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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_583_Библиотеки_им_академика_М_И_Перельмана
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T. Pitzen et al.
Lowery GL, McDonough RF.The signicance of hardware failure in
anterior cervical plate xation. Patients with 2- to 7-year follow- up.
Spine. 1998;23:181–7.
Morscher E, Sutter F, Jenny H, et al. Die vordere Verplattung der
Halswirbelsaule mit dem Hohlschrauben-Plattensystem aus
Titanium. Chirurg. 1996;57:702–7.
Panjabi MM, Isomi T, Wang JL. Loosening at the screw-vertebra
junction in multilevel anterior cervical plate constructs. Spine.
1999;24:2383–8.
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cal follow-up review of Caspar plates in 49 patients. J Neurosurg.
1996;84:957–61.
Pitzen TR, Chrobok J, Stulik J, etal. 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.
Pitzen T, Drumm J, Berthold C, etal. Degenerative cervical spine dis-
eases: fusion vs. total disc replacement: what can be done when?
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Rechtine GR, Cahill DW, Gruerenberg M, etal. The synthes cervical
spine locking plate and screw system in anterior cervical fusion.
Tech Orthop. 1994;9:86–91.
Smith GW, Robinson RA.The treatment of certain cervical spine dis-
orders by anterior removal of the intervertebral disc and interbody
fusion. J Bone Joint Surg Am. 1958;40:607–24.
Spivak JM, Chen D, Kummer FJ.The effect of locking xation screws
on the stability of anterior cervical plating. Spine. 1999;24:334–8.
Stulik J, Pitzen TR, Chrobok J, Rufng S, et al. Fusion and failure
following anterior cervical plating with dynamic or rigid plates:
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trolled study. Eur Spine J. 2007;16(10):1689–94.
Swank ML, Lowery GL, Bhat AL, et al. Anterior cervical allograft
arthrodesis and instrumentation: multilevel interbody grafting or
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Wang JC, McDonough PW, Endow K, etal. The effect of cervical plat-
ing on single-level anterior cervical discectomy and fusion. J Spinal
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Wang JC, McDonough PW, Endow KK, etal. Increased fusion rates
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fusion. Spine. 2000;25:41–5.
Wang JC, McDonough PW, Kanim LE, et al. Increased fusion rates
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Zechmeister I, Winkler R, Mad P.Articial total disc replacement ver-
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Anterior Cervical Discectomy
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andFusion
FrankGrochulla
28
28.1 Introduction and Core Messages
Anterior cervical discectomy and fusion (ACDF) is a
widely used technique and has become the gold standard for the treatment of cervical radiculopathy. The
surgical principles of the surgical treatment are the
decompression of neurostructures, the restoration of
the cervical lordosis, and the stabilization. The surgical
outcome is mainly dependent on the decompression
effect. Fusion rates are dependent on the number of
levels treated. Actually, there is no evidence for the
superiority of cage fusions compared to fusions with
autologous bone graft from the iliac crest, except that
of iliac crest donor site pain. In the 1950s, the rst
reports of anterior approaches to cervical disc pathology appeared. The two most common methods for
ACDF were described by Robinson and Smith in 1955
[1] and by Cloward in 1958 [2]. Robinson and Smith
did not decompress the neural structures and believed
that osteophytes and herniated discs would be reabsorbed during immobilizing the segment.
28.2 Indications
• Single or multiple level soft disc herniation
• Single or multiple level spondylosis
• Ossication of the posterior longitudinal ligament (OPLL)
• Trauma (vertebral body fractures, subluxations,
luxations)
• Tumors (vertebral body tumors or metastases)
• Infectious diseases
28.3 Contraindications
• Predominant posterior compression of the neural
structures
• Isolated traumatic disruption of the posterior elements
28.4 Technical Prerequisites
The technical prerequisites are the microscope, different
microsurgical instruments, retractor systems for ventral
approach to the cervical spine (e.g., Caspar retractor system),
high-speed drill, and the intraoperative uoroscopy.
28.5 Planning, Preparation,
andPositioning
ACDF is usually performed under general anesthesia with
optimum muscle relaxation.
The patient is positioned supine on the operating table. A
rolled towel or sandbag is placed under the cervicothoracic
junction between the shoulders for head and neck extension.
Head traction device incases with instability. Shoulder countertraction may be necessary, particularly in patients with
short necks and for approaches to the lower cervical spine
and the cervicothoracic junction. A right-sided approach is
generally recommended because it is easier for the righthanded surgeon. Some authors recommend a left-side
approach to reduce the risk of injury to the recurrent laryngeal nerve. However, a review of 328 cases [3] showed no
association between the side of the approach and the incidence of recurrent laryngeal nerve symptoms. The location
of the skin incision is estimated with a lateral uoroscopic
image.
F. Grochulla (*)
Metropol Medical Center, Clinic for Orthopedics, Trauma Surgery
and Spinal Surgery, Nuremberg, Germany
e-mail: frank.grochulla@mmc-nuernberg.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_28
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F. Grochulla
Fig. 28.2 Incision of the platysma muscle
Fig. 28.1 Skin incision
28.6 Surgical Technique
28.6.1 Approach
• The skin incision (3–4 cm) is usually slightly oblique
along Langer’s lines; this provides the best possible cosmetic result (Fig.28.1). A skin incision along the medial
border of the sternocleidomastoid muscle may be used for
multilevel disease.
• Dissection is carried sharply through the subcutaneous
tissue. The platysma muscle may be sharply divided
transverse or split longitudinally (Fig.28.2).
• After subplatysmal dissection, the supercial fascia overlying the medial border of the sternocleidomastoid muscle is sharply divided.
• The following deep dissection between sternocleidomastoid muscle and carotid sheath laterally and trachea, esophagus, and strap muscles of the neck medially is performed
careful with blunt nger dissection. In patients without previous ventral cervical surgery, blunt dissection is easily and
safely accomplished. In patients with previous ventral cervical surgery, sharp dissection may be necessary. In this
case, it is important to conrm that the sharp dissection
remains dorsal to the esophagus and the hypopharynx. A
placed nasogastric tube may be helpful to conrm the location of esophagus and hypopharynx by palpation.
• After entering the prevertebral space, the correct intervertebral disc is marked by uoroscopy.
• The longus colli muscles are elevated from the vertebral
bodies (Fig.28.3) and discs bilaterally, and self-retaining
Fig. 28.3 The longus colli muscles are elevated from the vertebral
bodies
retractors are placed under the longus colli muscle
(Fig.28.4).
• A drill guide is used to position the drill hole for the rst
distraction screw in the middle third of the inferior vertebral body (Fig.28.5a). The drilling direction is orientated
approximately parallel to the index disc space.
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Fig. 28.4 Self-retaining retractors are placed under the longus colli
muscle (with permission Aesculap AG, Tuttlingen, Germany)
28.6.2 Discectomy andFusion
• The distraction screw is inserted through the drill guide
with the screwdriver. The screw should not penetrate the
posterior cortex of the vertebral body.
• After drilling the hole, the second distraction screw is
placed into the middle third of the superior vertebral body
parallel to the rst screw (Fig.28.5b).
• The distractor is pushed onto the distraction screws as far
as possible up to the screw base plates.
• After distraction, an operating microscope with powerful
illumination should be used to improve the magnication
and lighting.
• Discectomy: following the incision of the anterior annulus (Fig.28.6a), the disc is completely removed from the
cranial and caudal end plates and in between the medial
borders of the uncinate processes (Fig.28.6b). Adequate
posterior disc removal is accomplished when the white,
vertically organized bers of the posterior longitudinal
ligament are well visualized.
• In the case of extruded and sequestered disc fragments
(Fig. 28.6c), perforations of the posterior longitudinal
ligament (OPLL) can be identied under microscopical
view. It is important to open the OPLL to explore all
201
sequestered epidural disc fragments. In most cases, it is
not necessary to remove all portions of the OPLL, unless
fragments have migrated bilaterally and extensively [4].
• If spondylosis/osteophytes are present, it is necessary to recreate an interspace height with parallel preparation of the
end plates with cylindrical or coronial burrs and to remove
posterior osteophytes with drills and Kerrison rongeurs.
• The complete resection of osteophytes is checked with a
blunt hook under uoroscopic control (Fig.28.7).
28.6.3 Preparation ofBone Graft Side: Bone
Graft Harvesting andImpacting
oftheBone
• The bone graft site is prepared with curettes and burrs, as
far as possible plane parallel.
• The height and a.p. depth of the intervertebral space are
measured with a gauge (Fig.28.8).
• Graft harvesting: the most commonly used area to harvest
tricortical grafts for ACDF is the anterior iliac crest.
• A skin incision and muscular detachment with monopolar
is performed over the anterior iliac crest.
• A tricortical bone graft with parallel cut edges is prepared
(oscillating saw with appropriate size for the graft)
(Fig.28.9a). A graft cutter is set to the measured depth of
the intervertebral space, and the correctly sized bone graft
is then cut from the iliac crest (Fig.28.9b).
• The bone graft is drilled and then screwed onto the graft
holder (Fig.28.10).
• The graft is impacted with slight press t under image
intensier guidance.
28.6.4 Cages
• The use of structural autografts for ACDF is related to a
relatively high rate of morbidity at the donor site in the
range of 10–25%.
• As an alternative, a variety of interbody cages are now
available for use in the cervical spine. The materials used
are carbon ber, polyether ether ketone (PEEK), titanium,
or bioabsorbable implants. The cages can be classied
into screw-in, box-type, and cylindrical design
categories.
• Interbody cages should provide the immediate loadbearing capacity while allowing bony fusion.
28.6.5 Plating
• Indications and techniques for the use of anterior cervical
plates are described in detail in Chap. 21
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Fig. 28.5 (a) Positioning the
rst drill hole in the inferior
vertebra with the drill guide.
(b) Sitting the second
(superior) distraction screw
(with permission Aesculap
AG, Tuttlingen, Germany)
F. Grochulla
Toothed bar
of the
distractor
Drill guide Drill guide
Drill bit
Inferior
distraction
screw
28.7 Postoperative Care
• Each of the surgical steps must be monitored and performed individually using an image intensier.
Patients can be mobilized on the day of surgery approximately 4–6h after surgery.
Soft drain for 24h. In the case of ACDF, a soft collar is
applied for 6–8weeks postoperatively.
• Adequate visualization is essential for performing the
decompression procedure safely. A microscope with powerful illumination should be used to improve the magnication and lighting.
• Width of decompression of the spinal canal: for an adequate decompression, an approximately 15-mm bony dis-
28.8 Tips andTricks
section centered over the midline is necessary. If nerve
root decompression is part of the surgical procedure, a
• Monitoring of the endotracheal cuff pressure and its
release after retractor placement can decrease the rate of
recurrent laryngeal nerve temporary paralysis [5].
• Excessively, longus colli dissection can cause Horner’s
syndrome. The incidence varies from 0.2% to 2% [6, 7].
Therefore, longus colli dissection should be limited to
4mm of the muscle.
wider discectomy/decompression on one or both sides
may be necessary.
• Manipulation of the nerve root is particularly problematic with the C5 nerve root, which appears to be more
vulnerable to injury. Therefore, extreme care should be
taken during performing discectomies in the level C4/5.
C5 palsy is more common in posterior approaches.
ab
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203
c
Fig. 28.6 (a) Incision of the anterior annulus. (b) The disc is completely removed. (c) Removal of sequestrates disc fragments
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F. Grochulla
Measuring the
height
Caliper gauge
Measuring the depth
Fig. 28.7 Complete resection/decompression is checked with a blunt
hook under uoroscopic control
a
Oscillating saw
hand piece
Fig. 28.9 (a) Bone graft
harvesting from the iliac crest
with oscillating saw. (b) Graft
cutter (with permission
Aesculap AG, Tuttlingen,
Germany)
Fig. 28.8 Measuring the height and the depth of the intervertebral
space (with permission of Aesculap AG, Tuttlingen, Germany)
b
Graft cutter
Depth of
Double saw
blade
Height of bone
graft / saw blade
resembles the
height of desired
intervertebral space
bone graft
28 Anterior Cervical Discectomy andFusion
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Graft holder
Depth
Height
205
References
1. Robinson RA, Smith GW.Anterolateral cervical disc removal and
interbody fusion for cervical disc syndrome (abstract). Bull John
Hopkins Hosp. 1955;96:223–4.
2. Cloward RB.The anterior approach for removal of ruptured discs. J
Neurosurg. 1958;15:602–14.
3. Beutler WJ, Sweeney CA, Conolly PJ.Recurrent laryngeal nerve
injury with anterior cervical spine surgery risk with laterally of surgical approach. Spine. 2001;26:1337–42.
4. McCulloch JA, Young PH, editors. Essentials of spinal microsurgery. Philadelphia: Raven Lippincott; 1998.
5. Apfelbaum RI, Kriskovich MD, Haller JR.On the incidence, cause,
and prevention of recurrent laryngeal nerve palsies during anterior
cervical spine surgery. Spine. 2000;25:2906–12.
6. Bertalanffy H, Eggert HR.Complications of anterior cervical discectomy without fusion in 450 consecutive patients. Acta Neurochir.
1989;99:41–50.
7. DePalma A, Rothmann R, Lewinnek G, et al. Anterior interbody
fusion for severe cervical disc degeneration. Surg Gynecol Obstet.
1972;134:755–8.
Fig. 28.10 The bone graft is drilled and screwed onto the graft holder
(with permission Aesculap AG, Tuttlingen, Germany)
Uncoforaminotomy
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KirstenSchmieder
29
29.1 Introduction and Core Message
In carefully selected cases and in experienced hands,
this surgical method provides good clinical results and
preserves motion in the affected segment [1, 2].
Uncoforaminotomy is a minimally invasive surgical
technique. The approach uses the uncovertebral joint
to create direct access to the neuroforamen. Within the
bony canal, there is a close proximity between the
bony borders and the nerve root. In cases of an additional hard or soft disc disease, a signicant narrowing
or obstruction is present. Via a ventral route on the side
of the symptoms, the offending lesion is removed
resulting in a decompression of the nerve root in its
neuroforaminal segment. Since the disc itself is left in
place, motion of the segment can be preserved [3, 4].
K. Schmieder (*)
Department of Neurosurgery, University Hospital
Knappschaftskrankenhaus Bochum, Bochum, Germany
e-mail: kirsten.schmieder@kk-bochum.de
29.2 Indications
• Unilateral disc herniation
• Unilateral osseous foraminal stenosis
• Unilevel hard or soft disc disease
• Bisegmental foraminal obstruction
• Failed conservative treatment
• Neurological decit correlating with the radiological
nding
29.3 Contraindications
• Cervical myelopathy
• Multilevel hard or soft disc pathology
• Ossication of the posterior ligament
• Bilateral foraminal obstruction
• Segmental instability
• Kyphotic malalignment of the cervical spine
29.4 Technical Prerequisites
Fluoroscopy, operation microscope, adequate instrumentation for ventral discectomy (punches, forceps, ball piler), and
drill (rosen und diamant, preferable high-speed drilling
system).
• Caspar retractor system or similar retractor for ventral
approach to the cervical spine
• No additional implantation system required
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_29
207
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Ster
muscle
Disc space
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Fig. 29.1 Anterior approach
to the cervical spine on the
side of the offending lesion
and the symptomatology
K. Schmieder
Larynx
Esophagus
Internal and
external carotid
artery
nocleidoideus
A: ventral approach
B: vertebral artery
Myelon
29.5 Planning, Preparation,
andPositioning
Prior to surgery, MRI or CT scans are reviewed to see
where exactly within the neuroforamen the offending process is located. Vertebral artery on the side of the approach
has to be localized. Knowledge of normal anatomy of the
uncovertebral joint and the surrounding structures is essential. The patient is placed on its back, and the head is on a
horseshoe- like positioning device. The uoroscopy is
draped sterile.
29.6 Surgical Technique
29.6.1 Approach
An anterior approach to the cervical spine is performed on the
side of the patient’s complaints (Fig.29.1). The skin incision
is placed in relation to the affected segment on the anterior
border of the sternocleidomastoid muscle about 3 cm long
(same incision used for ACDF). At the ventral surface of the
cervical spine, the self-retaining retractor is inserted and
placed above the longus colli muscle (Figs.29.2 and 29.3). No
Caspar pins are placed in the adjacent vertebral bodies. After
lateralization of the longus colli muscle at the level of the disc,
the lateral border of the adjacent vertebral bodies is identied
and the uncovertebral joint is localized (Fig.29.4).
Fig. 29.2 Insertion of the retractor system
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