Anterior Cervical Vertebrectomy: Tips and Traps

Paul R. Cooper, M.D.

Department of Neurosurgery, New York University Medical Center, New York, New York

nterior cervical vertebrectomy to treat myelopathy caused by spondylosis or ossification of the posterior longitudinal ligament (PLL) is a deceptively simple procedure. The operation is replete with pitfalls for unwary surgeons, and seemingly minor mistakes may prolong the operation, make the operation unnecessarily difficult, or result in failure to achieve adequate decompression of neural structures. In the worst circumstances, errors in judgment or technique may lead to injuries of the soft tissue structures of the neck, vertebral artery, or spinal cord and nerve roots. Failure to attend to details of bony reconstruction may lead to pseudoarthrosis and spinal deformity, necessitating reoperation. The discussion here is directed to the avoidance of these pitfalls. FIGURE 1. Operative positioning for anterior cervical vertebrectomy. The head is placed on a horseshoe-shaped headrest, which is adjusted to extend the neck. The arms are pulled inferiorly by 2-inch-wide adhesive tape, which is placed over the inner and outer aspects of the arms and forearms and secured to the bottom of the operating table. This maneuver maximizes observation of the lower cervical spine on fluoroscopic images. A footboard prevents the patient from being pulled inferiorly.

INTUBATION AND PATIENT POSITIONING

Patients with compression of the spinal cord are at increased risk of injury if the neck is manipulated rapidly or is placed in excessive extension. Therefore, all patients should be intubated while conscious, with the use of fiberoptic techniques. Nasal intubation is helpful for high cervical exposures (e.g., C3 vertebrectomy) because it allows the mouth to be closed, minimizing mandibular interference with exposure. Anesthesia is induced after it is observed that the patient is able to voluntarily move all extremities. Electrodes are routinely placed for somatosensory and motor evoked potential monitoring. After the neck is extended, wide adhesive tape is placed over the inner and outer aspects of the arms and forearms. Caudal fixation of the tape allows the shoulders to be pulled down and the lower cervical spine to be observed on plain x-rays or fluoroscopic images (Fig. 1). The head should not be rotated in either direction.

THE INCISION (see video at web site article)

External landmarks, such as the thyroid gland or cricoid cartilage, are not reliable guides for correct localization of the skin incision. The incision may be localized by using intraoperative fluoroscopy for guidance (Fig. 3). Alternatively, several skin staples may be placed on the lateral aspect of the neck, at, above, and below the intended skin incision; a single lateral x-ray is then obtained, and the site of the intended skin incision is adjusted in relation to the skin staples. A transverse incision is marked on the skin, in the upper one-third of the vertebral body to be resected, before the patient undergoes draping. The incision begins at the midline and proceeds laterally to the medial border of the sternocleidomastoid muscle. A vertical incision is cosmetically less acceptable than a transverse incision and is unnecessary for a single-level vertebrectomy. If spinal cord compression by osteophytes is present in the midline, then the side of the inci1129

INTRAOPERATIVE IMAGING
Intraoperative fluoroscopy is used to ensure accurate placement of anterior cervical plates and screws. If the anesthesia team and equipment are placed several feet above the head of the patient, then the fluoroscopic console may be moved rostrally away from the surgical team when it is not in use (Fig. 2).

Neurosurgery, Vol. 49, No. 5, November 2001

1130

Cooper
rostrally and caudally, between the undersurface of the platysma muscle and the superficial cervical fascia. The superficial cervical fascia is incised in a rostrocaudal direction, along the medial border of the sternocleidomastoid muscle. The superficial fascia should be opened for as long a distance as possible rostrally and caudally, to provide the exposure needed for vertebrectomy, bone grafting, and plate placement. The carotid artery may then be palpated posterior to the sternocleidomastoid muscle. All additional soft tissue dissection is performed bluntly. By using both index fingers, a natural plane can be developed between the sternocleidomastoid muscle and carotid artery laterally and the trachea and esophagus medially. Avoidance of sharp dissection at this point minimizes the risk of injury to the esophagus or the hypopharynx. Handheld retractors are placed firmly against the anterior aspect of the vertebral bodies, ensuring that the esophagus is out of the field medially and the carotid artery laterally. The prevertebral fascia is opened sharply, exposing the longus colli muscles.

FIGURE 2. Operating room configuration for cervical vertebrectomy. The anesthesiologists and anesthesia table are located well above the head, allowing room for the C-arm fluoroscopic unit to be moved into and out of the operating field as needed. The base of the operating microscope is kept below the fluoroscopic unit and is located on the patients left side, regardless of the side of the approach. Because the fluoroscopic unit and the microscope are not used simultaneously, they do not interfere with each other.

MIDLINE IDENTIFICATION AND SOFT TISSUE RETRACTION

In the absence of large anterior osteophytes, the space between the longus colli muscles is a reliable guide to the midline and may be marked before the longus colli muscles are mobilized. Large osteophytes may displace the longus colli muscles on one side or the other, thus obscuring the location of the midline. Preoperative computed tomographic scans may be used to define the relationships of osteophytes to the midline. Sufficient mobilization of the longus colli muscles is necessary to obtain sufficient mediolateral exposure to allow adequate resection of the vertebral body and to ensure that selfretaining retractors remain engaged. I use the bipolar cautery to simultaneously cauterize and free the medial aspect of the longus colli muscles from their attachments to the vertebral body to be resected, as well as one-half the length of the adjacent vertebral bodies. Scissors dissection causes bleeding in the longus colli muscles and should be avoided. The use of the monopolar cautery should also avoided, because the spread of heat and current can result in injury to the recurrent laryngeal nerve or other soft tissue structures. Retraction is achieved by using modular retractor blade sets, such as those manufactured by Aesculap (Tuttlingen, Germany) or Medtronic Sofamor Danek (Memphis, TN). Toothed retractor blades are placed beneath the longus colli muscles, at the level of the middle of the body to be resected. The ratchet mechanisms of both of these retractor systems provide sufficient mechanical advantages to allow excellent mediolateral retraction of soft tissues. The length of the blades is important; too short a blade results in disengagement of the blade as the retractor is opened, and too long a blade makes drilling awkward. The lengths of the two blades used are usually symmetrical, but a longer or shorter blade medially or laterally can be used to rotate the retractor apparatus and may be helpful in yielding a more unobstructed view of the area to

FIGURE 3. Fluoroscopic image of the cervical spine in the lateral projection. A hemostat has been placed on the skin over the body of C5, the level of the intended incision.

sion is irrelevant. If osteophytes are asymmetrical, then an incision contralateral to the osteophytes allows better visualization of the osteophytes. Recent data indicate that the incidences of recurrent laryngeal injury are similar, regardless of the side of the incision.

SOFT TISSUE DISSECTION

The platysma muscle lies just under the subcutaneous tissue and varies greatly in thickness. The fibers (which run in a rostrocaudal direction) are spread, and scissors are used to develop a plane beneath the muscle, after which the muscle is cut perpendicular to its fibers. A plane is then developed

Neurosurgery, Vol. 49, No. 5, November 2001

Anterior Cervical Vertebrectomy

be drilled. Blunt blades are then placed superiorly and inferiorly. After placement of the retractor blades, the anesthesiologist is asked to deflate the cuff on the endotracheal tube. After 20 seconds, the cuff is reinflated to just occlude the space between the trachea and the tube; the cuff is left in this position for the remainder of the operation. There is now evidence that this maneuver decreases the incidence of recurrent laryngeal injury, by reducing the pressure against the recurrent laryngeal nerve between the endotracheal tube and the retractor blades as the nerve enters the larynx (1).

1131

FIGURE 5. Postoperative axial computed tomographic scan for a patient with inadequate decompression. The surgeon operated from an incision made in the right side of the neck, and the decompression is skewed to the left, which is a typical mistake made when orientation with respect to the midline is lost. interstices. Bone wax should not be used for hemostasis, because it is not resorbed and it prevents bony fusion.

BONY RESECTION
The anterior longitudinal ligament over the disc spaces above and below the level to be resected is incised, and the most anterior portions of the discs are excised by using curettes and pituitary forceps. The anterior longitudinal ligament is then removed over the vertebral body to be resected and the contiguous portions of the adjacent upper and lower vertebrae. The mediolateral extent of the bone to be resected is marked. I usually resect 18 to 20 mm of bone in a mediolateral direction, to be certain that all osteophytes are resected (Fig. 4). The distance from the medial border of the foramen transversarium on one side to the contralateral foramen is approximately 30 mm in the midcervical spine (2). If the resection is limited to 20 mm, there will be 5 mm of bone on each side medial to the vertebral artery. To resect bone, I prefer to use the Stryker electric drill with an extra-rough, 6-mm, diamond burr, because this burr does not cut or snag soft tissues. It has the additional advantage, compared with cutting burrs, of being hemostatic on cancellous bone. After one-half the depth of the vertebral body has been resected, the operating microscope is brought into the field. The surgeon must be aware of the tendency to resect more bone on the side contralateral to the surgeon and to perform inadequate bone resection on the ipsilateral side (Fig. 5). Brief removal of the operating microscope from the field enables the surgeon to see the forest for the trees and to maintain midline orientation. As bone resection proceeds, the endplates of the adjacent vertebrae are also resected. Bleeding from cancellous bone may be controlled with bits of Gelfoam (Upjohn Co., Kalamazoo, MI) pushed into the bleeding bony

THE PLL
When the PLL is reached, the last bits of bone may be resected with fine curettes. The PLL is entered with a nerve hook, with care being taken to lift the ligament away from the dura. A sharp, Number 11 knife blade is used to cut down on the ligament over the nerve hook, thus exposing the dura. The PLL is composed of a thick anterior layer and a filmy posterior layer. If the shiny dura is not observed, then the posterior layer may need to be opened separately. Although the dura may be adherent to the ligament in patients who have undergone previous operations or exhibit ossification of the PLL, the ligament is generally separate from the dura. Apparent adhesions may result from failure to open the posterior layer of the PLL, which is normally adherent only to the thick anterior layer. Fine Kerrison rongeurs are used to resect the PLL to the edges of the bone exposure. Resection of the PLL ensures that extruded disc fragments are not overlooked and that osteophytes that may be buried in the PLL are resected (Fig. 6). Epidural veins are most prominent laterally, and venous bleeding in this location usually indicates that resection has proceeded sufficiently laterally. Although venous bleeding may be controlled with the bipolar cautery, small bits of thrombin-soaked Gelfoam are equally effective and are associated with less risk of injury to nerve roots.

FIGURE 4. A, preoperative postmyelographic computed tomographic scan in the axial projection, showing spinal cord compression by a broad-based osteophyte. B, postoperative scan, showing 18-mm decompression, the minimum needed to decompress the spinal cord for this patient. Neurosurgery, Vol. 49, No. 5, November 2001

FIGURE 6. Intraoperative photograph, showing the site of cervical vertebrectomy and removal of the PLL. The squared-off sides of the remaining bone should be noted. Distracting pins can be observed above and below the bone resection.

1132

Cooper

BONY RECONSTRUCTION
Reconstruction of the vertebrectomy may be performed by using fibula or iliac crest allografts or iliac crest autografts. I use iliac crest allografts, to avoid the morbidity of a second incision. I prefer iliac crest to fibular allografts, because fusion occurs more rapidly with iliac crest allografts. The graft is cut 2 mm larger than the rostrocaudal length of the vertebrectomy. The anteroposterior depth of the graft is cut to 13 mm, which ensures that the graft is well away from the anterior surface of the dura in all but the smallest adults. Distraction on the cervical spine may be exerted by using Caspar distracting pins or by having the anesthesiologist pull on the head in the long axis of the patients body. Care should be taken to avoid excessive distraction, because this may be a cause of postoperative interscapular pain. I screw a Caspar graft-holder into the graft and hammer the end of the graft-holder, forcing the graft into the area of the vertebrectomy. Use of the graft-holder prevents the graft from rotating, ensuring that it fits evenly as it is hammered into place. When the graft is almost flush with the anterior aspect of the adjacent vertebral bodies, the graft-holder is removed and a bone tamp is used to slightly countersink the graft (Fig. 7).

FIGURE 8. Fluoroscopic image obtained after placement of a graft and plate for cervical vertebrectomy.

tem, fluoroscopic guidance during screw insertion ensures accurate screw placement, avoiding the graft and adjacent disc spaces. Engagement of the posterior cortex by the screw is unnecessary, and screws 14 to 16 mm in length are usually sufficiently long to accomplish fixation while avoiding penetration of the spinal canal.

ANTERIOR INSTRUMENTATION
The fluoroscopic unit is brought into the field, and an anterior cervical plate is chosen. A wide variety of plates are available, and generally none is clearly superior. Plates should have locking mechanisms that prevent screw backout. The plate should be secured in the midline with temporary holding pins and should be short enough that the ends do not overhang adjacent disc spaces (Fig. 8). Regardless of the sys-

CLOSURE AND POSTOPERATIVE MANAGEMENT

A Jackson-Pratt drain is placed in the prevertebral space and brought out through a stab wound placed adjacent to the incision. The superficial cervical fascia and platysma muscle are closed in separate layers, using interrupted sutures. A subcuticular suture is placed, and the skin is approximated by using paper adhesive strips. No external immobilization is used. The drain is removed the morning after surgery, and the patient is allowed to resume normal activities.
Received, March 6, 2001. Accepted, July 5, 2001. Reprint requests: Paul R. Cooper, M.D., Department of Neurosurgery, New York University, 550 First Avenue, New York, NY 10016. Email: paul.cooper@med.nyu.edu

FIGURE 7. Intraoperative photograph obtained after placement of an iliac crest autograft, which is countersunk at the site of the vertebrectomy.

REFERENCES
1. Apfelbaum RI, Kriskovich MD, Haller JR: On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine 25:29062912, 2000. 2. Oh SH, Perin NI, Cooper PR: Quantitative three-dimensional anatomy of the subaxial cervical spine: Implications for anterior spinal surgery. Neurosurgery 38:11391144, 1996.