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29 Uncoforaminotomy
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Fig. 29.3 Lateral mobilization of the longus colli muscle with a
dissector
209
29.6.2 Microsurgical Decompression
• Drill an upper uncoforaminotomy down to the neuroforamen (Fig.29.5) [5, 6].
• Prevent a too lateral drilling (vertebral artery!) [7, 8].
• Control the direction and depth with uoroscopy [9].
• Beware that at level C6/7, the vertebral artery enters the
cervical spine from lateral.
• Identify the neuroforamen after reaching the posterior
border of the vertebral body (Fig.29.6).
• Remove the longitudinal ligament above the nerve root.
• Remove offending disc material or osseous spurs.
• Identify the nerve root.
• Make sure that the lateral osseous portion of the neuroforamen is removed.
• Using a small dissector or nerve hook, the medial part of
the foramen is checked (Fig.29.7).
• Using a small punch, remaining parts of the longitudinal
ligament are removed if necessary (Fig.29.8a, b).
• Control the localization of the removed disc material with
the morphology on the preoperative images.
• Follow the course of the nerve root into the neuroforamen
(Figs.29.9 and 29.10).
Fig. 29.4 Identication of the lateral border of the vertebral body and
the uncus
Fig. 29.5 Upper uncoforaminotomy with a high speed drill (cave: ver-
tebral artery!)
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K. Schmieder
a
Fig. 29.6 Identication of the posterior border of the vertebral body
and the neuroforamen
b
Fig. 29.7 Mobilization of the disc material with a nerve hook
Fig. 29.8 (a, b) Removal of the disc material with a small punch
29 Uncoforaminotomy
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Fig. 29.9 Inspection of the nerve root in its intraforaminal part
211
29.7 Tips andTricks
• In the event of a venous bleeding from the epidural intraforaminal plexus, use a small collagen sponge and a cotton to apply gentle pressure and wait for some time. It will
stop bleeding, and the removal of the material is possible.
In some cases, a small piece of collagen sponge has to be
left in place.
• If the insight into the neuroforamen is not sufcient, an
enlargement of the uncoforaminotomy may be necessary.
If so, drill away the adjacent part of the vertebral body
offending the direct view into the neuroforamen.
References
1. Pechlivanis I, Brenke C, Scholz M, Engelhardt M, Harders A,
Schmieder K. Treatment of degenerative cervical disc disease
with uncoforaminotomy – intermediate clinical outcome. Minim
Invasive Neurosurg. 2008;51:211–7.
2. Schmieder K, Kettner A, Brenke C, Harders A, Pechlivanis I,
Wilke HJ. In vitro exibility of the cervical spine after ventral
uncoforaminotomy. Laboratory investigation. J Neurosurg Spine.
2007;7:537–41.
3. Jho HD.Microsurgical anterior cervical foraminotomy for radiculopathy: a new approach to cervical disc herniation. J Neurosurg.
1996;84:155–60.
4. Jho HD. Editorial: failed anterior cervical foraminotomy. J
Neurosurg Spine. 2003;98:121–5.
5. Hayashi K, Yabuki T.Origin of the uncus and of Luschka’s joint in
the cervical spine. J Bone Joint Surg. 1985;67:788–91.
6. Orono C, Sherman MS, Schlechter D. Luschka’s joint– a degenerative phenomenon. J Bone Joint Surg. 1960;42:853–8.
7. Benazzo F, Alvarez AA, Nalli D, etal. Pathogenesis of uncus deformation and vertebral artery compression: histologic investigations
of the uncus and dynamic angiography of the vertebral artery in the
cadaveric spine. J Spinal Disord. 1994;7:111–9.
8. Ebraheim NA, Lu J, Haman SP, et al. Anatomic basis of anterior surgery on the cervical spine: relationships between uncusartery- root complex and vertebral artery injury. Surg Radiol Anat.
1998;20:389–92.
9. Hirsch C, Schajowicz F, Galante J.Structural changes in the cervical spine– a study on autopsy specimens in different age groups.
Acta Orthop Scand. 1967;109(Suppl):34–41.
Fig. 29.10 Postoperative CT scan of the uncoforaminotomy
Anterior Cervical Plating
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TobiasPitzen, JörgDrumm, GregorOstrowski,
andMichaelRuf
30
30.1 Introduction and Core Messages
Anterior cervical decompression and fusion using an
autologous bone graft has been developed in the midand late 1950s of the last century by different groups
(see Chap. 29). Using this technique for xation of
traumatic instability of the cervical spine, it was shown
that the treated segment was prone to displacement [1].
To avoid graft complications such as graft dislocation
or graft settling and to avoid the necessity of an external orthesis—i.e., a halo body jacket—anterior cervical plating was rst used by Hermann [2], who
published his experiences in 1975. Several other
authors already had reported their results [2–4] when
Caspar in 1989 [5] presented a standardized technique
using a unique system of instruments for positioning,
approach, decompression, fusion, and stabilization, as
well suitable implants (bicortical screws and plates).
Since then, the plate has been redesigned several times
and monocortical screws as well as thicker revision
screws have been developed and several other plate
designs (dynamic, rigid, and others working between
dynamic and rigid) have been developed. Two important questions arise connected to these design options
of cervical plates:
1. Is there a need for bicortical xation?
Looking at the results of two biomechanical
studies [6, 7], there is to the authors knowledge
T. Pitzen (*)
Center for Spine Surgery, Orthopedics, and Traumatology, SRH
Klinikum Karlsbad- Langensteinbach, Karlsbad, Germany
e-mail: tobias.pitzen@srh.de
J. Drumm · G. Ostrowski · M. Ruf
Center for Spine Surgery, SRH Klinikum KarlsbadLangensteinbach, Karlsbad, Germany
probably no need to x a cervical plate with bicortical screws. These studies did not see any difference
for three-dimensional segmental stability, screw
pullout or insertional screw torque when bicortical
screws versus monocortical screws were used.
However, the screws should be chosen as long as
possible their length should be around 80% of the
depth of the vertebra and free spinning screws must
be avoided, Fig.30.1, also see Sect. 30.5.
2. What type of plate: dynamic, rigid, or semi-dynamic
or semi-rigid?
Current biomechanical concepts of anterior cervical spine plates are no longer completely unconstrained due to a possible screw pullout, resulting in
loss of stability and/ or soft tissue compression.
Dynamic plates, for example, allow screws to settle
in cranio-caudal direction [8]. This design feature
results in loading of the graft or cage during the
ongoing fusion process. A more rapid fusion may be
expected [9, 10]. Against pullout, however, the
screws are secured by a special connection between
the head of the screw and the plate, so that the
screws should not be backed out. Rigid plate designs
are characterized by a tight xation between the
head of the screws and the plate. They do not allow
motion in any direction between the screws and the
plate. Thus, this type of plate is often preferred, if
highly unstable situations are diagnosed and brought
to surgery. There is, however, no mechanical proof
for this [11]. A clinical study—looking at speed of
fusion, implant complication rate, loss of segmental
lordosis, and segmental height—showed that a
dynamic plate is more favorable with respect to
speed of fusion and rate of implant-associated complications; a rigid plate is favorable when looking at
loss of lordosis and height. There have been no sig-
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_30
213
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nicant differences in clinical aspects [9, 10]. It is
difcult to transfer these results to other plates of
other companies and even more if so called semirigid or semi- constrained designs—designs, placed
within the dynamic ones and constrained (rigid)
ones with respect to their mechanical properties—
should be judged.
30.2 Indications
In any pathology of the anterior aspect within the subaxial
cervical spine treated by anterior decompression, bone graft
(or cage) insertion an anterior plate, xed by screws within
the vertebral body may be used as an additional stabilization
to increase initial stability, avoid graft/cage dislocation and
accelerate the time to fusion. In particular, the main indications for this procedure include [5, 12–14]:
• Degenerative disease of the cervical spine (with the clinical signs of radiculopathy and/or myelopathy). The use of
an anterior plate following monosegmental discectomy
and fusion is usually not necessary, however recommended by the authors.
• Trauma. Note, that anterior plating is also sufcient in
cases of less severe posterior instability [15]
• Tumor
• Rheumatoid instability
• Spondylodiscitis
• Failed surgery of the cervical spine
30.3 Contraindications
• Hypersensitivity to any of the implant materials
30.4 Technical Prerequisites
• Adjustable head neck-rest according to Caspar (Braun
Aesculap, Tuttlingen, Germany), head xed using a clamp
according to Mayeld or Gardner–Wells, shoulders pulled
down by tape,
• C-Arm,
• Preferred plate to be used, including set of screws and
instruments
T. Pitzen et al.
Fig. 30.1 Schematic drawing of the monocortical screws in place,
axial view
30.5 Surgical Technique
• Anterior cervical discectomy and graft/cage insertion is
nished
• Resect remaining anterior osteophytes (create normal
anatomic conditions)
• Length of the plate is determined using lateral uoroscopy (it should not touch the adjacent discs and should
be bend to the patient’s individual lordosis, if possible.
Please note: this is not possible with every type of
plate!)
• Fix the plate temporarily by spikes in the upper and lower
vertebral bodies exactly in the midline.
• Drill two burr holes into each vertebral body, insert the
screws in a convergent angle. The screws should be as
long as possible. However, perforation of the posterior
cortical shell is not necessary (Figs.30.1, 30.2, and 30.4).
Again, there is no proof that bicortical screw xation is
necessary to ensure tight xation [6, 7].
• Check the nal situation by uoroscopy. Figures30.2
and 30.3 give an example of a perfectly placed 4-segmental ABC plate (Aesculap, Tuttlingen, Germany) in
anterior- posterior (AP) as well as lateral projection,
Figs.30.4 and 30.5 depict the same projections for a vertebral body replacement procedure.
30 Anterior Cervical Plating
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Figs. 30.2 and 30.3 Lateral
and AP projection of a
cervical spine x-ray, showing
a 4 segmental plate in perfect
position following 4
segmental ACDF with
bone-lled cage
215
30.6 Tips andTricks
• Note that any plate is designed to be xed within the midline (Figs.30.3 and 30.5). Fixing the plate in the midline
prevents screw malpositioning toward the roots, which
may happen if the plate is xed lateral to the midline
(Fig.30.6). Therefore, it is benecial to mark the midline
at the initial steps of the surgery, before the longus colli
muscle is detached. If this is not possible, there are two
other options: give yourself an orientation where the midline is, by checking the zygapophyseal joints on both
sides or take an x-ray in AP projection (not possible if you
use Caspar’s head neck rest as described above). However,
using the technique described above, correct positioning
of the plate is easy.
• If dynamic plates are used, it is of special importance, to
use plates as short as possible (see Figs.30.2 and 30.4):
these plates allow the graft/cage to settle some millimeters into the adjacent vertebral body, thus resulting in a
shortening of the anterior aspect. As a result, the plate
may touch the adjacent discs, thus maybe producing some
kind of adjacent level pathology. Thus, “think short” if
using dynamic plates.
• The plate should be temporarily xed with two or more
spikes. Take care that these spikes are not placed within
the holes of the distraction screws, this will NOT work.
• Although there is no evidence that lling the cervical
spine cage is necessary for earlier fusion, it is easy to
apply bone into the perforation of the cage used. To do so,
grasp the bone from the adjacent anterior rims of the disc
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T. Pitzen et al.
Figs. 30.4 and 30.5 Lateral and AP projection of a cervical spine
x-ray. Vertebral body replacement C6, insertion of a Harms cage lled
with autologous bone graft and an anterior dynamic plate. Please note
removed. This technique has been described and evaluated by the authors [16].
• The importance of lateral uoroscopy cannot be overemphasized, check the direction as well as the position of the
screw. Again: To our knowledge, there is no proof that
engaging the screws into the posterior cortical shell does
increase the initial postoperative stability or pullout force
or screw torque [6, 7]. Note, however, that the screws
should be as long as possible. Therefore, the author prefers
to orient the screws toward the adjacent discs if possible
(Fig.30.2).
the length of the plate (think short!) and the length of the screws: not
bicortical, but approximately 80% of the vertebral body depth
• Insertional screw torque is important to obtain tight
implant xation [17]. Therefore, if the screw can just be
inserted with very low torque, or the screw is even free
spinning, do not hesitate to use a thicker screw (revision
or rescue screw) or to enlarge the burr hole, to ll the burr
hole with bone cement (methylmetacylate cement) and to
insert the screw again. After hardening of the cement, the
screw is nally tightened with usually very high torque
[18]. The authors never saw any implant loosening using
this technique. You also may use a rescue screw with
thicker core and outer diameter.
30 Anterior Cervical Plating
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Fig. 30.6 Coronal CAT scan reconstruction: Plate xed outside the
midline, potentially harmful to roots and vertebral artery
References
1. Van Petegham PK, Schweigel JF.The fractured cervical spine rendered unstable by anterior cervical fusion. J Trauma. 1979;19:110–4.
2. Hermann HD. Metal plate xation after anterior fusion of unstable fracture dislocationof the cervical spine. Acta Neurochir.
1975;32:101–11.
3. Böhler J, Gaudernack T.Anterior plate stabilization for fracturedislocations of the lower cervical spine. J Trauma. 1980;20:203–5.
4. Orozco DR, Llovet TR.Osteosintesis en las lesiones traumaticas y
degeneratives de la columna vertebral. Revista Traumatol Chirurg
Rehabil. 1972;1:45–52.
217
5. Caspar W, Barbier D, Klara PM. Anterior cervical fusion and
Caspar plate stabilization for cervical trauma. Neurosurgery.
1989;25:491–502.
6. Pitzen T, Wilke HJ, Caspar W, Steudel WI, Claes L.Evaluation
of a new monocortical screw for anterior cervical fusion and plating by a combined biomechanical and clinical study. Eur Spine J.
1999;8:382–7.
7. Pitzen T, Barbier D, Tintinger F, Steudel WI, Strowitzki M.Screw
xation to the posterior cortical shell does not inuence peak torque
and pullout in anterior cervical plating. Eur Spine J. 2002;11:494–9.
8. Brodke DS, Gollogly S, Alexander Mohr R, Nguyen BK, Dailey
AT, Bachus AK.Dynamic cervical plates: biomechanical evaluation of load sharing and stiffness. Spine. 2001;26:1324–9.
9. Pitzen TR, Chrobok J, Stulik J, Rufng S, Drumm J, Sova L, Kucera
R, Vyskocil T, Steudel WI.Implant complications, fusion, loss of
lordosis, and outcome after anterior cervical plating with dynamic
or rigid plates: two-year results of a multi-centric, randomized, controlled study. Spine. 2009;34(7):641–6.
10. Stulik J, Pitzen TR, Chrobok J, Rufng S, Drumm J, Sova L, Kucera
R, Vyskocil T, Steudel WI.Fusion and failure following anterior
cervical plating with dynamic or rigid plates: 6-months results of a
multi-centric, prospective, randomized, controlled study. Eur Spine
J. 2007;16(10):1689–94.
11. Dvorak MF, Pitzen T, Zhu Q, Gordon JD, Fisher CG, Oxland
TR. Anterior cervical plate xation: a biomechanical study to
evaluate the effects of plate design, endplate preparation, and bone
mineral density. Spine. 2005;30(3):294–301.
12. Caspar W, Geisler F, Pitzen T, etal. Anterior cervical plate stabilization in one– and two– level degenerative disease: overtreatment
or benet? J Spinal Disord. 1998;11:1–11.
13. Caspar W, Pitzen T, Papavero L, Geisler FH, Johnson TA.Anterior
cervical plating for the treatment of neoplasms in the cervical spine.
J Neurosurg. 1999;1:27–34.
14. Caspar W, Pitzen T.Anterior cervical fusion and trapezoidal plate
stabilization for re– do surgery. Surg Neurol. 1999;52:345–52.
15. Pitzen T, Lane C, Goertzen D, Dvorak M, Fisher C, Barbier D,
Steudel WI, Oxland TR.Anterior cervical plate xation: biomechanical effectiveness as a function of posterior element injury. J
Neurosurg. 2003;99:84–90.
16. Pitzen T, Kiefer R, etal. Filling a cervical spine cage with local
autograft: change of bone density and assessment of bony fusion.
Zentralbl Neurochir. 2006;67:8–13.
17. Ryken TC, Clausen JD, Traynelis VC, Goel VK. Biomechanical
analysis of bone mineral density, insertion technique, screw torque,
and holding strength of anterior cervical plate screws. J Neurosurg.
1995;83:324–9.
18. Pitzen TR, Drumm J, Bruchmann B, Barbier DD, Steudel
WI.Effectiveness of cemented rescue screws for anterior cervical
plate xation. J Neurosurg Spine. 2006;4(1):60–3.
Cage Implantation intheCervical Spine
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UweVieweg
31
31.1 Introduction and Core Messages
Anterior cervical discectomy is the most common surgical procedure used to treat damaged cervical discs.
Its goal is to relieve pressure on the nerve roots or on
the spinal cord by removing the ruptured disc. In the
operation, the soft tissues of the neck are separated,
and the disc is removed. In order to maintain the normal height of the disc space, the surgeon may choose
to ll the space with a bone graft or cage. This chapter
describes the implantation of a fusion cage [1–3].
31.2 Indications [1–9]
• Degenerative disease of the cervical spine with clinical
signs (radiculopathy, myelopathy) as described in Chap. 19.
• Single or multilevel soft disc herniation.
• Disc ligament injuries with additional plating.
31.3 Contraindications
Fig.31.8) or similar retractor for ventral approach to the cervical spine. A ring retractor system (Synthes Synframe) is an
alternative. Different interbody fusion cages can be used (see
Fig.31.12a–f).
31.5 Planning, Preparation,
andPositioning
The patient is positioned supine on the operating table, and
the head is supported on a Mayeld horseshoe headrest.
General anesthetic giving optimal muscle relaxation is
administered. The neck is placed in a neutral position with
the aid of uoroscopy. Note: shoulder roll placed between
scapulae to increase neck extension in this patient whose
fracture reduced in extension (see Fig.31.1). The arms are
tucked to the side. Wrist restraints with long extensions or
shoulder tape can be useful to enhance X-ray visualization
(see Fig.31.2a–c). The location of the incision is estimated
• Predominant posterior compression of the neural structures.
31.4 Technical Prerequisites
Fluoroscopy, operating microscope, adequate instrumentation for ventral discectomy (punches, forceps), high-speed
drill (rose and diamond), Caspar retractor system (see
U. Vieweg (*)
Department of Conservative and Surgical Spine Therapy with
Interdisciplinary Spinal Deformities Centre and Rummelsberg
Sectional Center, Hospital Rummelsberg, Schwarzenbruck,
Germany
e-mail: uwe.vieweg@sana.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_31
Fig. 31.1 Positioning of the patient with a roll placed between the
shoulder blades. Padding is placed under the shoulders
219
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U. Vieweg
a
b
Fig. 31.2 (a–c) Special shoulder-, arm-, head-xation systems
c
Fig. 31.3 Marking of the skin incision with the aid of the C-arm
using the lateral uoroscopic image (see Fig. 31.3).
Localization of the skin incision to the level of pathology via
external landmarks (see Fig.31.4): hard palate–arch of atlas,
lower border of mandible–C2/3, hyoid–C3, thyroid cartilage–C4/5, cricoid cartilage–C6 and carotid tubercle (anterior transverse process)–C6.
Fig. 31.4 (a) Skin incision in relation to the anatomical level. External
landmarks are hard palate–arch of atlas, (b) lower border of mandible–
C2/3, (c) hyoid–C3, thyroid cartilage–C4/5, (d) cricoid cartilage–C6,
(e) carotid tubercle (anterior transverse process)–C6
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