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Cervical Spine and Cervicothoracic Junction—Anterior Approach

Summary of Key Points Many pathologies can be addressed through an anterior approach to the cervical spine, with degenerative spine disorders being the most common. The anterior approach to the subaxial cervical spine is a well-tolerated procedure for discectomy, corpectomy, and anterior instrumentation. The ventrolateral approach provides an expanded surgical exposure to the vertebral artery. The anterior approach to the cervicothoracic junction requires careful planning regarding…

Posterior Percutaneous and Minimally Invasive Approaches to Decompression and Arthrodesis of the Cervical Spine

Summary of Key Points Posterior minimally invasive surgery (MIS) approaches to the cervical spine have been shown to have clinical outcomes that are comparable to traditional open approaches, with a reduction in length of hospital stay and narcotic use and an earlier time to mobilization. Prospective and randomized controlled trials have shown comparable clinical outcomes in patients with cervical radiculopathy treated with MIS posterior cervical decompression…

Dorsal Subaxial Cervical Instrumentation Techniques

Summary of Key Points Posterior cervical instrumentation is effective in stabilizing the subaxial cervical spine. Acceptable choices of instrumentation include lateral mass screw fixation and cervical pedicle screws. Careful preoperative planning with an understanding of patient-specific anatomy and instrumentation options is essential. Interfacet grafts may be useful adjuncts to dorsal instrumentation to treat radiculopathy or enhance the prospect of fusion. Adaptations in cervical instrumentation techniques have…

Cervical Laminoplasty

Summary of Key Points Open-door laminoplasty and double-door laminoplasty are the primary surgical treatment for patients with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL). Cervical laminoplasty is indicated for patients with multisegmental canal stenosis and lordotic alignment. Laminoplasty is not recommended in patients with kyphotic cervical alignment, spinal instability, or larger OPLL occupation ratio or disc herniation. In these cases, fusion surgery…

Posterior Cervical Decompressions: Cervical Laminectomy and Laminoforaminotomy

Summary of Key Points Cervical spondylosis with resultant neural compression is the most common cause of spinal cord dysfunction in adults. Compression and dynamic forces on the spine contribute to spinal cord dysfunction in cervical spondylotic myelopathy. Posterior approaches to the cervical spine afford an effective means of decompression. Careful understanding of the posterior cervical anatomy is paramount. Patient selection for posterior cervical decompressive procedures is…

Cervical Spine and Cervicothoracic Junction—Posterior

Summary of Key Points Understanding the anatomy of the cervical spine and neck is of the utmost importance for the surgeons operating in this region. The anatomy of this region can be classified from superficial to deep and further analyzed by system, including muscle, bone, nerves, vasculature, and soft tissue. Each level of the cervical spine has unique bony anatomy, and as a result the location…

Endoscopic and Transnasal Approaches to the Craniocervical Junction

Summary of Key Points The endoscopic transnasal approaches provide a direct surgical trajectory to anteriorly located lesions at the craniocervical junction. Clinical series demonstrate low rates of postoperative infection after endoscopic transnasal approaches to intradural pathology despite nasal contamination. Endoscopic transnasal odontoidectomy allows preservation of the soft palate, and patients can restart an oral diet on the first postoperative day. On sagittal imaging, a line drawn…

Occipitocervical Spine Posterior Approaches for Fusion

Summary of Key Points The upper cervical spine presents many unique challenges to successful stabilization, including complex anatomy and limited access corridors. Because of the high degree of mobility at these levels, internal screw fixation is often required to achieve successful bony fusion and stability. Odontoid screw fixation is the preferred motion-preserving option for repair of odontoid fractures, although dorsal fixation techniques without fusion are being…

Occipitocervical Spine Approaches for Decompression

Summary of Key Points Instability of the craniocervical junction can result in severe neurological compromise. Instability can result from traumatic, neoplastic, rheumatological, infectious, congenital, or iatrogenic etiologies. The dorsal approach is most commonly used when fusion of the occipitocervical region is indicated. Ventral approaches are indicated in cases with ventral pathology causing neural compression and with irreducible subluxations. Endoscopic transnasal and transoral approaches may improve visualization…

Cervical Spine Construct Design

Summary of Key Points Spine constructs should be patient- and pathology-specific. Constructs require supplementation with adequate bone grafting to provide long-term stability. Cervical spine constructs may be applied in situations of clinical instability, for maintenance or correction of alignment, or for treatment of refractory pain. Most cervical spine constructs are applied in the neutral mode. Cervical constructs usually conform to one or more of five basic…

Spine Readmissions and Reoperations

Summary of Key Points Identification of predictors of readmission and reoperation is important to help address perioperative management and potentially both decrease readmissions and improve outcomes. The risk of spine instability, neural damage, and infection increases with revision surgery; and thus avoidance of reoperation is paramount. Limitations created by scar tissue, lack of native tissue plans, and prior surgical decompressions make successful outcomes in revision surgery…

Implant Wear, Degradation, and Breakage

Summary of Key Points Implant wear remains a concern for arthroplasty devices, and with the increase in spinal disc arthroplasty it is essential to conduct comprehensive assessments of the implant mechanical integrity, bearing surface, and host tissue interactions, as well as particulate attributes, to understand the short- and long-term causes and effects of implant wear. There are two forms of metal implant wear debris: particulate shed…

Postoperative Spinal Deformities

Summary of Key Points Postoperative spinal deformity manifests as an inability of the spine to maintain an adequate loadbearing capacity or withstand dynamic forces, which may occur because of iatrogenic reasons intraoperatively (decompression, instrumentation), pseudarthrosis, or the inevitable phenomenon of rigid posterior spinal fusion (i.e., adjacent segment disease). During spinal decompressions, prophylactic fusion should be performed after multilevel cervical laminectomy to decrease the risk of postlaminectomy…

Vascular and Soft Tissue Complications

Summary of Key Points Soft tissue and vascular complications related to spinal surgery are usually predictable and vary depending on the region being operated upon. Cervical spine surgery–related soft tissue complications frequently include dysphagia, hoarseness, and vocal fold motion impairment. Less frequent is vascular injury. Otorhinolaryngological consultation is particular useful in addressing these soft tissue complications. Vascular injury is often approached with the assistance of vascular…

Posttraumatic and Idiopathic Syringomyelia

Summary of Key Points Posttraumatic and idiopathic syringomyelia represent a heterogenous group of neurological conditions characterized by fluid collections in the parenchyma of the spinal cord. Obtaining a detailed history and examining the entire neuraxis is required for effective treatment to be directed at the underlying pathology when possible. Magnetic resonance imaging evaluation with phase-contrast cine flow imaging is useful and may on occasion identify subarachnoid…

Arachnoiditis and Syringomyelia

Summary of Key Points Syringomyelia is the formation of a fluid cavity within the spinal cord thought to result from a pathophysiological disruption of cerebrospinal fluid flow. Arachnoiditis is the scaring of the arachnoid and pia resulting from multiple etiologies, most commonly infection, subarachnoid hemorrhage, or prior lumbar surgery. Arachnoiditis is a well-known predisposing condition to syringomyelia. Radicular and myelopathic symptoms of arachnoiditis typically progress despite…

Arachnoiditis

Summary of Key Points Arachnoiditis is a nonspecific inflammatory process of the arachnoid layer of the spinal cord or cauda equina. There are three stages in the progression of arachnoiditis, including inflammation, fibroblast proliferation, and collagen deposition. There are many causes of arachnoiditis that may be infectious or noninfectious. Myelography or magnetic resonance imaging can be used to confirm the clinical suspicion of arachnoiditis. Spinal cord…

Cerebrospinal Fluid Leak: Repair and Outcomes

Summary of Key Points Cerebrospinal fluid (CSF) fistulas and pseudomeningoceles are rare complications of spinal surgery. CSF fistulas usually develop shortly after surgery, resulting in increased postoperative morbidity, duration of hospitalization, and cost of care. Pseudomeningoceles develop more slowly and may remain asymptomatic. In the absence of CSF wound drainage, magnetic resonance imaging is the imaging study of choice for diagnosis. Beta-2 transferrin level is more…

Neurological Complications of Common Spine Operations

Summary of Key Points Neurological complications associated with spine surgery may result in a need for additional surgery, prolonged length of stay, and need for subsequent care (rehab, therapy, assistive devices). The spinal cord is at risk in any spine surgery above the conus medullaris, typically located at L1‒L2. C5 palsy is the most common nerve root injury in both posterior and anterior cervical procedures. Anterior…

Preventing Postoperative Infections: An Evidence-Based Approach

Summary of Key Points Although most surgeons understand the importance of sterile technique in preventing surgical site infections, other steps can be taken before, during, and after the procedure to reduce the risk. Thorough preoperative evaluation, including nasal Staphylococcus aureus carrier testing and nutritional assessment of at-risk individuals, can lower the risk of surgical site infection (SSI). Appropriate timing, selection, and duration of antibiotics are important…