1. Surgery for cervical spine disease
Patrick Statham,
Consultant Neurosurgeon,
Western General Hospital, Edinburgh

2. Format Anatomy and load bearing Spectrum of Pathology
Clinical examination and assessment
Differential diagnosis
Special tests
Approaches
Instrumentation and prosthesies
Specific pathology
The future

3. Functional units: anatomy and pathology
Occiput C1 and C2
C3 to C7
Cervicothoracic junction

5. Longus colli

6. Spinal cord anatomy

7. Gross cervical cord anatomy

8. Human cervical spine

10. Occipital-Atlanto Complex C0 C1
C0-C1 Flex/Ext 10-15° 13°
Lat Flex 8°
Axial Rot 0°

11. Atlanto-Axial Complex C1 C2
C1-C2 Flex/Ext 10°
Lat Flex 0°
Axial Rot 47°
40% to 50% of axial Rotation
The first 45° of axial rotation

12. Atlanto-Axial Complex C1 C2 – Coupling C1 C2 Biconvex cartilagenous articulation Double threaded screw

18. Cervical Spine Kinematics & Anatomy
Flexion/Extension 145°
Axial rotation 180°
Lateral flexion °
Atypical C1 C2 C7
Typical C3-C6

19. Lower cervical Spine C3-C7 – Coupling
On lateral bending the spinous processes go to the covexity of the curve
C2-2° of coupled axial rot for every 3° of lateral bending
C7-2° of coupled axial rot for every 7.5° of lateral bending
Angle of incline of the facet joints in the sagittal plane increases cephalocaudally

20. Cervical Spine instability
Misjudgement – Death or major neurological deficit
– Un-necessary surgery with risk of surgical complications
Definition
“Clinical stability is defined as the ability of the spine to limit its patterns of displacement under physiologic loads so as not to damage the spinal cord or nerve roots.”
White and Panjabi Clin Orthopaedics 1975

21. Cervical Spine instability C0 C1 C2
Transverse ligament 7-8 mm
Tectorial membrane
Posterior A-O A-A membranes
Nuchal Ligament
Wolf et al. J Mt Sinai Hosp. NY. 23:283,1956

22. Cervical Spine instability C2-C7
Flex-Ext All ant structures + 1 post
All post structures + ant
Laminectomy
In children - Kyphosis

23. Cervical Spine instability C2-C7
Radiology

24. Cervical Spine instability C2-C7
A Check List
Ant elements destroyed 2
Post elements destroyed 2
Sagittal translation >3.5 mm 2
Sagittal angulation > 11° 2
Spinal cord damage 1
Nerve root damage 1
Abnormal disc narrowing 1
Dangerous Loading anticipated 1
Total of 5 or more = unstable
White et al Spine 1:15, 1976.

25. Spectrum of pathology
Prolapsed discs, osteophytic compression: ‘wear and repair’
Inflammatory: rheumatoid, ankylosing spondylitis
Trauma: odontoid, rotatory subluxation
Neoplastic: meningiomas, schwannomas, metastatic cord compression,intrinsic cord
Congenital Klippel Feil, fused, Down’s, enterogenous cysts
Infection: discitis, osteomyelitis, epidural abscess

26. Clinical examination Posture Tone Clothing zips, velcro Power
Sensation
Deep tendon reflexes
Co ordination
Gait
Clothing zips, velcro
Aids: stick, wheelchair
Deformity OA,RhA, AS, klippel feil, Downs
Other disease; cancer

27. dermatomes

28. Diagnosis MRI CT or CT myelogram Nerve conduction studies Blood CSF
Multiple sclerosis
Mononeuritis multiplex
Peripheral n entrapment (median, ulnar)
SACDC
Brachial amyotrophy

29. Clinical assessment Natural history of condition
Risks and benefits of the intervention
Alternatives; collar halo physiotherapy
Appropriateness for this particular patient

30. Surgical approaches C1/2 anterior: trans oral
C1/2 posterior: midline sub-occipital
Sub-axial anterior: anterior cervical decompression
Sub-axial posterior: cervical laminectomy, laminoplasty, foramenotomy

31. Results: NASCIS 2 6 weeks: ‘no statistical difference between groups’
6 months: MPSS improved PP (p=0.012), Touch (p=0.042)
1 year:(95%) ‘no significant differences in neurological function by treatment group’

32. Bracken 1993: segmental and longtract recovery in NASCIS 2

34. Disc prolapse C6/7

35. Anterior cervical approach

38. PATIENT POSITIONING
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43. Plate removal, disc decompression, solis cage and graft

44. Total discectomy, iliac graft,
Anterior locking plate