CERVICAL SPONDYLOTIC MYELOPATHY: VENTRAL DORSAL OR COMBINED APROACH VENTRAL CERVICAL APPROACH, COMPLICATIONS AND AVOIDANCE MANAGEMENT

CERVICAL SPONDYLOTIC MYELOPATHY: VENTRAL, DORSAL OR COMBINED APPROACH VENTRAL CERVICAL APPROACH , COMPLICATIONS AND AVOIDANCE MANAGEMENT
 GABRIEL VARGAS, MD CLINICA CARLOS ARDILA LULLE UNIVERSIDAD AUTONOMA DE BUCARAMANGA BUCARAMANGA COLOMBIA XIV WORLD CONGRESS OF NEUROLOGICAL SURGERY WORLD FEDERATION OF NEUROSURGICAL SOCIETIES BREAKFAST SESSION SEPTEMBER 1, 2009 BOSTON ,USA

OBJECTIVES
•ANATOMIC CONSIDERATIONS OF CERVICAL SPINE
•ANTERIOR CERVICAL APPROACH TECHNIC
•INDICATIONS
•COMPLICATIONS OF THE ANTERIOR APPROACH AND AVOIDANCE

SPINE SURGERY MOTION PRESERVATION <--- SPINE SURGE --- > FUSION

CERVICAL SPINE DYNAMICS

Movement and Load with permission C Cure, MD Neurosurgeon

CLINICAL PICTURE AND ADVICES
DEFINE LEVELS TO TREAT
•BE AWARE OF CREATING NEW COMPLICATIONS DURING THE SURGERY
•AGING DIFERENT THAN DISEASE
•AVOID PROFILACTIC SURGERY

GOALS OF SURGICAL TREATMENTCERVICAL MYELOPAT
•ADECUATE DECOMPRESSION
•STABILIZATION
•MAINTANING OR RESTORING CERVICAL LORDOSIS RESULTS
•IMPROVE NEUROLOGICAL DEFICIT
•CONTROL PAIN

SELECTION OF APPROACH
•VENTRAL , DORSAL OR COMBINED
• Cervical Alignment and contour,
• Number of vertebral segments involved in the stenosis
• Cause of the spinal cord compression (ventral, dorsal, or combined spinal canal pathology)
•Patient metabolic factors
• Surgeon’s experience

INDICATIONS FOR CERVICAL SURGERY ANTERIOR APPROACH
Surgical treatment for cervical spinal stenosis is indicated in patients who have moderate-to-severe impairment in their neurological function. MYELOPATHY OR MYELORADICULOPATHY

ANTERIOR APPROACH TECHNICS ONLY VENTRAL: CENTRAL STENOSIS DISC SPACE

WHERE IS THE COMPRESSION

WHERE IS THE STENOSIS ONLY VENTRAL INDICATION
•Mainly confined to adyacent disc levels
•Osteophytic change
•Disc Herniation
•Neural Foraminal stenosis

                        

 

ANTERIOR APPROACH IN THE PRESENCE OF KYPHOSIS
•FRONT-BACK-FRONT: ventral discectomy + dorsal release with osteotomies screws and rods + ventral graft and artrodesis
•BACK-FRONT-BACK: dorsal release osteotomies and lateral mass screws unlocked + ventral discectmomy , graft and fusion + dorsal locked screws Mummaneni, Haid, Rodts, Jr., Neurosurgery 60[Suppl 1]:S-82–S9, 2007

ANTERIOR AND POSTERIOR COMPRESSION

STRUT GRAFT VS MULTIPLE DISCECTOMY
•CAGE FUSION WITH PLATE FIXATION MULTILEVEL DISCECTOMY(27 PATIENTS )
•ANTERIOR CORPECTOMY WITH ILIAC BONE FUSION (35 PATIENTS)
•RESULTS
•JOA scores (preoperatively 11.1+/-2.1 and 10.4+/-3.5, postoperatively 14.3+/-2.4 and 13.9+/-2.1, respectively)
•Significant decrease in the visual analog pain scores (preoperatively 8.5+/-1.1 and 8.7+/-1.5, postoperatively 2.9+/-1.8 and 3.0+/-2.0, respectively).
•Both groups A and B showed a significant increase in the cervical lordosis after operation
•Fusion rates (96.3% and 91.4%, respectively).
•Three patients (two 2-level corpectomies and one 3-level corpectomy) had construct failures that required a second operation
•Eight of 35 patients who underwent iliac bone fusion had donor site pain. The hospital stay in group A was significantly shorter than that in group B (P=0.022).

Journal of spinal disorders & techniques. 01/01/2008; 20(8):565-7 Anterior corpectomy with iliac bone fusion or discectomy with interbody titanium cage fusion for multilevel cervical degenerated disc disease Authors: Shiuh-Lin Hwang, Kung-Shing Lee, Yu-Feng Su, Tai-Hung Kuo, Ann-Shung Lieu, Chih-Lung Lin, Shen-Long Howng, Yan-Feng Hwang

BIOMECHANICS OF ANTERIOR DECOMPRESSION AND FUSION
7 HUMAN CADAVERIC FRESH FROZEN CADAVERIC SPECIMENS
•THREE LEVEL DISCECTOMY C3–C4, C4–C5, and C5–C6 with polymethyl methacrylate interbody grafts
•SINGLE CORPECTOMY OF C5 AND DISCECTOMY at C3–C4 PMMA strut graft/interbody spacer
•TWO LEVEL CORPECTOMY + STRUF GRAFT RECONSTRUCTION WITH POLYMETHYLMETHACRYLATE •SEGMENTAL PLATE FIXATION C3 TO C6 IN ALL CASES
•All specimens underwent a pure moment application of 2 Nm with regards to flexion–extension, lateral bending, and axial rotation. Three-dimensional motion analysis with an optical tracking device RESULTS •Three-level discectomy and combined one-level discectomy and corpectomy with segmental fixation was significantly more rigid in flexion–extension and lateral bending than the two-level corpectomy with end constructplate fixation (P 0.05)

Enhancement of Stability Following Anterior Cervical Corpectomy: A Biomechanical Study Kern Singh, MD,* Alexander R.Vaccaro,MD, †Jesse Kim, MS,* Eric P. Lorenz, MS, *Tae-Hong Lim, PhD,* and Howard S. An, MD* Spine 2004;29:845– 849

VENTRAL STRATEGIES
•Single-level Discectomy •Multilevel discectomy
•Cervical corpectomies
•Discectomy one level + Corpectomy

MULTILEVEL DISCECTOMY
•Segmental plate fixation affords a more biomechanically rigid construct with regards to flexion–extension and lateral bending
•Segmental plate fixation may lessen the likelihood of plate dislodgment as witnessed in end construct plate fixation following multilevel cervical corpectomies.

SURGICAL TECHNIC Anterior approach of the cervical spine

SURGICAL TECHNIC
•FIDE preferance of the surgeon (Dominance)
•Location of the recurrent (left)
•Manual Retractor •Cloward Retractor (Longus Colli)
•PROCEED WITH
•CLOWARD OR SMITH
•Microdiscoidectomy MULTILEVEL, osteophytes
•Interbody Caspar Distractor
•IMPLANT

        

INCISION AND POSITION

ANATOMY

MANUAL RETRACTION 

                                          

EXPOSURE AND RETRACTION

DISCECTOMY AND REMOVE OSTEOPHITES

PARCIAL CORPECTOMY AND DISCECTOMY

DECOMPRESSION

REVISION

 

DECOMPRESSION OF MEDULLA REMOVE LIGAMENT IF NECESSAR

GRAFT

GRAFT

 

       

Intraoperative X-Ray

PLATING

CORPECTOMY + PLATING

MICROSCOPE DURING ALL THE PROCEDURE

GRAFT CT CONTROL

COMPLICATIONS OF VENTRAL APROACH
• Tang and Rao, Semin Spine Surg 21:148-155 2009
• Mummaneni et al, Neurosurgery 60[Suppl 1]:S-82–S-89, 2007
• Flynn et al: 82,114 cases Spine 7:536-539, 1982
• Fountas et al:1,015 cases Spine 32:2310-2317,200

NON NEUROLOGIC COMPLICATIONS VENTRAL CERVICAL APPROACH Complication DONOR SITE ILIAC CREST 5 - 20% DISPHAGIA 5,6 - 9,5% POSTOPERATIVE HEMATOMA 5,6% TRANSIENT SORE THROAT 4,8 – 5,2% ESOPHAGEAL PERFORATION 0,3 - 0,43% SUPERFICIAL WOUND INFECTION 0,1%

NEUROLOGIC COMPLICATIONS VENTRAL CERVICAL APPROACH Complication SYMPTOMATIC RECURRENT LARYNGEAL NERVE PALSY 7,9 – 3,1% RLNP DIAGNOSTICATED BY LARINGOSCOPE POP 24,2% VERTEBRAL ARTERY INJURY 0,5% WORSENING PREEXISTING MYELOPHATY 0,2 - 3% RADICULOPATHY DE NOVO 0,19% MYELOPATHY DE NOVO 0,1% DURAL TEAR 0,15% HORNER´S SYNDROME 0,1 %

BIOMECHANICAL COMPLICATIONS VENTRAL CERVICAL APPROACH Complication INSTRUMENTACION BACK OUT O,1% GRAFT EXTRUSION 1,7% NON UNION ¿ - 52% ?% SUBSIDENCE ??%

ANGULATION OR COLAPS
•LOSS OF HIGH
•ANGULATION
•ASYMPTOMATIC

COMPLICATIONS RELATED TO ANESTHESIA AND POSITIONING AND AVOIDANCE

RANGE OF COMPLICATION: TRACHEOBRONQUIAL LACERATION DUE TO INTUBATION AVOIDANCE: SIZE OF ENDOTRACHEAL TUBE . DURATION OF SURGERY

RANGE OF COMPLICATION: HIPOTENSION AVOIDANCE: KEEP 80 –100 mm Hg SYSTOLIC

RANGE OF COMPLICATION: HIPEREXTENSION OF THE NECK : CORD COMPRESSION AND WORSENING MIELOPATHY IN SEVERE STENOSIS AVOIDANCE: DETERMINE RANGE OF MOTION PREOP WITHOUT NEUROLOGICAL SYMPTOMS NECK IN MILD EXTENSION AND ROTACION

RANGE OF COMPLICATION:EXTREME ROTATION OF THE NECK: VERTEBRAL OR CAROTID ARTERY FLOW OCLUSSION AVOIDANCE: MILD ROTATION ANESTHESIOLOGIST CHEK TEMPORAL ARTERY PULSE PERIODICAL
RANGE OF COMPLICATION: PERIPHERAL NERVE INJURY: NEURAPRAXIA , ULNAR, BRACHIAL PLEXUS, MEDIAN NERVE
AVOIDANCE: RISK FACTORS: OBESITY , COMORBIDITY (DIABETES , MIELOMALACIA) APPROPIATE PADDING , AVOID EXCESIVE TRACTION. ELECTROPHISIOLOGIC MONITORING

RANGE OF MOTION

MRI

POSTOPERATIVE HEMATOMA AND AIRWAY OBSTRUCTION COMPLICATION:AIRWAY OBSTRUCTION INMEDIATE POSTOPERATIVE PERIOD
ETIOLOGY: INCISIONAL HEMATOMA
MAGNAGEMENT AND AVOIDANCE :
•REMOVE SKIN SUTURES AT THE BEDSIDE
•REINTUBATION OR TRACHEOSTOMY
•REVISION OF INCISION AT THE OPERATING ROOM
COMPLICATION: AIRWAY OBSTRUCION 24-48 H POSTOPERATIVE
ETIOLOGY: PHARINGEAL EDEMA :
•SURGERY + 5H •+ 3 LEVELS (C2-C3-C4)
•BLOOD LOSS + 300 ml.
•DISLOGEDMENT OF GRAFT OR PLATE
MAGNAGEMENT AND AVOIDANCE:
•TIMELY RECOGNITION
•CAREFUL MONITORING
•OCASSIONALY REINTUBATION OR TRACHEOSTOMY
•CONSIDER CORTICOSTEROIDS
•CONSIDER DIURETICS

RECURRENT LARINGEAL NERVE INJURY
•SOME AUTORS PREFER LEFT SIDE BELOW C4
•BREUTER NO CORRELATION WITH SIDE OF OPERATION MORE RELATED TO PROCEDURE •DISCECTOMY (2,5%)
•PLATING (3%) •CORPECTOMY (3,5%)
•REVISION SURGERY (9,5%)

RECURRENT LARINGEALNERVE INJURY
•HOARSENNES
•VOCAL FATIGUE
•PERSISTENT COUGH
•ASPIRATION
•DISPHAGIA
•AIRWAY OBSTRUCTION
•COMPENSATION WITH OTHER SIDE
•AVOID BILATERAL APPROACH

DISPHAGIA
•DIMINISHED WITH TIME 50,2% (1 M) 32,2% (2 M) 17,8% (6 M) 12,5% (12 M)
•RELATED TO EXTENSIVE SURGERY (+ 3 LEVELS)
•IF PERSISTENT REMOVE PLATE
•BMP2 ?

ESOPHAGEAL INJURY
•RARE AND POTENTIALLY FATAL
•22/10,000 CERVICAL SPINE RESEARCH SOCIETY IN 1987
•TIME TO PRESENTATION :INTRAOPERATIVE TO 11 YEARS
•CAUSES: DIFFICULT SURGERY EXPOSURE, RETRACION, PROMINENT OR MIGRATED HARDWARE
•SYMPTOMS: NECK OR TROAT PAIN, ODINOPHAGIA, DYSPHAGIA. CERVICAL ABSCESS INCISIONAL DRAINAGE, SUBCUTANEOUS AIR, MEDIASTINITIS, MENINGITIS, UNEXPLAINED FEVER
•X RAYS : AIR AROUND THE GRAFT , PLATE OR SCREWS
•ESOPHAGOSCOPE OR CT WITH CONTRAST
•MANAGEMENT IF DETECTED AT THE TIME OF SURGERY : REOPERATION
•DELAY IN TREATMENT RESULTS IN HIGH MORBIDITY AND POTENTIALLY MORTALITY

SPINAL CORD INJURY
CAUSES: INADVERTENT MECHANICAL INJURY OR INDIRECT FOR POSITIONING
•BEST PROFILAXIS : CONSTANT ATENTION TO THE RISK
•MORE LIKELY TO OCCUR DURING REMOVAL OF POSTERIOR LONGITUDINAL LIGAMENT AND OSTEOPHYTES
•INTRAOPERATIVE SOMATOSENSORY EVOKED POTENTIAL AND TRANSCRANIAL MOTOR EVOKED POTENTIAL
•IF DETECTED MRI AND CT : SURGERY BASED ON FINDINGS
•INTRAVENOUS STEROIDS NO CLEAR EVIDENCE

NERVE ROOT INJRUY •Inadvertent injury to the nerve root during surgery or nerve root traction caused by shifting of the cord after decompression surgery •Most recovery 100% after 12 months •Phisical and Occupational therapy

VERTEBRAL ARTERY INJURY •Courses through foramen transversario of C2 to C6 •Incidence : 0,5% •Causes : Excesivelly wide decompression, Unrecognized anomalies in the course of the vessel, Loss of orientation to the midline •Prevention is the key : Preoperative evaluation of the artery foramen

KEEP THE MIDLINE

VERTEBRAL ARTERY

VERTEBRAL ARTERY INJURY MANAGEMENT
•Tamponade with a finger or hemostatic packing.
•Direct repair challenging, but possible
•Derotate the Head to the neutral position
•Endovascular treatment , clipping or ligation shoul be considere

SYMPATETHIC TRUNK INJURY
INCIDENCE : 0,1% – 4%
•Horner´s Syndrome •Spontaneous recovery 6 – 12 months
•The sympathetic trunk and its ganglia lay anterior to the bellies of the longus colli and capitis muscles, closer to the medial border of the musculature at C6 than at C3.5
•Prevention: Dissection superficial to the longus muscle should be minimized. Retractors always under the Longus. Avoid excesive retraction

THORACIC DUCT INJURY
•FINDINGS: chylomediastinum or a chylous pleural effusion
•RISK : Left sided approach C7-T1

Case Presentation

                                         

Postoperative