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Minimally Invasive Spine Surgery pp 201–214Cite as

Minimally Invasive Posterior Cervical Fixation

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Abstract

Posterior fixation techniques continue to play a vital part in the treatment of cervical spine pathology. Evolving from semirigid techniques such as wiring to dynamic screw-plate constructs, modern techniques employing screw rod constructs now allow for far more robust stabilization after cervical decompression. Additionally, interfacet and transfacet techniques have further added to the armamentarium available to surgeons to achieve rigid arthrodesis and maintainance of correction. With the implementation of minimally invasive tissue-sparing techniques during posterior cervical instrumentation, significant improvements in soft tissue morbidity, blood loss, pain, recovery, return to work, infection, and reoperation rates have also been observed and documented. Contemporary three-dimensional intraoperative imaging techniques also provide enhanced accuracy and localization during instrumentation of the posterior cervical anatomy. When used with newer perioperative pharmaceutical and anesthetic protocols as well as with modern intraoperative neurmonitoring modalities such as motor evoked potentials, the combination of these surgical technologies has served to greatly enhance the efficacy, safety,,accuracy, and outcomes of posterior surgical decompressive and instrumentation procedures.

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Author information

Authors and Affiliations

  1. The Spine Clinic of Los Angeles, University of Southern California Neuroscience Center at Good Samaritan Hospital, Los Angeles, CA, USA

    Larry T. Khoo & Roya Gheissari

  2. Department of Neurological Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, USA

    Zachary A. Smith

Authors
  1. Larry T. Khoo
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  2. Zachary A. Smith
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  3. Roya Gheissari
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Corresponding author

Correspondence to Larry T. Khoo .

Editor information

Editors and Affiliations

  1. Department of Orthopedic Surgery, Rush University Medical Center, Chicago, IL, USA

    Frank M. Phillips

  2. Texas Back Institute Texas Health Presbyterian Hospital Plano Scoliosis and Spine Tumor Center, Plano, TX, USA

    Isador H. Lieberman

  3. Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA

    David W. Polly Jr.

  4. Department of Neurological Surgery, University of Miami/Jackson Memorial Hospital, Miami, FL, USA

    Michael Y. Wang

Appendices

Quiz Questions

  1. 1.

    Which type of posterior cervical instrumentation offers the most rigid form of fixation in the treatment of cervical spine pathology?

    1. (a)

      Laminar/facet wiring techniques

    2. (b)

      Transpedicular screw-rod fixation

    3. (c)

      Lateral mass screw-rod fixation

    4. (d)

      Transfacet screw-rod fixation

    5. (e)

      Intrafacet allograft/titanium fixation

  1. 2.

    What type of anesthetic protocol is needed when utilizing intraoperative motor evoked potentials and triggered or running evoked motor potentials for monitoring of cervical spinal procedures?

    1. (a)

      Routine general anesthesia

    2. (b)

      Regional anesthesia only

    3. (c)

      TIVA (total intravenous anesthetic) protocol (porofol)

    4. (d)

      Cerebral burst suppression therapy

  1. 3.

    3-D intraoperative imaging and navigation is most useful to improve the accuracy of which type of posterior cervical fixation?

    1. (a)

      Cervical posterior lateral mass fixation

    2. (b)

      Cervical transfacet fixation

    3. (c)

      Laminar and facet wiring techniques

    4. (d)

      Cervical pedicle screw instrumentation

  1. 4.

    Which of these techniques can be utilized to reduce bleeding, perioperative pain, and time to recovery after posterior cervical surgical procedures?

    1. 1.

      Preinjection of approach tissues with local anesthetic and epinephrine

    2. 2.

      Soft tissue dilation with tubular or mini-open techniques

    3. 3.

      Maintaining anatomical soft tissue attachments to dorsal laminar, facet, and spinous processes

    4. 4.

      Use of a postoperative Jackson-Pratt Drain

      1. (a)

        1 and 3 only.

      2. (b)

        2 and 4 only.

      3. (c)

        1,2, and 3 are true.

      4. (d)

        None of the above are true.

Answers

  1. 1.

    (b) Transpedicular rod fixation constructs of the posterior cervical spine have the highest pullout strength and when combined in polyaxial screw-rod constructs provide the most rigid fixation of the posterior cervical spine particularly in multiaxial force directions such as shear and rotation.

  2. 2.

    (c) As the combination of somatosensory evoked potentials (SSEPs) and transcortical motor evoked potentials (MEPs) provides the highest sensitivity and specificity for detecting intraoperative neurological events during cervical spinal surgery, it is crucial that appropriate anesthetic protocols such as propofol and TIVA (total intravenous anesthetic) only techniques be used.

  3. 3.

    (d) As cervical pedicles can have very small dimensions as well as significant angular variance in their trajectory, 3-D intraoperative CT-type imaging combined with navigation can significantly enhance the accurate and safe placement of screw instrumentation by providing real-time virtual guidance in the axial plane.

  4. 4.

    (c) All of the first three techniques have been shown to reduce muscular pain, spasm, and bleeding and to decrease soft tissue instability and atrophy in the perioperative and postoperative period. The use of a Jackson-Pratt drain to prevent blood or seroma pressure on the wound, in and of itself, is not useful in this regard.

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Khoo, L.T., Smith, Z.A., Gheissari, R. (2019). Minimally Invasive Posterior Cervical Fixation. In: Phillips, F., Lieberman, I., Polly Jr., D., Wang, M. (eds) Minimally Invasive Spine Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-19007-1_19

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  • DOI: https://doi.org/10.1007/978-3-030-19007-1_19

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-19006-4

  • Online ISBN: 978-3-030-19007-1

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