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3 Cervical Disc Arthroplasty
31© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_4
Chapter 4
Posterior Cervical Positioning
JosephRabe
Introduction
Surgical positioning of patients who are to undergo posterior cervical surgery is
complicated and needs to be performed correctly to achieve successful surgical out-
comes and avoid intraoperative and postoperative complications. There are a variety
of indications for posterior cervical surgery including posterior cervical decompres-
sion via laminoplasty or laminectomy, nerve root decompression through forami-
notomies, and various instrumented fusions including occipitocervical, atlantoaxial,
and/or subaxial fusion. During these cervical operations, the patients are placed in
nonphysiologic conditions for extended periods of time that would not be tolerated
by an awake individual. In order to achieve the best postoperative outcomes, it is
vital to understand potential pitfalls, mechanisms, and etiologies of the various
complications. While the overall risk of complication is low, the morbidities and
possible mortality can be potentially devastating.
Initial Evaluation
A thorough preoperative evaluation needs to be performed by both the surgeon and
anesthesia team to ensure safety during intubation and positioning. Preoperative
safe ranges of cervical motion that do not produce or reproduce symptoms need to
be determined, especially in myelopathic patients. In cases of severe myelopathy,
the anesthesia team may need to consider awake ber-optic intubation [1]. It is also
important in patients with spinal cord injury or myelopathy to ensure hypotensive
anesthesia is avoided. Anesthesia should maintain the mean arterial pressure (MAP)
J. Rabe (*)
Department of Orthopaedics, MedStar Georgetown University Hospital, Washington, DC, USA
32
at 80mm Hg to ensure adequate spinal cord blood ow during surgery. In these
patients, arterial lines should be placed in order to better monitor and control the
MAP.The position of the neck during the surgery is determined by the operation
being performed. Patients undergoing both occiput-C2 and subaxial procedures
need the chin to be exed in order to allow adequate visualization of the occipito-
cervical junction and reduce the overlap of the facets and laminae inferiorly to facil-
itate decompression [1]. In the case of fusion, the patient’s neck should be placed in
neutral to slight extension to create the desired post-fusion lordosis [1]. Any pro-
tracted placement of the cervical spine in hyperexion or hyperextension can con-
tribute to underlying spinal cord injury. In myelopathic patients, neuromonitoring
sensory evoked and motor evoked potentials are frequently used. Pre-positioning
signals can be obtained and repeated post-positioning to assure no neurologic injury
with neck manipulation or hyperextension.
Room Setup andEquipment (Fig.4.1)
Basic room setup:
– Radiolucent bed with a sheet folded placed on top
– Gel rolls x2
Fig. 4.1 Room setup and equipment
J. Rabe
33
– Mayeld head rest and pins with betadine ointment
– A 4-inch cloth tape
– Pillow case
– Towel clips
– Small foam donuts x4
– Gray foam pad x2
– Large C-arm machine
– Long back table
– Bovie and bipolar machines
Positioning
The patient is initially brought into the room, and the anesthesia team will intubate
on the bed while taking care not to excessively mobilize the cervical spine. The
neuromonitoring technician will insert leads throughout the body to allow for peri-
operative monitoring. The Mayeld retractor is attached to the head. When select-
ing the pin entry points, it is important to ensure the Mayeld clamp can be freely
rotated over the nose once the patient is placed into the prone position. The desired
position for the retractor is to place the single skull pin as close as possible to the
centerline of the patient’s head while the two rocker pins at equal distance on the
opposite side of the patient’s head from the single skull pin. The placement of both
sides of the retractor should be above the ear, specically above the temporal line
[2]. Retractor placement inferiorly into the temporalis muscle should be avoided to
decrease pin slippage due to decreased bone purchase and to decrease bleeding after
removal [2]. The single pin should be placed just above the pinna and again superior
to the temporal line and slightly anterior to help control exion of the neck and the
angle of the pins as close as possible to 90 degrees (perpendicular) to the patient’s
skull [2]. It is important to avoid placing the pins over uneven or fragile bone such
as the frontal sinuses, abnormally thin bone, near the orbit, or temporal fossa [2]. If
the pin is placed too high, again it will lose purchase within the skull secondary to
the overall curvature [2].
The patient is then carefully ipped and rested on the two gel rolls, wrapped
within pillowcases that are taped down to the bed, and positioned underneath the
patient’s chest. The surgeon should control the head during the ip with at least
three assistants supporting the torso, pelvis, and legs. It is important to allow the
abdomen to hang free to increase venous return to the heart and decrease pressure
applied to the lungs during inhalation [1]. The Mayeld retractor is then connected
to the bed with the neck in the optimal degree of exion to extension based on the
procedure being performed. The patient’s knees are placed onto two 7-inch foam
donuts, and two or three pillows are placed underneath the legs and feet to decrease
the stretch on the sciatic nerve. Sequential compression devices are placed and con-
nected on bilateral legs. The bed controls are then used to place the patient in reverse
Trendelenburg position to help reduce intraoperative bleeding secondary to
decreased pressure in the epidural venous plexus [1]. The bed is then exed at the
4 Posterior Cervical Positioning
34
knees to prevent the patient from sliding when in reverse Trendelenburg. The elbows
(to protect the ulnar nerve) and wrist are then well padded with gray foam pads, and
the arms are tucked at the patient’s side. The white sheet beneath the bed is then
brought up and around the patient. Each end is rolled up and secured to the opposite
side of the sheet by two towel clamps being careful not to grab the skin. The arms
are then secured with 4-inch cloth tape starting above the patient’s shoulders and
unrolled over the patient’s back and fastened to the distal end of the bed. The tape
allows increased visualization of the cervical spine with radiographs, but increased
traction will increase the risk for iatrogenic brachial plexus injury [1]. All bony
prominences and peripheral nerves are double checked to be well padded to ensure
protection against intraoperative skin breakdown and neuropraxia. At this stage,
anesthesia should conrm that all IV and arterial access lines are functioning nor-
mally. Radiographs are then obtained to ensure adequate visualization after posi-
tioning has nished. The surgical site is then shaved superiorly to the occiput and
four 10–10 drapes are placed. The patient is then prepped and draped in the normal
sterile fashion (Fig.4.2).
After the procedure, the patient is unhooked from the Mayeld clamp on the
operating room bed and ipped onto the hospital bed with the Mayeld retractor in
Fig. 4.2 Patient
preparation and positioning
J. Rabe
35
place. It is important that the surgeon is at the head of the bed and cognizant of mov-
ing the retractor at the same rate as the body while the patient is ipped. The
Mayeld retractor is then unscrewed and the prongs removed from the patient’s
scalp. It is not uncommon to encounter brisk venous scalp bleeding. It can be help-
ful to have 4 × 4’s in reach during removal to be able to hold pressure until the
venous ooze has stopped which may take upwards of 5min.
Other potential complications that are less common include [3, 4]:
• Pressure necrosis at the pin sites requiring local wound care
• Scalp or eye laceration secondary to slipping of the pins requiring pressure dress-
ing, suture closure, or ophthalmology consultation
• Middle meningeal artery laceration leading to epidural hematoma or AV stula
formation requiring neurosurgical consultation
• Skull fracture
• Air embolism or CSF leak requiring neurosurgical consultation
References
1. Wiesel SW. Operative techniques in orthopaedic surgery: Lippincott Williams & Wilkins;
2012.
2. Cohen-Gadol A.Skull clamp placement: introduction. YouTube. 2014:7. www.youtube.com/
watch?v=EUevdYSc4ik.
3. Lee MJ, Lin EL.The use of the three-pronged Mayeld head clamp resulting in an intracranial
epidural hematoma in an adult patient. Eur Spine J. 2010;19(2):187–9.
4. Mesn A, Gjolaj J, Lemma MA. A method for intraoperative repositioning of the cer-
vical spine during posterior cervical surgery. Orthopedics. 2011;34:597–9. https://doi.
org/10.3928/01477447-20110627-19.
4 Posterior Cervical Positioning
37© Springer Nature Switzerland AG 2020
J. R. O’Brien et al. (eds.), The Resident’s Guide to Spine Surgery,
https://doi.org/10.1007/978-3-030-20847-9_5
Chapter 5
Posterior Cervical Fusion Surgery:
Occiput toC2
R.TusharJha andFaheemA.Sandhu
Overview
Occipitocervical fusion (OCF) with instrumentation is used to treat congenital, trau-
matic, and acquired pathologies of the craniovertebral junction that lead to spinal
instability and neural compression. Patients with minor occipitocervical instability
can be asymptomatic. As instability and, in turn, neural compression progress,
symptoms including occipital headaches, neck pain, lower cranial nerve dysfunc-
tion, gait instability, and even autonomic dysfunction can present.
Foerester rst described reconstruction of the occipitocervical junction with the
use of bular strut grafts in 1927 [5]. In the next few decades that followed, various
wiring techniques were described to stabilize and enhance arthrodesis of the pos-
terior elements. The last few decades have seen the advent of polyaxial screws,
occipital plating systems, and cranial bolt techniques that are now used routinely
for OCF.
Indications
The craniocervical junction can be affected by congenital, acquired, and traumatic
etiologies. Several developmental abnormalities affecting the craniovertebral junc-
tion will be mentioned in this section, but the details of embryology and develop-
mental errors leading to these conditions are outside the scope of this chapter.
Craniocervical instability is seen in 14 to 24% of Down syndrome patients.
However, the incidence of symptomatic instability is less than 1% [11]. Grisel’s
syndrome is an inammatory and spontaneous subluxation that affects the
R. T. Jha · F. A. Sandhu (*)
Department of Neurosurgery, MedStar Georgetown University Hospital,
Washington, DC, USA
38
craniovertebral junction following parapharyngeal infection. Occipitocervical
fusion is rarely indicated as immobilization with a sterno-occipital mandibular
immobilizer is often sufcient. Atlas assimilation is a result of failure of segmenta-
tion between the fourth occipital sclerotome and rst cervical sclerotome resulting
in secondary basilar invagination. This places an abnormal axial load on the cervical
motion segments and can lead to craniocervical instability. Initially, this instability
is reducible. Overtime a panus begins to form around the dens. The basilar invagina-
tion remains reducible until the age of 15. However, after mid-adolescence this
instability becomes irreducible.
Primary basilar invagination is a defect that implies prolapse of the vertebral
column into the foramen magnum. In ventral basilar invagination, the clivus is short
and horizontally oriented. This shortens the basiocciput and displaces the plane of
the foramen magnum in an upward direction relative to the spinal column. In
paramesial basilar invagination, condylar hypoplasia dorsally displaces the clivus
into the posterior fossa. The resultant clivoaxial angle produces deformation of the
craniomedullary neuroaxis. Chiari malformation is associated with basilar invagi-
nation in about 25 to 30% of individuals.
Acquired abnormalities of the craniocervical junction can be classied as rheu-
matoid and nonrheumatoid entities. The synovial lining of the craniocervical joints
is affected early in patients with rheumatoid disease. AOD and basilar invagination
occur, respectively, in approximately 39% and 11% of patients with rheumatoid
arthritis [18]. These patients experience neck pain and myelopathy from instability
and spinal cord compression. Untreated patients with myelopathy have a grim prog-
nosis due to progressive neurologic decline and immobility. The primary treatment
goals for patients with rheumatoid arthritis at the craniocervical junction are relief
of compression on the neuroaxis and stabilization. Achieving these goals is depen-
dent on the location of compressive pathology. Treatment of reducible lesions in
which relief of compression can be obtained by restoring alignment of the cranio-
cervical junction can be accomplished by positioning and occipital cervical instru-
mented stabilization. If there is any irreducible pathology, such as a panus, causing
ventral compression, then this must be rst addressed prior to posterior instrumented
stabilization.
Nonrheumatoid-acquired causes of craniocervical junction are rare but include
ankylosing spondylitis, Reiter’s syndrome, forms of psoriatic arthritis, and infec-
tious etiologies, among others. Evaluation of craniocervical joint and treatment
using posterior occipital cervical instrumentation is similar to that in rheumatoid
patients.
Contraindications
The major contraindication for OC instrumentation and fusion is irreducible anterior
compression of the cervicomedullary junction. Performing OC instrumentation
without decompressing any anterior pathology will propagate progressive neurologic
R. T. Jha and F. A. Sandhu
39
decline of the patient. OCF using occipital keel screws and plates is not feasible in
patients who are undergoing or have already been treated with a suboccipital crani-
ectomy. Instrumentation of the C1 lateral mass or C2 pars or pedicle with polyaxial
screws is contraindicated in patients with bony destruction. Pars or pedicle screws of
C2 may be contraindicated in specic cases of aberrant vertebral artery.
Relevant Surgical Anatomy
A dorsal approach to the occipitocervical region requires dissection through several
muscular layers. The trapezius is the most supercial muscle, and it arises from the
external occipital protuberance (EOP), the ligamentum nuchae, and the spinous pro-
cesses of the seventh cervical and all thoracic vertebrae. The second layer of mus-
cles include the levator scapulae and splenius cervicalis laterally and the splenius
capitis and semispinalis capitis medially. Underlying the splenius capitis are the
erector spinae muscles including the iliocostalis, longissimus, and spinalis.
The vertebral artery (VA) is, arguably, the structure to be most cognizant of when
performing surgery in the OC region. Injury to the VA can result in irreversible and
catastrophic outcomes. The third segment of the VA emerges from the vertebral
foramen of C1, turns dorsomedially, and travels around the lateral mass of C1in a
groove on the posterior ring called the sulcus arteriosus. In approximately 8% to
15% of the population, calcication of the posterior atlanto-occipital membrane can
form a bony covering over the VA as it runs in the sulcus arteriosus [23]. This ana-
tomical variant is called the arcuate foramen or ponticulus posticus, and it should be
recognized prior to surgery to prevent catastrophic placement of C1 lateral mass
instrumentation through the VA.The vertebral artery then ascends toward the fora-
men magnum in the midline and pierces the dura to become intradural. It is impor-
tant to recognize the vertebral venous plexus that surrounds the vertebral artery.
Bleeding from this plexus can occur during dissection around the atlanto-axial joint
and should not be confused for vertebral artery bleeding. The C2 nerve root is also
encountered during dissection around the inferior lateral mass of C1, and dissection
should carefully proceed around the nerve root and its dorsal root ganglion (DRG).
The craniocervical junction is also an intricate osseous and ligamentous com-
plex. The dens of C2 articulates with the dorsal surface of the anterior ring of C1 by
the transverse ligament. This ligament essentially straps the dens against the ante-
rior ring of C1 and allows C2 to pivot with respect to C1. The axis and the occiput
share four attachments: the alar ligament courses obliquely from the posterior lat-
eral surface of the dens to the anterior medial surface of the occipital condyles; the
apical ligament courses from the medial aspect of the foramen magnum to the tip of
the dens; the tectorial membrane, which is an extension of the posterior longitudinal
ligament; the ascending and descending bands of the cruciate ligament that course
from the anterior rim of the foramen magnum to C2.
The occipitoatlantal and atlanto-axial joints account for approximately 25% of
exion and extension movement of the neck. The atlanto-axial joint is responsible
5 Posterior Cervical Fusion Surgery: Occiput toC2