PROCEDURE 46 Cervical Spine

Rudolf Reindl

PITFALLS

• Before embarking on a stabilization technique, the spine should be well aligned and the facet joints reduced. If a closed reduction maneuver is ineffective or deemed to be unsafe, an open reduction will be required first.

Anterior and Posterior Stabilization

Indications

Acute fractures and dislocations that result in acute cervical spine instability require early stabilization to prevent acute or gradual displacement that can cause spinal cord compression.

Traumatic lesions resulting in progressive deformity of the cervical spine despite appropriate conservative measures may require surgical stabilization.

Controversies

• While the posterior approach offers the most predictable method of achieving a satisfactory reduction and the strongest biomechanical construct, the anterior approach allows for easier patient positioning and less extensive soft tissue dissection. Disk material and retropulsed bony fragments will require an anterior approach.

Examination/Imaging

A detailed neurologic examination is imperative as it may influence the timing and character of the surgical treatment.

Radiographs should be obtained in anteroposterior (AP), lateral, and swimmer’s views.

• Although computed tomography (CT) with reconstruction has replaced these standard views in some Level 1 trauma centers, they remain the standard radiologic tests for the diagnosis of significant cervical spine pathology.

• For optimal views of the C7/T1 level, traction should be applied to the upper extremities. Despite adequate traction, the T1-4 levels can usually not be visualized with a standard lateral view. A swimmer’s view will demonstrate severe pathology in this zone (Fig. 1).

The CT scan is paramount in preoperative planning and should be used in all surgical cases. The scan should include the entire cervical spine, and continue caudally to T4.

Magnetic resonance imaging (MRI)

• MRI is used for evaluation of disks and ligaments. In the unconscious or sedated patient, it may be the only test that reveals significant soft tissue disruption. Additionally, the spinal cord may show evidence of injury not appreciated by other modalities (Fig. 2).

• Most patients should undergo preoperative MRI unless the delay in obtaining this test is detrimental to the patient’s outcome, or if there are specific contraindications to MRI.

FIGURE 1

FIGURE 2

Treatment Options

• Nonoperative treatment is acceptable in mostly osseous injuries and in the pediatric population provided that good alignment is obtained and maintained. This may range from the application of a soft collar to the installation of a halo vest. The failure rate of these modalities is higher in mostly ligamentous and soft tissue injuries. In the obese patient, bracing is less effective, and the elderly may not tolerate bracing well.

PEARLS

• Assure satisfactory fluoroscopic visualization of the affected levels preoperatively.

Slightly oblique views may be necessary to visualize the lower levels if the shoulders obscure the view.

AP fluoroscopy may be useful for C7 and T1 pedicle screw placement.

• Taping suggestions

Prepare the skin with a transparent film dressing spray (OpSite spray) to improve adhesion of tape.

Use surgical foam tape (3 M Micropore tape) to prevent excessive arm traction.

Surgical Anatomy

An anterior or posterior approach may be used (Fig. 3).

Structures at risk include:

• Carotid sheath—common carotid artery, jugular vein, vagus nerve

• Strap muscles

• Superior and inferior thyroid arteries

• Recurrent laryngeal nerve

• Sympathetic chain

• Vertebral arteries

• Spinal cord

FIGURE 3

Positioning

Anterior approach (Fig. 4A)

• The patient is placed in the supine position on a radiolucent table.

• Slight extension is used if the spine is reduced.

• A Mayfield head rest and Gardner-Wells traction are applied.

• The arms are placed at the patient’s side with slight traction.

• Exposure of the iliac crest is optional.

Posterior approach (Fig. 4B)

• The patient is placed in the prone position on a radiolucent table.

• Slight extension is used if the spine is reduced.

• A Mayfield head rest, Mayfield tongs, or a halo ring is used to prevent direct pressure on the eyes during surgery. Traction is optional.

• The arms are placed at the patient’s side with slight axial traction.

• Exposure of the iliac crest is optional.

FIGURE 4

Equipment

• Gardner-Wells tongs

• Mayfield head tongs

• Mayfield head rest

• Halo ring

• Radiolucent table

• Foam tape

PITFALLS

• Once the spine is reduced, traction is optional and serves to stabilize the head during the operative procedure and to counteract traction on the arms. In most cases, 5–10 lbs is satisfactory. Excessive traction on the head, fixing the spine in a distracted position, may lead to late instability and hardware failure.

• Prolonged excessive traction on the arms may lead to brachial plexus injuries.

• Care needs to be taken to prevent any pressure on the eyes, especially in the prone position. Cases of blindness have been reported with this type of positioning. Mayfield head tongs or a halo ring allows for stable positioning without any pressure on the eyes in the prone position.

PITFALLS

• Anterior approach

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