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. 2021 Mar;18(1):55-66.
doi: 10.14245/ns.2040528.264. Epub 2021 Mar 31.

Circumferential Operations of the Cervical Spine

Andrei Fernandes Joaquim  1 , Nathan J Lee  2 , K Daniel Riew  2
Affiliations

Circumferential Operations of the Cervical Spine

Andrei Fernandes Joaquim et al. Neurospine. 2021 Mar.

Abstract

Generally, a combined anterior and posterior cervical approach is associated with significant morbidity since it requires an extended operative time, greater intraoperative blood loss, and both anterior- and posterior-related surgical complications. However, there are some instances where a circumferential cervical fusion can be advantageous. Our objective is to discuss the indications for circumferential cervical spine procedures. A narrative review of the literature was performed. We include the indications for circumferential cervical approaches of the senior author (KDR). Indications for circumferential approaches include: (1) high-risk patients for pseudoarthrosis, (2) cervical deformity (e.g. , degenerative, posttraumatic, cervicothoracic kyphosis), (3) cervical spine metastases (especially those with multilevel involvement), (4) cervical spine infection, (5) unstable cervical trauma, (6) movement disorders and cerebral palsy, (7) Multiply operated patient (especially postlaminectomy kyphosis and patients with massive ossification of the posterior longitudinal ligament), and when (8) early fusion is desirable. Circumferential procedures may be useful in many different cervical spine conditions requiring surgery. Despite its advantages, particularly with reducing the risk for pseudarthrosis, the benefits of a combined approach must be weighed against the risks associated with a dual approach. With appropriate preoperative planning, intraoperative decision-making, and surgical techniques, excellent clinical outcomes can be achieved.

Keywords: Anterior cervical approach; Circumferential; Combined cervical approaches; Posterior cervical approach.

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Conflict of interest statement

The authors have nothing to disclose.

Figures

Fig. 1.
Fig. 1.
(A) This 80-year-old lady with chronic obstructive pulmonary disease and chronic use of steroids had a previous C2–T1 fusion for treating a Dropped Head. She developed a cervicothoracic kyphosis due to an insufficiency fracture at T1, with vertebral collapse, as demonstrated on sagittal computed tomography scan (B), anteroposterior (C), and lateral (D) cervical x-rays, and sagittal T2 sequence magnetic resonance imaging (E). She underwent a T1 corpectomy and fusion, followed by revision of the posterior instrumentation, from C2 to T3, as demonstrated in the anteroposterior (F) and lateral (G) postoperative x-rays.
Fig. 2.
Fig. 2.
This 65-year-old woman with severe osteoporosis had C7–S1 posterior fusion, a C4–5 anterior cervical discectomy and fusion, as demonstrated in the long-standing lateral x-ray (A) and lateral cervical x-ray (B). She developed a symptomatic postjunctional kyphosis. A multilevel anterior discectomies and fusion were performed, from C4–7 followed by posterior C47 supplementation, connecting the cervical rods with the posterior thoracic rods, as demonstrated in the postoperative cervical lateral x-ray (C).
Fig. 3.
Fig. 3.
This 71-year-old lady with a breast cancer metastatic tumor at T1 with spinal cord compression, with vertebral T1 collapse at sagittal computed tomography scan (A) and spinal cord compression at T2 sequence sagittal magnetic resonance imaging (B), underwent a T1 corpectomy, followed by a posterior C7–T12 fusion, with immediate stability as shown in lateral cervical plain radiograph (C).
Fig. 4.
Fig. 4.
This 51-year-old lady (A) had a previous 2-level anterior cervical discectomy (C3–5) and fusion with a postlaminectomy kyphosis as shown in lateral x-rays (B, C). She was an opioid-dependent and recent smoker. She had plate removal, multilevel anterior cervical discectomy and fusion (C2–3, C5–6, C6–7, T1–2) followed by a C2–T2 fusion, with good correction (D).
Fig. 5.
Fig. 5.
Preoperative lordosis position test—the patient is placed in a supine position with the neck extended for several minutes—if the patient develops paresthesia, weakness, or pain in the arms, an anterior approach at the stenotic levels or a posterior foraminotomy is necessary during a posterior surgery to avoid postoperative C8 and T1 deficits.
Fig. 6.
Fig. 6.
Illustrative pictures of the foraminal height at the level of C5–6. When there is some disc height loss (A) at the level of foraminal stenosis, a foraminotomy-alone will not fully address cranial-caudal stenosis, once extension for deformity correction (B) will cause compression due to decrease foraminal height. In such cases, restoration of disc height via an anterior approach (C) is needed prior to cervical extension and a posterior foraminotomy. Red arrows represent vertical increase of the cervical foramen.
Fig. 7.
Fig. 7.
Illustrative view of the patient position – a reverse Trendelenburg position is preferred to reduce retropharyngeal edema. Intermittent pneumatic stocking to prevent deep vein thrombosis is required.
Fig. 8.
Fig. 8.
The senior author prefers to use a 1/4-inch Penrose drain after anterior cervical surgery. This involves supported by steristrips about the wound, an abdominal pad, and transparent adhesive, as illustrated in the 3 pictures above.
See this image and copyright information in PMC

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