2. Introduction
Improvement or preservation of neurological
function,
Prevention or correction of spinal deformity
Maintenance of spinal stability
Anterior approach in 51-60%
Posterior approach in about 35%
Combined
3. Modified Japanese Orthopedic Association Score (mJOA) Of ≤ 12 is a
Definite Indication For Surgery In Patients With Cervico spondylotic
myelopathy.
For patients who have a mjoa score of >12 on presentation, the decision to
proceed with surgery should be based on an individualized basis.
The timing of surgery depends upon the patient's clinical presentation.
4. Factors
Location of compression: anterior or posterior:
Single or multilevel compression:
Presence or absence of congenital spinal stenosis,
Alignment of the cervical spine:
Presence or absence of instability:
Smoking
Others
Developmental stenosis,
Preexisting neck pain
Prior cervical spine surgery,
5.
6. Anterior Approach
Indication
Cervical disk herniation with persistent
radiculopathy after conservative
measures
Cervical disk herniation with spinal
cord compression
Cervical disk herniation with significant
spinal canal compromise
Cervical spondylosis with multiple disk
herniations and anterior osteophytes
Contraindication
Posterior cervical pathology is best treated
with posterior approaches with or without
fusion.
Patients whose careers prohibit any risk for
voice alterations may best be treated with
posterior foraminotomies or laminectomies.
7. Anterior Cervical Discectomy without Fusion
Single level compression anteriorly
Normal cervical lordosis
No instability seen on dynamic radiographs.
8. Instability
Subluxation of more than 3.5 mm on static radiographs
More than 11 degrees of angulation between adjacent segments
Subluxation of more than 4 mms on dynamic radiographs
9. Anterior Cervical Discectomy with Fusion
Two level compression anteriorly,
Presence of segmental kyphosis i.e. angulation of more than 11 degrees
between adjacent segments
Instability seen in static or dynamic radiographs
When Factors 2 and 3 are present, even patients with single level disease
should undergo fusion.
10. Position
• Supine with the bed in a slight
reverse Trendelenburg
position.
• Place an inflatable cushion
between the scapulae.
• Consider using monitoring
before and after positioning if
myelopathy is present.
• Wrap arms in gel pads to
protect the ulnar nerve. Secure
the patient to the table wit
tape and seat belt
16. Remove ventral and then dorsal osteophytes with a curet, Kerrison
rongeur, or high-speed bur.
Remove end plates to expose blood-rich cancellous bone.
Contour a graft if necessary, and tap into the shelf space.
Reinforce with metal plate; the shortest plate possible is preferred.
Screw the plate into the vertebrae with superior screws angled upward
and inward and inferior screws angled inward and posterior.
17. Fusion
Un-instrumented
Instrumented
The material that is used to replace the disc is most often autograft less
commonly, allograft or spacers made of titanium polyetheretherketone
(PEEK) or carbon.
18. Autologous Graft
Iliac crest graft
Wellknown high rates of fusion.
The disadvantages include donor site
morbidity like pain, hernia, and
lateral femoral cutaneous nerve
injury.
The angulation of the iliac crest might
pose problems when more than two
levels of corpectomy is done.
Fibular Allografts
Avoidance Of Donor Site Morbidity,
Unlimited Supply,
Ready Availability In Different Sizes
And Shapes,
It Can Be Used For More Than Two
Levels Of Corpectomy
The Disadvantages Include: Fusion
Rates Are Inferior To Autologous
Grafts, Especially, When Used For
More Than Two Levels Of
Corpectomy
19. Allograft
PEEK Cages
Avoiding donor site morbidity,
Ready availability in different sizes,
Radiolucency
Modulus of elasticity of this material
is almost similar to bone
Titanium Cages
These cages are available in different
sizes; when combined with ventral
plate fixation they provide excellent
stability by resisting flexion,
extension and lateral bending.
disadvantages high modulus of
elasticity
difficult to assess fusion, and, when
revision surgery is required,
titanium cages are difficult to revise.
20. ANTERIOR CERVICAL
CORPECTOMY
Pathology that extends beyond the interspace level
Narrow spinal canal who cannot be treated by a posterior only procedure
because of associated kyphosis or instability
21. Posterior approach
Indication
Correction of cervical kyphotic
deformity
Decompression of the cervical spinal
cord in degenerative spondylotic
myelopathy
Excision of ossified posterior
longitudinal ligament (PLL)
Treatment of osteomyelitis that fails non
operative management
Resection and stabilization of vertebral
body tumor
Management of traumatic fractures of
the subaxial spine or as part of
circumferential stabilization with
fracture-dislocations
Contraindication
Previous radiation to the anterior neck
obscures dissection planes.
Multiple prior anterior surgeries and severe
anterior soft tissue injury are
contraindications.
Aberrant vertebral artery anatomy is a
relative contraindication and requires
attention to width of the corpectomy trough.
Chin on chest deformity is best treated with
cervicothoracic fusion and T1osteotomy.
Anterior bony ankylosis secondary to
degenerative or inflammatory disease is a
contraindication.
This procedure cannot be done in patients
with medical contraindications to general
anesthesia.
22. Laminectomy
Cervical canal stenosis,
≥3level disease,
Associated posterior compression due to thickened infolded ligamentum
flavum
Patients with associated multilevel OPLL.
23. Indication
Multilevel cervical stenosis with preservation
of normal lordotic curvature
Diffuse ossification of posterior longitudinal
ligament
Posterior cord compression resulting from
buckling of thickened ligamentum flavum
Posterior exposure of intraspinal pathology,
including tumor, vascular malformation,
infection, and hematoma
Factors limiting anterior neck dissection,
including short neck, scarring from previous
anterior neck dissection or radiation.
Contraindication
Straightening of normal cervical
lordosis or kyphotic sagittal
alignment
Cervical instability resulting from
trauma, tumor invasion, or
connective tissue disorder
Broad-based ventral pathology that
may not be readily accessed from a
posterior approach
24. Complications
The development of post-laminectomy kyphosis,
Development of post-laminectomy membranes
Future posterior fusions are compromised by the dura being exposed over
multiple levels
Even if the patient does not develop neurological deterioration due to post
laminectomy kyphosis, the stretching of the posterior musculo-
ligamentous structures due to altered alignment often leads to disabling
neck pain.
27. Laminectomy with Lateral Mass Fusion
Fusion prevents the development of post laminectomy kyphosis,
Patients with multilevel disease with associated subclinical instability brought
out in dynamic radiographs can be dealt with by this procedure,
Fusion decreases the chance of dynamic compression due to repetitive micro
trauma that is known to occur in CSM,
As laminoplasty is known to cause worsening of axial neck pain, laminectomy
with lateral mass fusion may be preferable in patients with multilevel disease
with significant neck pain preoperatively
Patients with multilevel disease with neutral cervical alignment or in those
with reducible cervical kyphosis,
Lateral mass fusion is an option as the cervical alignment can be restored prior
to securing the instrumentation. performing standalone laminectomy or
laminoplasty may worsen the cervical alignment.
28. Indications
Multilevel cervical stenotic myelopathy (≥3level disease) with preserved
cervical lordosis,
Multilevel cervical stenotic myelopathy (≥3level disease) with subclinical
instability requiring posterior decompression with fusion.
Patients with multilevel disease and neutral cervical alignment or a
reducible cervical kyphosis in whom a lordotic alignment can be achieved
by appropriate positioning before securing the screw rod system
29. Indications
Cervical instability from multilevel
anterior cervical diskectomies or
corpectomies
Increase in posterior tension band in
patient with kyphotic cervical curve
who requires an anterior procedure
Posterior cervical laminectomy for
myelopathy to reduce pathologic
motion
Contraindications
Aberrant vertebral artery anatomy
Lateral mass fracture or lateral mass
of inadequate size
30. Trajectory takes the screw away from the vertebral artery which lies ventral to the lateral
mass and the rostral
Angulation is to avoid the nerve root traversing deep to the superior facet of the caudal
spinal segment.
In addition, such a trajectory also increases the volume of bony purchase in the lateral
mass.
Usually, to achieve bicortical purchase 3.5mm diameter screws with a length of 14 mms
are used
31. An technique
Entry point is located 1 mm medial to the midpoint of The lateral mass
and the direction of the screw is 30* laterally and 15* rostrally
The lateral trajectory takes the screw away from the vertebral artery which
lies ventral to the lateral mass and the rostral angulation is to avoid the
nerve root traversing deep to the superior facet of the caudal spinal
segment.
In addition, such a trajectory also increases the volume of bony purchase
in the lateral mass. Usually, to achieve bicortical purchase 3.5mm diameter
screws with a length of 14 mms are used.
32.
33.
34.
35.
36.
37.
38. Laminoplasty
It is a motion preserving procedure
The disadvantage of laminectomy, namely, the development of
postlaminectomy membrane is avoided
Unlike in laminectomy, because the posterior bony elements are
preserved, revision posterior surgery is not compromised by the exposed
dura,
Laminoplasty can be combined with fusion,
In patients who develop adjacent segment degeneration after multilevel
anterior decompression and fusion, laminoplasty is a viable option
39. Indications
Patients with preserved cervical lordosis
if they have:
Multilevel cervical stenotic
myelopathy (≥3level disease)
Cervical canal stenosis
Posterior cord compression at
multiple levels.
Contraindication
Presence of cervical kyphosis
40. Technical factors
The laminar door should be opened for a minimum of 10-12 mms;
openings less than this dimension will not lead to adequate space for the
cord to shift posteriorly and openings more than 18 mms will lead to
increased shift resulting in higher incidence of segmental root palsy,
An opening of 10-12 mms will increase the anteroposterior diameter of the
spinal canal by 45 mms and the cross sectional area by 90-120 mm 2
A posterior shift of the cord of ≥3 mms is required for good outcomes.
41. Open door laminoplasty
Two grooves are created at the lamina
facet junction;
The groove retains the inner cortex of
the lamina on the hinge side and a
through and through groove is made
on the open side.
The lamina is kept open by one of the
following methods:
Autologous grafts, allografts,
hydroxyapatite spacers, titanium
miniplates or simply by suturing the
spinous processes to the facets.
Double door laminoplasty
Two grooves are created, one on
either side at the lamina facet
junction.
In both the grooves, the inner cortex
is kept intact.
The laminae are then opened and a
graft is kept in between the opened
laminae.
The grafts can be sutured in place
using non absorbable sutures
42.
43.
44.
45. Combined approach
When there is both ventral and dorsal compression of the thecal sac or if
A patient with multilevel disease had developed kyphosis.
In patients with severe osteoporosis or those with poor bone quality due to
renal disease or heavy smokers in whom poor bone fusion is anticipated,
If a multilevel corpectomy is necessary, a combined approach should be
undertaken. [
46. Complications
Postoperative axial neck pain
Segmental root palsy with an incidence of approximately 5%
Closing of the laminar door
Worsening of the cervical alignment
47. Overall perioperative complication rate was 15.6%
The rate of major complications was 7% and the delayed complication rate
was 4%
The complication rates of anterior, posterior and combined approaches
were 11%, 19% and 37% respectively.
48. Prognosis
The compression ratio assessed by magnetic resonance imaging (MRI) can
provide a clue to the prognosis.
This ratio is assessed by dividing the smallest anteroposterior diameter of
the spinal cord by the broadest transverse diameter of the spinal cord.
The presence and If the postoperative MRI shows good decompression
and yet the patient has less than expected outcome, then other causes that
might contribute to disability in these patients like lumbar canal stenosis,
normal pressure hydrocephalus and neurodegenerative conditions should
be sought.
49. Poor prognosis
Ratio is 0.4, especially, after surgery
Persistence of focal high signal
intensity in T2 images
Lack of re expansion of the cord
Good prognosis
An increase in the compression ratio
to >0.4
The transverse area of the spinal cord
increases to more than 40 mm 2
