospital complication; secondary outcomes were total cost, length of stay, and in-hospital mortality. Multivariate logistic regression was performed. In total 84,607 admissions were identified, of which 1455 were morbidly obese. Morbid obesity was associated with 97% higher in-hospital complication rates (13.6% vs. 6.9%), sustained across nearly all complication types (cardiac, renal, pulmonary, wound complications, among others). Mortality among the morbidly obese was slightly higher (0.41 vs. 0.13, P < 0.01) as were average hospital costs ($108,604 vs. $84,861, P < 0.0001). Length of stay was longer as well (4.8 d vs. 3.5 d, P < 0.0001). All effects were less pronounced in posterior cervical fusions. On multivariate analysis, morbid obesity was the most significant predictor of complications in the anterior cervical and posterior lumbar fusion groups (more than age, demography, and other comorbidity). Morbid obesity seems to increase the risk of multiple complication types in spinal fusion surgery, most particularly in anterior cervical and posterior lumbar approaches.

Osteoblastoma of C2 Corpus: 4 Years Follow-up

Osteoblastomas are rare neoplasms of the spine. The majority of the spinal lesions arise from the posterior elements and involvement of the corpus is usually by extension through the pedicles. An extremely rare case of isolated C2 corpus osteoblastoma is presented herein. A 9-year-old boy who presented with neck pain and spasmodic torticollis was shown to have a lesion within the corpus of C2. He underwent surgery via an anterior cervical approach and the completely-resected mass was reported to be an osteoblastoma. The pain resolved immediately after surgery and he had radiologic assessments on a yearly basis. He was symptom-free 4 years post-operatively with benign radiologic findings. Although rare, an osteoblastoma should be considered in the differential diagnosis of neck pain and torticollis, especially in patients during the first two decades of life. The standard treatment for osteoblastomas is radical surgical excision because the recurrence rate is high following incomplete resection.

Surgical treatment of degenerative cervical spine diseases: Analyses of 90 patients clinical study

The effect of degenerative cervical spine surgery depends on good understanding of the pathogenesis and clinical course of disease with a detailed neurological and neuroradiological examination. Surgical approach should be considered separately for each pathological substrate in order to avoid additional morbidity. The aim of our study is to present the results of treatment through analysis of large clinical series focusing on anterior surgical approach with iliac crest graft fusion without cervical plating. The retrospective analysis of 90 patients operated on Neurosurgery of CHC Zemun, from 2008 to 2011, was done. In 81 patients cervical disc herniation was found in one or two levels, and 9 patients had spinal canal stenosis with polydiscopathy. Preoperatively 50 patients had cervical myelopathy, and 40 patients had radiculopathy as dominating clinical sign. Anterior cervical approach was performed in 79 patients, and 11 patients were operated by posterior approach. The treatment outcome was as follows: good outcome 16 (16.8%) patients, improved condition 65 (72.2%), without improvement 6 (6.7%), bad outcome 3 (4.3%). The anterior cervical approach with iliac crest autologous graft fusion, and without additional cervical plating, is reliable treatment option with results comparable to reported clinical series with sintetic graft placement and anterior cervical plate stabilisation.

Treatment of cervical radiculopathy by anterior cervical discectomy and cage fusion

<b>Introduction:</b> Since the pioneering days of the anterior cervical approach introduced by Cloward <i>et al.</i> in the early 1950s, anterior cervical discectomy and fusion (ACDF) has been the standard procedure for most discogenic and degenerative cervical spinal lesions. Although traditional interbody fusion using iliac bone can maintain the patency of the neuroforamen and ensure solid fusion, selection of patients, and of surgical procedure for ACDF is a continuous challenge. <b>Aim:</b> The aim of this study was to assess the results of cervical discectomy and fusion with cervical cages in treatment of cervical radiculopathy clinically and radiologically. <b>Materials and Methods:</b> Eighteen patients suffering from cervical radiculopathy were operated upon using this technique. They were 15 males and 3 females. Clinical and radiological assessment, visual analog scale (VAS) for neck and arm and modified Oswestery neck disability index (NDI) were done preoperatively and at 4 weeks, 3, 6, and 12 months postoperatively. Polyetheretherketone (Peek) cages filled with iliac bone graft were used after cervical discectomy. The levels operated upon were C 5-6 in 16 patients and C4-5 in 2 patients. <b>Results:</b> Marked clinical improvement as regard arm and neck pain, and NDI was observed. The pre and post operative mean and standard deviations (SD) of the various scores were as follows. VAS for pain in arm reduced from mean of 8 (SD 1.76) to mean 0.4 (SD 0.4), VAS for neck pain reduced from mean of 3.5 (SD 1.58) to mean of 0.8 (SD 0.47), and NDI from mean of 20.2 (SD 0.89) to 2.1(SD 1.05). Fusion occurred in all patients. Subjectively 79% of the patients reported marked improvement in neck pain, and 95% reported marked reduction in arm pain. <b>Conclusion:</b> Anterior cervical discectomy and cage fusion resulted in high fusion rate with minimal preservation of lordosis.

頚椎症に対する前方アプローチ

頚椎症に対する前方アプローチ

Clinically Relevant Anatomy of High Anterior Cervical Approach

An anatomic study of anterior cervical dissection of 11 embalmed cadavers and measurement of structures relative to cervical spine. To determine the anatomic relationship of the hypoglossal nerve (HN), internal and external superior laryngeal nerves (ESLNs), superior thyroid artery (STA), and superior laryngeal artery (SLA) to cervical spine and demonstrate any vulnerability. The anterior approach is a common approach to the cervical spine. Much of the operative morbidity in high cervical region is related to neurovascular injury leading to dysphagia, dysphonia, impaired high-pitch phonation, and impaired cough reflex. Eleven adult cadavers (5 male/6 female) were dissected bilaterally to expose structures of the high anterior cervical region. The HN consistently traveled toward the midline at C2-3 and was safe caudal to C3-4. In 95% of dissections, the internal superior laryngeal nerve (ISLN) was exposed within 1 cm of C3-4. The path of the ESLN was variable, but it was safe above C3-4 and below C6-7. The ESLN was deep to the STA, and it was less bulky and tauter than the ISLN in all dissections. The origin of the STA was quite variable along the carotid artery, but it was most commonly located at C4. Two anatomic variants of the SLA were observed. In 15 dissections, the SLA branched off the superior thyroid. In six dissections, the SLA branched directly from external carotid artery. There was no appreciable side-to-side variation in the neurovascular structures studied. On the basis this study, spine surgeons can have enhanced knowledge of high anterior cervical anatomy. The neurovascular structures in this study did not demonstrate side-to-side anatomic variation; therefore, patient pathology and surgeon preference should dictate the operative side.

An anterior high cervical retropharyngeal approach for C1–C2 intrafacetal fusion and transarticular screw insertion

Craniovertebral instability is a significant challenge to neurosurgeons. We describe an alternative anterior high cervical retropharyngeal approach for C1–C2 intrafacetal fusion and transarticular screw insertion. We dissected 10 cadaveric specimens and fixed the atlantoaxial joint with C1–C2 intrafacetal fusion and transarticular screw insertion. We achieved good surgical exposure and fixation in all cadavers with this technique. The anterior high cervical retropharyngeal approach for C1–C2 intrafacetal fusion and transarticular screw insertion may provide an alternative fusion technique for craniovertebral fusion.

Observation of the anterior surgery treatment effect on high cervical spine trauma

Objective To explore the anterior surgery treatment effect on high cervical spine trauma. Methods Collected 7 patients who were in our hospital, 5 males and 2 females, aged from 23 to 62 years, with high cervical injury, from 2006 to 2010; among them, 3 cases had odontoid fractures, 4 csses had odontoid fractures with atlantoaxial dislocation. The group were reset by releasing anterior cervical approach, and cannulated screw fixation of odontoid fractures. Results All patients were followed for 6 months to 4 years; the group adopted high anterior approach to expose the complete fixation placement had no case of hypoglossal nerve, carotid artery, carotid sheath, superior laryngeal nerve injury, and posterior wall injury of pharynx; after the operation, it had little influence on cervical rotation, and didn' t have vertebral artery and spinal cord injury; what's more, neurological symptoms were obviously relieved after surgery. Conclusion The anterior cannulated screw fixation of odontoid process fracture and dislocation of atlantoaxial joint can improve the stability of high cervical spine, has exact fixation, does not affect the activities of C1 and C2, has fewer complications, and whose clinical results were satisfactory. Currently,there are many surgical treatments of high cervical injury; each has its own advantages and disadvantages;choosing a different surgical treatment should base on the injury characteristics of patients and whether the patients have vertebrae dislocation; except that, also should strictly control its indication, and give the patients stable fixation and tell them to do some exercise not affecting the joint before the relieving of the symptoms. Key words: High cervical spine injury ; Anterior approach ; Odontoid process fracture

The Cervical Anterior Approach for the Resection of Superior Posterior Neurogenic Tumor: A Case Report

Many approaches for resection of the superior mediastinal tumors have been reported. We introduce an approach, which we call the cervical anterior approach. This approach is only cervical and does not require a sternotomy. Merits of this approach include the ability to remove the tumor without opening the mediastinal or parietal pleura, as well as obviating draining the thoracic cavity. The tumor is also directly visible, and the surgeon can avoid injury to the great vessels. This approach is recommended when the tumor is located superior to the third thoracic vertebra level, when it borders the great vessels, and when it does not border the trunk of the brachial plexus or nerve root. This approach is easy and safe for surgical procedures.

An anterior approach to spinal pathology of the upper thoracic spine through a partial manubriotomy

Surgical pathology in the region of the upper thoracic spine (T1-4) is uncommon compared with other regions of the spine. Often times posterior and posterolateral approaches can be used, but formal anterior decompression often requires a low anterior cervical approach combined with a sternotomy, which yields significant perioperative morbidity. The authors describe a modified low anterior cervical dissection combined with a partial manubriotomy that they have used to successfully access and decompress anterior pathology of the upper thoracic spine. Their modified approach spares the sternoclavicular joints and leaves the sternum intact, decreasing the morbidity associated with these added procedures.

High Anterior Cervical Approach to the Clivus and Foramen Magnum: A Microsurgical Anatomy Study

Surgical exposure of lesions located along the ventral foramen magnum (FM) and clivus poses a unique set of challenges to neurosurgeons. Several approaches have been developed to access these regions with varying degrees of exposure and approach-related morbidity. To describe the microsurgical anatomy of the high anterior cervical approach to the clivus and foramen magnum, and describe novel skull base extensions of the approach. Eight adult cadaveric specimens were included in this study. The high anterior cervical approach includes a minimal anterior clivectomy and its lateral skull base extensions: the extended anterior far-lateral clivectomy and the inferior petrosectomy. The microsurgical anatomy and exposure of the various extensions of the approach were analyzed. In addition, the capability of complementary endoscopy was evaluated. With proper positioning, the minimal anterior clivectomy exposed the vertebrobasilar junction, proximal basilar artery, anteroinferior cerebellar arteries, and 6th cranial nerve. The lateral skull base extensions provided access to the anterior FM, mid-lower clivus, and petroclival region, up to the Meckel cave, contralateral to the side of the surgical approach. The high anterior cervical approach with skull base extensions is an alternative to the classic approaches to the ventral FM and mid-lower clivus. A minimal anterior clivectomy provides access to the midline mid-lower clivus. The addition of an extended anterior far-lateral clivectomy and an inferior petrosectomy extends the exposure to the anterior FM and cerebellopontine angle lying anterior to the cranial nerves. The approach is also ideally suited for endoscopic-assisted techniques.

Cervical intradural disc herniation and cerebrospinal fluid leak

Cervical intradural disc herniation (IDH) is a rare condition and only 25 cases of cervical have been reported. We report a 45-year-old male who presented with sudden onset right lower limb weakness after lifting heavy weight. Magnetic resonance imaging of the cervical spine showed C5/6 disc prolapse with intradural extension. The patient underwent C5/6 discectomy through anterior cervical approach. Postoperatively, the patient improved in stiffness but developed cerebrospinal fluid leak and the leak resolved with multiple lumbar punctures.

Combined Pre- and Retrovascular Extraoral Approach for Tumors at Lateral Mass of the Atlas

a series of 9 patients surgically treated with a novel combined pre-and retrovascular extraoral approach to lateral mass of the atlas (LMA) is examined. to describe the efficacy of combined pre- and retrovascular extraoral approach in achieving a wide exposure and aggressive resection of tumors at the LMA. the anatomic complexity and closeness to vital neurovascular structures raise technical difficulties in the surgical access to the LMA. Although various approaches, such as transoral approach, high anterior cervical approach, anterior lateral approach, and far lateral approach, have been reported in literature, wide exposure for the tumors at the LMA remains a unique challenge. for our experience in the surgical exposure of the upper cervical spine, we have developed a combined pre- and retrovascular extraoral approach to the atlas since 2001. Nine patients with neoplastic lesions at the LMA were surgically treated through this combined approach. Reconstruction of stability was achieved by a posterior occipitocervical fusion through a posterior approach under the same anesthesia. this combined approach provided an excellent surgical field exposure to ensure the successful tumor resection while preventing the vertebral artery or nerve from injury. There was no operative mortality or severe morbidity in this series. Complications included 1 instance of transient dysphagia and 2 instances of transient trouble swallowing liquids. The symptoms of local pain and pharyngeal discomfort relieved, and patients suffering from spinal cord compression recovered well with 1 level of the Frankel scale when reevaluated 3 months after operation. With a follow-up period of 16 to 100 months, 1 patient with chondrosarcoma developed local recurrence at the 14th month of postoperation and died of respiratory and circulatory failure 39 months after surgery. No evidence of local recurrence was found in other patients. the combined pre- and retrovascular extraoral approach provides an advantageous alternative to previous reported approaches. For selected cases with tumor lesions at the LMA, this combined approach offers more benefits, through which a wide exposure with well-protected vertebral artery favoring radical excision could be achieved without complications normally associated with transoral surgery.

Vertebroplasty of the C2 Vertebral Body and Dens Using an Anterior Cervical Approach: Technical Case Report

This article is the first description of an anterior approach for a biopsy and vertebroplasty of the C2 body and dens. A 52-year-old woman presented with a 9-month history of neck pain and a destructive lesion of the dens. The patient was treated with pain medication as well as steroid injections without relief of her pain. A biopsy and vertebroplasty of the C2 body and dens was performed using an anterior cervical approach. This report describes the first vertebroplasty of C2 using an open anterior cervical approach.