Posterior Surgical Approach to the Cervical Spine

General Principles

A careful history and physical examination, as well as appropriate imaging studies, should be performed preoperatively in all patients. The surgical approach depends on the condition being treated, the specific signs and symptoms, and the patient’s expectations. Once surgery is planned for the patient and a posterior approach is chosen, the physical examination should be focused on ensuring that the appropriate landmarks and tactile cues, such as the external occipital protuberance and large C2 and C7 spinous processes, can be palpated. Other less common but important anatomic preoperative considerations include evaluating for unusual anatomy such as an aberrant vertebrobasilar artery, location and condition of preexisting scars in the setting of a revision procedure, and a Klippel-Feil segment or other congenital anomaly that could alter or complicate the surgical approach.

Imaging

An essential step in preoperative preparation is obtaining appropriate imaging studies. Anteroposterior, lateral, and open-mouth plain film radiographs of the cervical spine with full and clear views from C1 to T1 should be standard parts of the diagnostic evaluation. Preoperative computed tomography (CT) scans can help define the bony anatomy and facilitate the preoperative plan. Magnetic resonance imaging (MRI) is almost universally obtained before cervical spine surgery as well because these imaging sequences allow evaluation of the neural structures and disks and provide additional information on potential infections, tumors, or other pathologic processes. A thorough review of all available imaging should be completed when selecting the optimal surgical approach for the patients’ disorder.

Indications and Contraindications

A broad range of disorders may be addressed through a posterior approach to the cervical spine. It is easiest to consider the approach in two distinct anatomic regions: the occipitocervical junction (including the occiput to C2) and the subaxial cervical spine (C3 to C7). Although the approach to both regions is similar, the anatomy, function, and associated pathologic features of these two vertebral segments differ. Therefore, it is simpler to discuss these regions separately throughout this chapter. At the occipitocervical junction, both posterior decompressions and posterior fusions can be performed. Various types of decompressions, including that of the skull base, foramen magnum, spinal canal, and nerve roots, can be accomplished through this approach. A posterior approach is indicated for posterior occipitocervical and C1 to C2 fusions for atlantoaxial dissociations, C1 or C2 fractures, transverse cervical ligament disruptions, tumors, or infections. In the subaxial cervical spine, decompression of the canal and nerve roots, including laminectomy, laminoplasty, and keyhole laminoforaminotomy, can be performed through a posterior approach. Posterior fusion procedures for fractures, tumors, or infections can be undertaken through this approach. Additionally, treatment of facet joint dislocations and excision of some herniated disks can also be accomplished through a posterior approach.

If the posterior approach to the cervical spine is the most direct and least invasive access to the pathologic process being treated, this approach has essentially no contraindications. Having said that, many cervical spine disorders are better surgically managed through an anterior approach (see Chapter 3 ). Thus, it is important to consider the specific pathologic process and to determine the most appropriate and least invasive approach before the surgical procedure.