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31 Cage Implantation intheCervical Spine
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31.6 Surgical Technique [1–3, 6, 8]
31.6.1 Approach
• The Cloward standard approach to the anterior cervical
spine [2] is recommended (see Fig.31.6).
• A transverse skin incision should be made on the left or
right side for access. The author prefers access from the
right. (see Fig.31.4 demonstrated the incisions on the left
side.) The recurrent laryngeal nerve may be traumatized
during the deepest layer of the approach. Many surgeons
prefer a left side approach because the nerve takes a more
predictable course on this side, descending into the thorax
with the carotid sheath, curving around the aortic arch and
ascending between the trachea and esophagus to supply
the larynx. On the other hand, a right-side approach may
be easier for a right-handed surgeon. Yet, the recurrent
laryngeal nerve descends with the carotid sheath and
curves around the subclavian artery to ascend into the
neck at a higher level than on the left.
• The incision should be medial to the anterior border of the
sternomastoid muscle and should extend to the midline.
For cosmetic reasons, we recommend a diagonal incision
along the Langer’s line. Alternatively, a longitudinal incision can be made along the anterior edge of the sternocleidomastoid muscle.
• The skin is undermined in a cranial and caudal direction.
• Immediately following the incision, the platysmas muscle is
identied and incised (see Fig.31.5). Directly beneath the
skin lies the platysma, which may be divided longitudinally
(in line with the bres) with the tip of the index ngers.
Fig. 31.5 Identication and incision of the platysmas muscle
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Fig. 31.6 Axial schematics of the Smith–Robinson approach (standard
anterolateral approach) to the middle anterior cervical spine, trachea,
strap muscle, longus coli muscle, pretracheal fascia, prevertebral fascia,
supercial fascia
Alternatively, the platysma may be divided, without functional consequences, in line with a transverse incision.
• The deep cervical fascia is next identied as an investing layer that splits around the sternocleidomastoid. It
is supercial to all of structures of the neck except the
platysma and external jugular vein. The sternocleidomastoid may now be gently laterally retracted (see
Fig.31.5).
• Blunt dissection using scissors reveals the carotid sheath
(carotid artery, internal jugular vein, vagus nerve).
• When the omohyoid muscle has been found, it should be
passed either cranially (C2–5) or caudally (C5–T2) or
should be severed.
• The trachea and esophagus are moved toward the middle,
and the carotid artery and jugular vein are moved to the
side. Both are then protected with metal retractors which
can occasionally cause a sore throat or hoarseness for a
short time after surgery.
• The attachments of the longus colli muscle are separated
on both sides by means of alternating use of scissors,
bipolar forceps, and swab (see Fig.31.7).
• The relevant disc is localized using intraoperative
uoroscopy.
• Once the correct level has been identied, the longus colli
muscles are moved away from the lateral edge of the anterior cervical vertebra so that retractors will be able to
engage the tissue (see Fig.31.8).
• Ventral spondylophytes are removed with a high-speed
drill or Luer.
• After exposure of the anterior aspects of the spine and
detachment of the medial insertion of the longus colli
muscles on both sides, the soft tissue is retracted using the
Caspar cervical retractor. Retractor valves are inserted
under the belly of each muscle (see Fig.31.8). The cervical ring of the Synframe retractor system can also be used
as an alternative.
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Fig. 31.7 Pushing the two longus colli muscles aside with small swabs
Counter retractor
(Longitudinal)
Basic retractor
(Transverse)
Caudad/
Caudal
Fig. 31.8 Caspar cervical retractor system in position. (With permis-
sion of Aesculap AG, Tuttlingen, Germany)
Cephalad
Cranial
U. Vieweg
31.6.2 Discectomy andDecompression
• The midline between the two longus colli muscles is
marked using a small diamond burr.
• The Caspar distraction screws are positioned. Note: they
should be placed centrally in the midline of the vertebral
body.
• A drill guide is used to position the drill hole for the
rst distraction screw in the middle of the inferior vertebral body. The drilling depth of the drill is xed at
8mm to exclude the possibility of inadvertent penetration into the spinal canal. The drilling direction is usually approximately parallel to the adjacent vertebral end
plates. The screw should not penetrate the posterior cortex (see Chap. 19). Screws with self-cutting threads
should be used. The correct choice of thread length is
determined by the anteroposterior diameter of the vertebral body. The screw should not penetrate the posterior
cortex.
• The distraction screw is inserted through the drill guide
using the screwdriver. Care must be taken to screw in the
distraction screw right up to its base plate in order to
embed it rmly in the vertebral body. This prevents screw
pullout during the distraction process.
• After removing the moveable distractor arm, the drill
guide is tted onto the toothed distractor bar, and this
assembly is positioned over the distraction screw which is
already in place.
• After drilling in the center of the vertebral body, the second (superior) distraction screw is screwed in, and the
drill guide assembly is removed. The drill guide is subsequently taken off the distractor bar and replaced by the
moveable distractor arm.
• The disc is then excised near the anterior longitudinal
ligament and detached using a sharp spoon and curette
(Fig.31.9).
• The disc should be completely removed from the cranial
and caudal end plates and laterally from the uncovertebral
joints, with Kerrison rongeurs and straight curettes (see
Fig.31.10a, b).
• Discectomy is completed under mild distraction, and
decompression of the neural structures is then performed.
The posterior longitudinal ligament is normally retrieved
and detached as far as is necessary to remove osteophytes
using the longitudinal ligament dissector.
• The dorsal spondylosis is ablated with a high-speed burr
and punch, and the posterior longitudinal ligament is
removed. Note: when the high-speed diamond burr is used
to remove the dorsal edge or dorsal osteophytes, care
should always be taken to ensure that the end plates remain
undamaged.
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a
b
Fig. 31.9 Cutting into the disc with a microscapel
• After the disc has been removed, the posterior longitudinal ligament is also removed revealing the anterior aspect
of the dura.
31.6.3 Cage Implantation
• Once the neural structures have been fully decompressed,
the appropriate implant size can be determined with the
aid of the trial implants (see Fig.31.11a).
• Using the insertion instrument set, the cage is introduced
into the intervertebral space (see Fig.31.11b). The implant
should usually lie centrally about 1–2mm in front of the
rear edge.
• By relaxing the Caspar retractor, the ligaments are reactivated so that the implant is held securely in the intervertebral space (see Fig.31.11c). The cage must be rmly held
and not easy to move!
Fig. 31.10 (a, b) Removal of the disc with rongeurs
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c
Fig. 31.11 (a) Determining implant size. (b) Cage implantation. (c) Cage in situ
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d
c
225
ef
Fig. 31.12 Different interbody fusion cages. (a) Syncage with Chronos (Synthes). (b) C-Space PEEK (Aesculap). (c) C-Space Titan Plasmapore-
coated (Aesculap). (d) Cervios Titan cage (Synthes). (e) Zero-P cage with integrated plate (Synthes). (f) Hydro Deltacor
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U. Vieweg
References
1. Bailey RW, Badgley CE.Stabilization of the cervical spine by ante-
rior fusion. J Bone Joint Surg Am. 1960;42:565–94.
2. Bartels RH, Donk RD, Feuth T.Subsidence of stand-alone cervical
carbon ber cages. Neurosurgery. 2006;58(3):502–8.
3. Cloward RB.The anterior approach for removal of ruptured discs.
J Neurosurg. 1958;15:602–17.
4. Bednar DA, Al-Tunaib AW. Failure of reconstitution of open-
section, posterior iliac-wing bone graft donor sites after lumbar spinal fusion. Observations with implications for the etiology of donor
site pain. Eur Spine J. 2005;14(1):95–8.
5. Chen Y, Lu G, Wang B, etal. A comparison of anterior cervical
discectomy and fusion (ACDF) using self-locking stand-alone
polyetheretherketone (PEEK) cage with ACDF using cage and
plate in the treatment of three-level cervical degenerative spondy-
lopathy: a retrospective study with 2-year follow-up. Eur Spine J.
2016;25(7):2255–62.
6. Faldini C, Chehrassan M, Miscione MT, etal. Single-level anterior cervical discectomy and interbody fusion using PEEK anatomical cervical cage and allograft bone. J Orthop Traumatol.
2011;12(4):201–5.
7. Kao TH, Wu CH, Chou YC, etal. Risk factors for subsidence in
anterior cervical fusion with stand-alone polyetheretherketone
(PEEK) cages: a review of 82 cases and 182 levels. Arch Orthop
Trauma Surg. 2014;134(10):1343–51.
8. Moon HJ, Kim JH.The effects of anterior cervical discectomy and
fusion with stand-alone cages at two contiguous levels on cervical
alignment and outcomes. Acta Neurochir. 2011;153(3):559–65.
9. Sasso RC, Smucker JD, Hacker R, et al. Clinical outcomes of
BRYAN cervical disc arthroplasty: a prospective, randomized, controlled, multicenter trial with 24-month follow-up. J Spinal Disord
Tech. 2007;20(7):481–91.
Implantation ofaCervical Disc
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Prosthesis
UweVieweg
32
32.1 Introduction and Core Messages
Anterior cervical decompression and interbody fusion
with an internal xation device (ACDF, or anterior cervical decompression and fusion) has, for some time,
been the classic treatment for cervical spondylosis, but
this technique could result in accelerated degeneration
of the adjacent level. It was hypothesised that this
degeneration could be prevented or at least decelerated
by replacing the diseased disc with a prosthesis, and
thus preserving motion. Over the last decades, numerous disc prostheses designs have been developed and
have been approved for specic indications. The evidence available to-date indicates that they help to prevent or slowdown degeneration of the adjacent disc
and segment [1, 2]. Disc replacement can restore the
physiological curvature and range of motion of the cer-
vical vertebrae to a greater extent than other forms of
treatment [3–5]. Implantation of a cervical disc prosthesis consists of two fundamental steps. The rst is
decompression of the neural structures, for which a
conventional approach via the left or right blood vessel
compartment is usually taken. The second step involves
thorough preparation of the site followed by secure,
central placement of the implant in the prepared space.
32.2 Indications
Clear
Clinically proofed and accepted
• Soft disc prolapse.
• Symptomatic cervical discopathy with neck and/or arm
pain with or without neurological-decit concordant with
MRI of disc pathology.
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_32
Questionable
• Preoperative segmental kyphosis or “straight neck.”
• Narrow, hard disc.
• Acute myelopathy with MRI signal changes.
• Osteophytic and sclerotic changes of the vertebral
bodies.
• Anterior or posterior longitudinal ligament ossications.
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32.3 Contraindications
• Spinal deformities following trauma and laminectomy.
• Spondylarthrosis, facet joint degeneration.
• Chronic degenerative spinal stenosis.
• Segmental instability (more than 3mm of translation).
• Segmental immobility (segmental mobility less than 2° in
exion and extension).
• Chronic myelopathy.
• Osteoporosis.
• Metal (CoCrMo) allergy.
• Pregnancy, rheumatoid arthritis, systemic illness.
• Deformation of the end plates.
32.4 Technical Requirement
• Head xed using a clamp according to Mayeld or
Gardner–Wells.
• C-arm.
• Microscope.
• High-speed drill.
The primary goal of cervical arthroplasty is to remove
the pathologically herniated disc while maintaining disc
height and preserving motion. This chapter describes the
implantation of the activ C prosthesis. The activ C intervertebral disc prosthesis is used to replace intervertebral
discs in the cervical spine. The activ C intervertebral disc
prosthesis consists of two components: superior prosthesis
plate with spikes for anchoring in the vertebral body and
inferior prosthesis plate with integrated polyethylene inlay
and central anchoring n for xation in the vertebral body.
The prosthesis plates and the polyethylene inlay together
form a ball-and-socket joint. The polyethylene inlay is
anchored to form-t in the inferior prosthesis plate (see
Fig.32.1).
The activ C intervertebral disc prosthesis is available in
six different sizes (XS, S, M, L, XL, and XXL) and up to
three different heights (5, 6, and 7mm). Activ C intervertebral disc prostheses are supplied fully pre-assembled.
Many designs have been advocated as replacements for
cervical discs. They consist of either articulating or nonarticulating components constructed from various materials
(see Table32.1 and Fig.32.2).
Fig. 32.1 (a, b) Activ C prosthesis in the implant holder
Table 32.1 Different articial disc prosthesis with different design details [3, 4, 6–12]
Device Prestige Activ C Bryan ProDisc C Cervicore
Company Medtronic Aesculap Medtronic Synthes Stryker
Articulating materials Metal-metal Metal-polyethylene Metal-
Theoretical centre of
rotation location
Initial xation Screws Combination of spikes
Superior
vertebra
Directly below the
inferior plate
and keel
32.5 Planning, Preparation,
andPositioning
• Patient’s neck is placed in a neutral position, not in hyper-
lordosis which is routinely used for anterior fusion tech-
niques (see Fig.32.3b).
• If necessary, the operating position is adjusted according
to a preoperative X-ray of the patient standing in a neutral
position.
• Positions of the head, the cervical spine, and the patient
are xed.
• Radiographic visibility of the relevant segments (lateral
and anteroposterior (AP) views) is ensured.
Note: Positioning of the patient’s neck in hyperlordosis
can result in inappropriate positioning of the prosthesis.
During the operation, the alignment of the prosthesis and the
spinal segment can wrongly appear as ‘correct’. As soon as
Porous coated
motion
Metalpolyethylene
Within implant Inferior vertebra Superior and
Milled bone Keels Screws and spikes Ridges
polyethylene
Metal-metal Metal-
polyethylene
Inferior vertebra
inferior vertebra
ab
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229
Fig. 32.2 Classication of
different designs for cervical
arthroplasty by the Cervical
Spine Study Group on
“articial cervical
nomenclature” [13]
Cervical artificial disc
Non-articulating Uni-articulating Bi-articulating
Metalmetal
Modular Non-modular
Metal-
poly
Ceramic-
poly
Ceramic-
ceramic
Metalmetal
Metal-
poly
Ceramic-
metal
Ceramic-
ceramic
Fig. 32.3 Skin incision (b) and planning of the skin incision. A horizontal ‘“cosmetic’” skin incision targeted with uoroscopy (a)
the spine returns to a neutral position in post-operative daily
life, the segment and the prosthesis can fall into a kyphotic
position.
• Most surgeons approach the upper part from the right and
the lower part (C5/6 and C6/7) from the left side because
of the anatomical positions of the recurrent nerves.
• A horizontal ‘cosmetic’ skin incision, targeted using uoroscopy, is currently preferred (see Fig.32.3b).
32.6 Surgical Technique
• The medial sheet is sharply cut, and the anterior spine is
accessed by approaching between the neuromuscular
32.6.1 Approach
bundle (v. jugularis, a. carotis, vagus nerve) and the visceral organs (trachea and oesophagus).
• A standard anterolateral approach allows a precise view
of all anterior parts of the cervical spine that are affected
during a discectomy and the implantation of a disc
prosthesis.
• Subaxial cervical spine can be approached from the right
or left side depending on surgeon’s preference.
• Cutting of the pre-vertebral lamina allows sharp dissection of the walls of the medial longus colli muscle. This
step is important in order to anchor the wound distractor
rmly and safely (regarding oesophagus) beneath the
muscle bundles. Alternatively, a Synframe (Synthes) or
Caspar retractor (Aesculap) (see Fig.32.4) can be used.
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Fig. 32.4 Caspar retractor. The PEEK material provides enough bio-
mechanical stability and, which features of radiolucency excellent visibility in both lateral and AP uoroscopic view (With permission of
Aesculap AG, Tuttlingen, Germany)
U. Vieweg
32.6.2 Instrumentation
• Midline marking.
The midline of the vertebral body in the sagittal plane is
usually determined from the following anatomic landmarks: position of the longus colli muscles, axis of symmetry of the anterior vertebral surface, and midline
between the processi uncinati (see Fig.32.4). The midline
is most reliably determined in AP X-rays from the position of the spinous processes and the midline between the
uncinate processes. The midline must be permanently
marked with a bone chisel or high-speed drill or by inserting midline pins/Caspar. After verication of the midline
position, the pins can be removed and replaced with the
Caspar screws, using the same bone hole screws (see
Fig.32.5a, b). Note: A nal check of the midline should
be made after placing the trial implant in the disc space.
• Preparation of the disc space.
Discectomy is performed using standard procedures. The
cartilaginous end plate has to be removed completely but
care should be taken to avoid any damage to the integrity
of the bony end plates. Decompression of neural elements
has to be precise and complete (microsurgical technique).
In lateral soft disc prolapse, the posterior longitudinal
ligament can be preserved as a tension band on the asymptomatic side and in the midline. Burrs, cutters, reamers, or
drills can be used for foraminal decompression or cutting
off the posterior osteophytes. Bone preparation should be
Fig. 32.5 Position of the midline marking pins or Caspar screws (a—lateral; b—AP view)
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