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Anterior Surgery for Cervical Trauma


Summary of Key Points

  • Outcomes of cervical trauma can range from minor disability to total loss of function or life, and early management may have a major impact on clinical outcomes.

  • Adherence to advanced trauma life support protocols, including proper spinal precautions, is imperative in preventing further damage after injury.

  • Minor or structurally stable cervical injuries can generally be treated with spinal immobilization with a collar for 6 weeks.

  • The anterior approach is well-established for subaxial cervical trauma and, although more challenging, may be used for upper cervical spine injuries as well.

  • Surgical management of upper and lower cervical trauma should be guided by a thorough understanding of anatomy, contemporary surgical techniques, and an understanding of contemporary classification systems.

  • The surgeon comfortable with the anterior approach will be able to effectively manage any surgically indicated cervical spine fracture with optimal visualization of the anterior neural elements, depending on the cervical level.

Recognition of cervical spine injuries begins in the field with prompt immobilization and transfer to a facility equipped to manage spinal trauma. Depending on the injury, surgical intervention may be required, with the approach tailored to the specific injury. The purposes of this chapter are to highlight the benefits of anterior surgery for cervical spine trauma, and to discuss indications for surgery, related surgical approaches and techniques, complication avoidance, and the anterior approach management of specific cervical spine injuries.

Initial Evaluation

Proper management of cervical trauma begins in the field. As with all trauma patients, management should initially focus on following advanced trauma life support principles by maintaining a patent airway, ensuring proper breathing, and identifying any circulatory injuries. Anyone experiencing neck pain after trauma should be suspected of having a cervical spine injury. First responders and other providers should also suspect trauma to the spine with any high-energy mechanisms or in patients with altered mental status. In these instances, spinal precautions, including cervical spine immobilization, are of the utmost importance in preventing additional injury. The head tilt–chin lift maneuver for securing an airway should be avoided when cervical injury is suspected, as this can increase compression of the spinal cord more than nasal or oral intubation; when additional means are needed to maintain airway patency, one should instead opt for the jaw thrust maneuver, as this creates less motion in unstable upper cervical spine injuries. Following initial triage, assessment for cervical trauma should be performed alongside a complete neurological examination, including inspection for superficial abrasions, as these can provide information about the intensity and nature of forces when history is lacking. In rare instances, damage to the spinal cord may occur after initial injury to the osseous structures, and frequently spinal shock may mask neurological deficits.

Imaging is of paramount importance, as it facilitates diagnosis of injuries and helps guide surgical management. Radiographic evaluation should include anteroposterior (AP), lateral, and open-mouth x-rays capturing the occiput to the top of the T1 vertebrae. It is important to properly visualize the cervicothoracic junction because C7 fractures and C7/T1 dislocations account for 17% of cervical trauma. Furthermore, these fractures and subluxations are some of the most frequently missed, likely because of overlay of the shoulders on films. , Techniques to improve visualization of the cervicothoracic region include caudally-directed traction on the arms during exposure or use of a swimmer’s view. Plain films can demonstrate osseous injury, overall sagittal alignment, differences in intervertebral distances, and evidence of cervical instability. The limitations of plain films are their low sensitivity for detecting fractures and ligamentous injury, which is reportedly as low as 30% to 60%. Similarly, flexion-extension films are not recommended in the acute peritrauma period because these views have been deemed inadequate in a majority of cases. ,

Advanced imaging is often indicated, given the limitations of x-rays. Computed tomography (CT) has been shown to have 99% to 100% sensitivity and 100% specificity in displaying a cervical spine fracture, according to the literature. , It can easily display fractures to the lateral masses, which plain films frequently miss, and provide clear visualization of the cervicothoracic junction. Sagittally reconstructed images can be used to identify fractures that would have been missed because of gantry passage through transaxial cuts, further improving the diagnostic capacity of CT. Recently, given the benefits of CT and its increasing availability and speed, it has been frequently used for triage of trauma patients and supplementation of findings on initial plain films. The major limitation of CT is its inability to identify purely ligamentous injuries; however, these injuries are frequently, but not always, stable if completely missed on CT, and therefore the use of alternative imaging methods such as magnetic resonance imaging (MRI) during triage rarely confers additional emergent utility. , Nevertheless, MRI should be used for identifying soft tissue injuries when suspected, and can provide additional information on overall spinal alignment, disc herniations, and unsuspected injury at other levels, as well as aid in preoperative planning.

Advantages of Surgical Management and the Anterior Approach

The goals of all treatment of cervical spine injuries are to return patients to maximum functional ability, minimize residual pain, restore neurological function when possible, provide stability, reduce fractures, and prevent further disability. Although noninvasive measures such as traction and orthotics can achieve some of these goals, surgery has many unique advantages over nonoperative treatment. It can securely stabilize the spine and reliably relieve spinal cord compression where nonoperative treatment would be insufficient, and is generally preferred over nonoperative management in unstable injuries owing to its ability to achieve optimal reduction, produce immediate stability, facilitate direct decompression of the cord and exiting roots, and allow early mobilization. Surgery also avoids the need for cumbersome external fixators, enhances early ambulation, and decreases patient reliance on nursing care.

There has been debate over whether the anterior approach or posterior approach is best suited for addressing specific injuries to the cervical spine. Regarding the upper cervical spine, the debate is ongoing, with injury characteristics playing a significant role in determining the ideal approach. This is because of the challenging nature of accessing the upper cervical portion of the spine, especially when considering variable patient morphology. Subaxial cervical spine injuries are less controversial, however, with the anterior approach being preferred by most practitioners when significant anterior cord compression is present. Nevertheless, surgeon preference and expertise play a major role in determining the approach best suited for managing traumatic cervical injuries.

Compared with the posterior approach, advantages to the anterior approach include reduced surgical soft tissue trauma, decreased intraoperative blood loss, and the ability to perform the procedure with supine positioning, which is beneficial in cases of cervical instability. Contraindications to an anterior-only approach include posterior lesions, which compromise the spinal cord or nerve roots and need to be addressed, clinically significant posterior dural leaks, and locked facet joints that are irreducible by traction or anterior open surgery, especially in instances where surgery is delayed. Highly unstable injuries, or those that do not appear stable intraoperatively following anterior fixation, may need a combined anterior-posterior surgery, which can be performed in a staged or sequential manner. , , This instability finding is often observed in patients with severely degenerated or stiff cervical spines, such as ankylosing spondylitis (AS), creating a major lever arm on the traumatized segment. Drawbacks of the anterior approach include reduced stability compared with posterior fixation, as seen in cadaveric studies.

Overview of Common Anterior Approaches and Complication Avoidance

Lateral Retropharyngeal (Whitesides) Approach to the Upper Cervical Spine

The Whitesides approach is best for accessing the upper cervical spine up to, but not including, the basiocciput. If more extensive distal work is required, the incision can be extended down to the sternal notch. This approach is rarely used for cervical injuries that require a C1‒C2 fusion for stabilization, such as unstable fractures or dislocations with compromised posterior elements. Patients are positioned with their head facing away from the side from which the incision is planned, and although the approach is significantly more challenging if the patient is in a halo for immobilization, it is still possible. Because it is an anterolateral approach, however, a second incision is required for injuries that require access to the contralateral side.

In general, the incision follows the sternocleidomastoid (SCM) to the border of the mandible, to the tip of the mastoid, and then to the posterior ear. The SCM is mobilized, and deep lymph nodes are dissected for access to the lateral mass of C1. One must be cautious to avoid injury to the spinal accessory nerve and vertebral artery during dissection, although the jugular vein can also be injured, as it is contained within the operative field. Occasionally, the greater auricular nerve may have to be sacrificed, which will result in an insensate patch of skin around the posterior aspect of the earlobe. The external jugular vein may also be ligated as needed. Excessive retropharyngeal swelling has been noted as a complication of this approach.

Smith–Robinson Approach: C2‒T1

The Smith–Robinson approach allows access to the spine from C2 to T1. Considerations when choosing this approach include patient morphology, including a high-riding sternum, a short neck, and a large body habitus. Patient positioning using the Smith–Robinson approach is supine with the neck slightly extended, with a bump under the shoulders to help improve exposure. It is important to avoid excess spinal extension in patients with symptomatic cord compression to avoid worsening of neurological symptoms. Occasionally, the mandible may impair access to the C2‒C3 or C3‒C4 disc space; if this is the case, this issue may be minimized with the use of nasal intubation, which allows the mandible to remain closed.

When planning the incision, the targeted levels for manipulation must be considered. Palpable landmarks such as the hyoid bone for C3, the thyroid cartilage for C4‒C5, the carotid tubercle for C6, and the cricoid cartilage for C6‒C7 may serve as guidelines for incision planning, although there may be some variability between sexes. , An additional factor to consider is the degree of exposure needed. For more extensive surgery, an oblique longitudinal incision is recommended, as it increases exposure, although a transverse incision is more cosmetic and may provide access to three or more disc levels. A transverse incision should be carried out from the anterior two-thirds of the SCM to the midline, while a longitudinal incision is carried out along the medial border of the SCM to the sternal notch, if necessary. If a prior neck operation was done, the contralateral side should be used to avoid dissection through scar tissue if both vocal cords are working well. If not, the side with compromised vocal cord function should be used for the approach to avoid unnecessary injury to the only vocal cord that is still working well. The presence of a recurrent laryngeal nerve injury should be ruled out preoperatively in patients with prior neck surgery via indirect laryngoscopy by an otolaryngologist. It is important to attain the appropriate advanced imaging studies prior to surgery so as to assess the course of the vertebral artery and avoid injuring an aberrant medial vertebral artery.

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