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32 Implantation ofaCervical Disc Prosthesis
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Fig. 32.6 Distraction forceps are used for distracting the treated segment. (a) Without and (b) With distraction
231
kept minimal in order to avoid creating too much bone
powder as this can serve as a focal point for later ossication. Preparation of the posterior uncus should be limited
to one-third of the total structure to avoid instability of the
segment.
• Distraction with Caspar retractor or distraction forceps.
Once the midline has been determined and the disc
compartment prepared (partial discectomy), the Caspar
screws for the distractor are inserted.
Note: For fusion procedures, the Caspar screws are usually
applied centrally in lateral alignment, and the distraction
force is transmitted via their shafts. In activ C implantation,
however, the Caspar distractor serves as a distraction holding device. The self-locking mechanism assures its stability
and keeps the vertebral end plates parallel. Maximal distraction force is created by means of distraction forceps,
and the interbody distance enlargement is passively followed by moving the distractor longitudinally.
Distraction forceps are used for distracting the treated
segment. The forceps are applied to the posterior part of
Fig. 32.7 Under X-ray control, tap the trial implant into the disc com-
partment until the safety stop touches the anterior side of the vertebral
body
the intervertebral space under uoroscopic control.
Distraction is increased gradually in parallel fashion.
Step- by- step distraction allows relaxation of the ligaments (see Fig.32.6a, b). The height of the space in the
treated segment should be compared with adjacent segments to avoid over-distraction. Careful observation of
joint ssure enlargement can be helpful. The forceps are
equipped with a locking mechanism to hold the distance.
• Trial implant (see Fig.32.7a, b).
Inserting the trial implant–verifying the size of the
required disc implant.
The safety stop position is adjusted in the AP direction
with the adjusting wheel. The safety stop is moved forward by turning the adjusting wheel counterclockwise
and backwards by turning the adjusting wheel clockwise.
Initially, the safety stop is moved forward as far as possible. The trial implant is then tapped into the disc compartment until the safety stop touches the vertebral body from
anterior. The size (depth and height) of the trial implant is
inspected under X-ray control. If necessary, adjusting
wheel is turned clockwise to move the safety
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Fig. 32.8 (a, b) Preparation
of the keel groove. The
gures show burr holes (No.
1 and 2) in lateral X-ray
view. The latter runs
immediately next to the trial
implant. Both burr holes end
1.5mm in front of the
posterior edge of the trial
implant
U. Vieweg
Fig. 32.10 Prosthesis in situ
distraction must be avoided. The trial implant should not
be introduced too far posterior. The midline and sagittal
midplane must be respected. Once the keel groove has
been reamed, the position of the prosthesis is xed and
Fig. 32.9 Implantation of the prosthesis. The prosthesis is carefully
inserted in the disc compartment by guiding the keel into the prepared
keel groove
can no longer be changed.
• Preparation of the keel bed, keel groove, and reaming (see
Fig.32.8a, b).
• Implantation of the articial disc (see Figs. 32.9 and
32.10).
stop back and push the trial implant in a posterior direction. Once the nal position has been reached, the distraction is released to see the actual angulation of the segment.
The distractor can be removed completely for a better
view. The trial holder is unlocked and removed. Note: The
trial implant is introduced in the distracted position. Over-
– Corresponding to the trial implant used.
– Apply slight distraction with the Caspar distractor.
– Attach the appropriate prosthesis to the insertion
instrument.
– Introduce the articial disc under lateral uoroscopic
control.
32 Implantation ofaCervical Disc Prosthesis
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233
– Detach the insertion instrument.
– Check the nal position in AP and lateral view.
– Correct the position if necessary.
– Release distraction.
– Check the position of the articial disc.
32.7 Tips andTricks
• The surgeon naturally has a duty to explain the potential
complications of disc prosthesis.
The operation can lead to infection, occasionally even
sepsis and meningitis; secondary bleeding with or without respiratory problems; injury of the oesophagus, trachea, carotid artery, and jugular vein; injury of the
recurrent nerve, spinal cord, and nerve roots; and cerebrospinal uid stula. Dislocation and migration of the
implant must also be considered. With regard to the cervical spine itself, the possible complications are a loss of
lordosis and increase in kyphosis, narrowing of the disc
space, fracture of the end plates, and heterotopic ossication (HO).
• When explaining the operation, it is important to describe
alternative methods such as fusion techniques, dorsal
decompression, and conservative treatment (physiotherapy, manual therapy osteopathy, and pain treatment).
• The dorsal edges of the bones should be sealed with
bonewax.
• Choosing the appropriate prosthesis size and insertion
position should prevent subsidence or extrusion of the
prosthesis.
References
1. Chang UK, Kim DH, Lee MC, etal. Changes in adjacent level
disc pressure and facet joint force after cervical arthroplasty compared with cervical discectomy and fusion. J Neurosurg Spine.
2007;7:33–9.
2. Sekhon LH. Cervical arthroplasty in the management of spondylotic myelopathy: 18-month results. Neurosurg Focus. 2004;15:E8.
3. Anderson PA, Rouleau JP. Intervertebral disc arthroplasty. Spine.
2004;29:2779–86.
4. Anderson PA, Sasso RC, Rouleau JP, etal. The Bryan cervical disc:
wear properties and early clinical results. Spine J. 2004;4:303S–9S.
5. DiAngelo DJ, Puttlitz CM.Biomechanical aspects associated with
cervical disk arthroplasty. In: Kim DH, Cammisa FP, Fessler RG,
editors. Dynamic reconstruction of the spine. NewYork/Stuttgart:
Thieme; 2006.
6. Boden SD, Balderston RA, Heller JG, etal. An AOA critical issue.
Disc replacements: this time will we really cure low-back and neck
pain? J Bone Joint Surg Am. 2004;86:411–22.
7. Kim SW, Shin JH, Arbatin JJ, et al. Effects of a cervical disc
prosthesis on maintaining sagittal alignment of the functional spinal unit and overall sagittal balance of the cervical spine. Spine.
2008;17:20–9.
8. Lafuente J, Casey AT, Perzold A, et al. The Bryan cervical disc
prosthesis as an alternative to arthrodesis in the treatment of cervical spondylosis. J Bone Joint Surg Br. 2005;87:508–12.
9. Leung C, Casey AT, Gofn J, etal. Clinical signicance of heterotopic ossication in cervical disc replacement: a prospective multicenter clinical trial. Neurosurgery. 2005;57:759–63.
10. Lin EL, Wang JC.Total disk arthroplasty. J Am Acad Orthop Surg.
2006;14:704–14.
11. Mummaneni PV, Haid RW. The future in the care of the cervical spine: interbody fusion and arthroplasty. J Neurosurg Spine.
2004;1:155–9.
12. Nabhan A, Ahlhelm F, Shariat K, et al. The Pro-Disc C prosthesis: clinical and radiological experience 1 year after surgery. Spine.
2007;32:1935–41.
13. Jaramllo-de La Torre J, Grauer JN, Yue JJ.Update on cervical disc
arthroplasty: where are we and where are we going? Curr Rev
Musculoskelet Med. 2008;1:124–30.
Percutaneous Anterior Endoscopic
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Cervical Decompression
StefanHellinger
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33.1 Introduction and Core Messages
As a bridge between open [1] and percutaneous therapy [2], endoscopy of the cervical spine started to be
used at the beginning of the 1990s, following good
experiences on the lumbar spine [3–5]. The principle
of microsurgery is combined with the minimally
invasive principles by bringing the optical level to the
forefront of pathology. Access morbidity has been
signicantly reduced by the percutaneous access
technique. Furthermore, a large proportion of the
intervertebral disc, in particular most of the brous
ring, is preserved. The pathology is only removed
selectively in the area of the nucleus pulposus and on
the dorsal brous ring. This preserves the remaining
biomechanical function of the degenerated intervertebral disc. By means of tried and tested minimally
invasive methods under vision, such as the use of a
laser to ablate and shrink tissue, the risk of complications has been further reduced, at the same time
enhancing efciency. The advancement of the endoscopic technique with increased miniaturization of
the telescope and working options led to restriction of
use (e.g., LASE system). Our objective was to create
an adequate working space in front of the telescope
while preserving the minimally invasive approach.
This was achieved by the use of dilation sheaths,
which force the base plate and upper plate apart in the
manner of a Caspar retractor and permit a working
eld of 5mm or 6mm. Here, visualization is sufcient to expose the ventral epidural space. A swiveling maneuver of the endoscope enables the dorsal
section of the intervertebral disc to be visualized
from one uncovertebral joint to the other. Removal of
disc material is limited to the pathologic part, in a
similar way to arthroscopic meniscus surgery.
Equally, the surgeon has to become accustomed to
the fact that limited viewing elds are lined up rather
than in joint arthroscopy. An irrigation system is used
to rinse the ablated disc material out of the viewing
eld and to achieve partial hemostasis.
33.2 Indications andContraindications
Indications are
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 questionable
• Preoperative segmental kyphosis or “straight neck.”
• Narrow, hard disc.
• Acute myelopathy with MRI signal changes.
• Osteophytic and sclerotic changes of the vertebral
bodies.
Contraindications are
• Serious cervical spinal stenosis.
• Migrated free disc sequestration.
• Pronounced spondylosis with large osteophytes.
• Collapsed disc space with or without instability.
• Calcications of the posterior spinal ligament.
S. Hellinger (*)
OOCC München MVZ, Munich, Germany
e-mail: info@ooccm.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_33
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S. Hellinger
As further instruments for endoscopic intervertebral disc
surgery are developed, the scope of application can undoubtedly be extended up to endoscopic fusion technology [6].
33.3 Technical Requirement
• Endoscopic System for anterior cervical endoscopic
decompression with endoscope and tting rongeurs,
burrs, and endokerrisons (Storz, Wolf, Joimax, Spinendos).
• Videosystem.
• Radiofrequency (e.g., Elliquence) or laser for
coagulation.
• Flouroscope.
For the endoscopic decompression, we use an enhanced
percutaneous endoscopic cervical discectomy (PECD) set.
The main component is a 4mm diameter endoscope with a
beroptic telescope and a 1.9mm working channel. Other
systems come in different sizes. This enables the camera to
be attached to the optical cable, which reduces the weight
and improves the balance of the endoscope during use.
Suitable instruments for the working channel are available.
A laser or radiofrequency unit can be used, as can a variety
of working sleeves, particularly dilation sleeves. The intervention is generally performed under general anesthesia. An
operation under local anesthesia and analgosedation in the
case of risk patients is also possible. The patient is positioned in the same way as for conventional anterior cervical
discectomy on the back with a caudalization of the shoulders. It is advisable to maintain a state of readiness for an
open surgical procedure, and to keep an operating microscope available. The level of the intervertebral disc that is to
be operated on is marked using the C-arm. Then an approximately 5mm skin incision is made at this level on the right
side, medially to the sternocleidomastoid muscle, and the
platysma is exposed without cutting. Following lateralization of the carotid artery and the jugular vein, and medialization of the larynx, trachea, esophagus and thyroid gland
by applying pressure with the index nger and middle nger, the anterior surface of the cervical spine can be touched.
Under uoroscopy, an 16 or 18G spinal needle is then
inserted into the intervertebral disc, preferably in the midline, via the skin incision (Fig. 33.1). The position of the
needle is checked in at least two planes with the C-arm. The
direction of the needle is toward the extrusion veried on
MRI.Then a guidewire and various obturators can be placed
on the intervertebral disc via the needle (Fig.33.2). A 5mm
or 6mm working sleeve, depending on the height of the disc
and the system, is inserted into the anterior brous ring via
the last obturator. The working sleeve can now be advanced
further into the disk space. The procedure is facilitated by
using a trephine and a shaver. Under endoscopic vision
(Figs.33.3 and 33.4), the intervertebral disc can be curetted
in a channel as far as the posterior brous ring. The pathological region of the posterior brous ring, previously identied by imaging, determines the angle of entry into the
Fig. 33.1 (a) Intraoperative photograph shows lateralization of the
carotid artery and the jugular vein, and medialization of the larynx, trachea, esophagus and thyroid gland by applying pressure with the index
nger and middle nger, this allows the anterior surface of the cervical
spine to be touched. Under uoroscopy, a dilator is then inserted into
the intervertebral disc. (b) Needle placement
33 Percutaneous Anterior Endoscopic Cervical Decompression
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Fig. 33.2 Intraoperative ouroscopy demonstrates the working canula
placed in the intervertebral disc with an instrument
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Fig. 33.4 For the endoscopic decompression we use an enhanced
PECD set from Storz. The main component is a 4mm diameter endoscope with a beroptic telescope and a 1.9mm working channel
33.4 Complications
Fig. 33.3 The placement of the cervical endoscope for discectomy and
decompression
intervertebral disc. This section of the disc is located and
ablated together with the prolapsed disc tissue. When so
doing, the working area can, if necessary, be extended as far
as the uncovertebral joints by swiveling the endoscope. If
required, the excision forceps or a microkerrison can be
used to carefully open the posterior spinal ligament and
expose the epidural space. Similarly, relatively small osteophytes can be ablated under uoroscopic vision using the
ring curette or kerrison. Furthermore, intervertebral disc
material that is still oating freely can be ablated and stabilized by laser or radiofrequency. A nal check is carried out
with the palpation hook.
The complication rate of percutaneous cervical decompression is extremely small, as is the case with non-endoscopic
percutaneous procedures. In our patients, there have been no
complications to date. Various complications have been discussed in the literature. In a multicenter study, 1750 cervical
endoscopic interventions on the cervical spine, employing
different techniques, have been recorded around the world.
In four cases, discitis occurred, in one case there was a permanent sensory decit, and in 5 cases nerve lesions with
motor damage was found. This corresponds to an average
incidence of complications in 0.6% of cases. Other, rare
events to be found in publications are vessel injuries with
hematoma, in one case a carotid injury, damage to autonomic
nerves with Horner syndrome, and two cases with recurrent
laryngeal nerve lesion out of 1200 interventions [7].
Inadequate decompression when using the endoscopic technique is reected in the incidence of secondary operations.
The multicenter study quotes 28 relevant cases, which represents 1.6%.
33.5 Tips andTricks
• It is obligatory to explain potential risks of complications
up to carotid or dural injuries and an eventual necessary
change to open surgery.
• The limits of the endoscopic anterior techniques have to
be claried in front of the patient and the alternatives such
as fusion techniques, dorsal decompression, and conservative treatment must be specied.
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S. Hellinger
• In the beginning of the surgery, it is helpful to start with a
small incision to gain mobility and to make a blunt dissection to the anterior spine with a mosquito clamp.
• The use of a shaver can fasten the transdiscal approach to
the anterior ligament.
References
1. Hankinson HL, Wilson CB. Use of the operating microscope
in anterior cervical discectomy without fusion. J Neurosurg.
1975;43(4):452–6.
2. Hellinger J. Technical aspects of the percutaneous cervical and
lumbar laser-disc-decompression and nucleotomy. Neurol Res.
1999;21(1):99–102.
3. Lee SH, Lee SJ, Park KH, etal. Comparison of percutaneous manual and endoscopic laser diskectomy with chemonucleolysis and
automated nucleotomy. Orthopade. 1996;25(1):49–55. in German
4. Chiu JC, Negron F, Clifford T, et al. Micro decompressive percutaneous endoscopy: spinal discectomy with new laser thermodiskoplasty for non-extruded herniated nucleus pulposus. Surg
Technol Int. 1999;8:343–51.
5. Fontanella A.Endoscopic microsurgery in herniated cervical discs.
Neurol Res. 1999;21(1):31–8.
6. Hellinger S. The fullendoscopic anterior cervical fusion: a new
horizon for selective percutaneous endoscopic cervical decompression. Acta Neurochir Suppl (Wien). 2011;108:203–7.
7. Chiu J. Clifford T Cervical endoscopic discectomy with laser
thermodiskoplasty. In: Savitz MH, Chiu JC, Yeung AT, editors.
The Practice of Minimally Invasive Spinal Technique. Richmond:
AAMISMS Education; 2000. p.141–8.
Part IV
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Posterior Cervical Spine
Overview ofSurgical Techniques
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andImplants
StefanSchären
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34.1 Introduction and Core Messages
A posterior approach to the cervical spine is indicated in
posteriorly situated lesions or as a supplement to anterior surgery. Great advancements in posterior instrumentation have been made over the last decades. Today,
modern versatile rod-screw systems allow easy and stable xation from the occiput to the upper thoracic spine.
If surgery is indicated, the choice of the approach
depends on etiology and location of the pathology and
the functional spinal stability considering the options for
appropriate decompression and stabilization. Posterior
decompressive approaches are suited for cases of posteriorly situated lesions compressing the spinal cord and/
or the exiting nerve roots. As an advantage, the posterior
approach is relatively simple not being compromised by
neural or vascular structures and can easily be extended
if necessary. Also, the posterior bony elements are usually very strong, providing excellent purchase for
implants even in the osteoporotic spine. Nevertheless,
intact anterior column is an important prerequisite for a
stable long- term result. In cases of anterior column
defect or kyphotic deformity, anterior or combined
approaches are indicated. Thanks to the continuous evolution of spinal instrumentation technology over the last
decades, versatile and powerful implants are available
that meet the specic demands of the cervical spine,
adding immediate stability and increasing the fusion
rate. The strength of the constructs allows minimal, if
any, external bracing. In addition, the latest generation
of implants is designed to be compatible with MRI and
allows to rapidly assess adequate decompression of neural structures or progression of pathological lesions
being treated. Due to the specic characteristics and the
techniques of stabilization for the craniocervical junction, the atlantoaxial articulations, and the subaxial cervical spine will be discussed separately. In reality,
pathologies rarely respect articial boundaries but cross
the various regions. Frequently, techniques must be
combined. The modern modular implants which have
been developed in the past decade are adapted to meet
these specic anatomical characteristics.
34.2 Approach andPositioning
The patient is placed in prone position with cushion under his
chest. Alternatively, a vacuum mattress or a spine frame may
be used. The head is xed in slightly exed position on a padded U-shaped headrest. Alternatively, a Mayeld clamp can
be used. A laterally placed image intensier should be
installed in xed position. As with occipitocervical fusion,
the neutral position of the head must be veried under image
intensier and compared to preoperative standard lateral
radiograph. Reduction and traction (always under image
intensier) are possible if necessary (fracture dislocation,
rheumatoid arthritis). The shoulders are pulled down with
adhesive straps. Shaving of the back of the head and of the
neck is required (patient must be informed prior to surgery!).
A standard midline approach is performed, and the posterior
elements of the spine of the levels to be addressed are exposed.
34.3 Occipitocervical Fusion
S. Schären (*)
Department of Orthopaedic Surgery/Spine, University Hospital,
Basel, Switzerland
e-mail: sschaeren@uhbs.ch
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_34
The craniocervical junction comprising occiput, atlas, and
axis represents a complex transition zone from the cranium
to the cervical spine. Its characteristic anatomy differs fundamentally from the subaxial spine. More than 50% of the
exion/extension and rotation of the head and neck occur in
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S. Schären
Fig. 34.1 (a, b) T2-weighted sagittal MRI of an 81-year-old patient
with invalidating neck pain shows inltration of corpus and dens axis
by plasmocytoma (1A). Occipitocervical (C0–C4) stabilization with
this area. As a result, high biomechanical forces and strong
lever arms are acting and challenging the attempt of surgical
stabilization. In order to neutralize these biomechanical
forces, instrumentation constructs must therefore have adequate dimensions and sufcient rigidity. At the same time,
the systems must offer great exibility to be easily adapted
to the multiple anatomical variations and leave enough room
for grafting, allowing for bony fusion to take place. The rst
occipitocervical fusion was reported in 1927 by Foerster
[1], who inserted a bular graft between the occiput and C7
to stabilize a progressive atlantoaxial dislocation after an
odontoid fracture. Since then, multiple methods of fusion in
this area have been developed: simple onlay bone grafts
with halo immobilization; wire, pin, or hook constructs;
rigid metallic loops or rectangles xed to the bone with
wires or screws. Today, modular rod-screw systems have
Cervix® (Synthes, Oberdorf, Switzerland) was performed. In view of
the malignant underlying disease of the lesion, the construct was augmented with PMMA (1B)
rod- screw systems could be demonstrated [4, 6]. Most stable are constructs including C2 reducing the number of segments to be included in the fusion [7]. For good and safe
anchoring to the suboccipital bone, it is essential to study
preoperatively the thickness of the bone and the position of
the dural sinuses on CT scans. In an anatomical study, the
thickness was found to be 8mm and more extending from
the occipital protuberance bilaterally for 23mm [8]. In pediatric patients, internal xation techniques have been applied
more hesitantly partly because fusion without internal xation is achieved more easily and partly because the implants
did not suit the smaller anatomy. Today, smaller implants
are available, and there is a tendency toward internal xation also in children [9]. Only anatomic constraints in children less than 1 year old usually still require fusion with
onlay techniques (Fig.34.1).
become the standard for occipitocervical stabilization in
adults [2–4]. The systems can be xed either by lateral mass
screws or transpedicular screws to the subaxial spine and be
34.4 Atlantoaxial Fusion
attached to the suboccipital bone by plates. They are easy to
contour and provide rigid internal xation allowing immediate mobilization with no or minimal external support, while
the fusion is taking place. High fusion rates are reported [2,
5]. In several biomechanical studies, superior stability of the
Techniques for isolated C1–2 fusion have gradually evolved
over the last several decades since Gallie described the place-
ment of a notched bone graft between the posterior arch of the
atlas and the spinous process of C2 secured by sublaminar
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