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Anterior Subaxial Cervical Fixation and Fusion Techniques


Summary of Key Points

  • Anterior subaxial fixation techniques have greatly evolved since first being described in the 1950s.

  • Current fixation techniques involve a combination of modular interbodies, titanium plates, and screws. The composition of the interbodies (titanium, allograft, etc.) and plates (dynamic or rigid) can vary based on surgeon preference and indications.

  • Compared with traditional titanium, polyetheretherketone interbodies have a modulus of elasticity closer to that of bone. Newer three-dimensionally printed and porous titanium interbodies have subsequently addressed these shortcomings.

  • Stand-alone interbodies offer a low-profile, less technically challenging option for single- or multilevel anterior cervical fusions.

  • Various surgeries for cervical myelopathy caused by ossified posterior longitudinal ligament have been described, such as skip corpectomy, anterior floating corpectomy, and anterior controllable antedisplacement fusion, which are detailed in this chapter.

  • Subsidence, adjacent segment disease, and pseudarthrosis are relatively common complications of anterior subaxial fixation techniques and need to be monitored in the postoperative period. When symptomatic and disabling, treatment often involves additional surgery.

Background

In the mid-20th century, the anterior cervical discectomy and interbody fusion (ACDF) was described by Smith, Robinson, and Cloward for the treatment of cervical radiculopathy and myelopathy. , Unlike the posterior approaches that were primarily used by surgeons at the time, anterior approaches became popularized because of their effectiveness at treating degenerative disc pathologies with minimal complication, high fusion rates and reduced patient recovery time, and allowing direct treatment of cervical kyphotic deformity. In fact, anterior approaches have become so popular that, even today, most surgeons still use the same approach described by Smith and Robinson in 1957. , In general, the main variations in anterior cervical fixation techniques have been the introduction and evolution of titanium instrumentation, plating, and a trend towards xenograft/allograft interbodies instead of iliac crest bone graft (ICBG). This chapter will primarily focus on the different types of anterior subaxial cervical fixation techniques, including dynamic versus static plates, various interbody options, interbody subsidence, and anterior fixation techniques used to treat cervical myelopathy caused by ossified posterior longitudinal ligament (OPLL).

Anterior Instrumentation

Rigid instrumentation of the anterior cervical spine includes the choice of an interbody graft, anterior plate, and vertebral body screws. Options for cervical interbodies include the use of ICBG, structural allograft, titanium cages, or polyetheretherketone (PEEK). The use of an anterior plate, either fixed or variable, prevents interbody dislodgement/extrusion and places the interbody graft in biomechanical compression when a patient’s neck is in extension. Vertebral body bone screws, either fixed or variable, are used to secure the anterior plate to the spine. There are numerous technical nuances to proper hardware placement to prevent complications such as graft subsidence, adjacent segment disease, and pseudarthrosis, which will be discussed in detail. ,

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