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779

Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
P AUL T ORNETTA III
EDITOR, VOL. 61

C OMMITTEE
P AUL T ORNETTA III
CHAIR
K ENNETH A. E GOL
M ARY I. O’C ONNOR
M ARK P AGNANO
R OBERT A. H ART

E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of


Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
in February 2012 in Instructional Course Lectures, Volume 61.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
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Advanced Techniques in
Cervical Spine Surgery
By Wellington K. Hsu, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Disorders of the cervical spine can lead demonstrated a high rate of anatomic by removing a portion of the superior
to compression of neural elements and variability and the importance of pre- articular facet. This procedure allows the
cause myelopathy, radiculopathy, or a operative imaging and planning before nerve root to be mobilized, increasing
combination of these conditions. Spinal surgery1-3. These studies have also es- the space between it and the disc. In
cord or nerve root compression can tablished reliable guidelines for screw many patients with foraminal disc her-
be caused by a soft herniated nucleus placement to avoid critical vascular, niation, a partial pediculectomy and
pulposus, osteophyte formation, facet neurologic, and visceral structures gentle retraction of the nerve root can
joint hypertrophy, and/or congenital during cervical spine instrumentation. aid in the discectomy, particularly when
abnormalities of the cervical spine. If Awareness of these principles is essen- there is soft disc pathology rather than a
nonoperative treatment fails, surgical tial to avoid complications and provide disc-osteophyte complex, which is dif-
treatment can often lead to excellent excellent outcomes. ficult to remove posteriorly. A preoper-
long-term clinical outcomes. The sur- ative computed tomography (CT) scan
gical treatment of these disorders de- Posterior Cervical Decompression is helpful in determining the etiology of
pends on patient preference, clinical Foraminotomy the foraminal compression. Posterior
findings, and the evidence-based litera- The foramina are bordered superiorly foraminotomies are contraindicated for
ture. In the properly selected patient, and inferiorly by the respective pedicles, centrally located disc herniations, cen-
posterior cervical decompression for the anteriorly by the disc and uncovertebral tral spinal canal stenosis, and ossifica-
treatment of radiculopathy provides joint, and posteriorly by the superior tion of the posterior longitudinal
potential advantages, including preser- articular facet. The average dimensions ligament.
vation of neck motion, avoidance of of a cervical foramen are 9 to 12 mm A posterior foraminotomy can be
complications from anterior surgery, in height and 4 to 6 mm in width4. These performed with the patient in either a
and fewer postoperative restrictions. foramina are oriented at an angle of sitting or a prone position. The sitting
A posterior fusion is indicated for 45 from the midsagittal plane. Conse- position decreases the incidence of
conditions involving an unstable, ky- quently, patients are more susceptible intraoperative bleeding. It carries a the-
photic, or severely spondylotic cervical to foraminal narrowing in the anterior- oretical risk of air embolism, but this
spine. Advances in the understanding posterior plane. position has been used in hundreds of
of cervical spine anatomy have greatly Patients with radiculopathy from cases without that complication5. When
enhanced the surgeon’s options for nerve root compression in the foramina the prone position is utilized, Mayfield
osseous fixation to achieve fusion. (Fig. 1) can benefit from a foraminot- or Gardner-Wells tongs are used to
Cadaveric and imaging studies have omy, which decompresses the nerve root stabilize the head. Both arthroscopic and

Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of
his immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits
from commercial entities (Stryker, Inc., and Pioneer Surgical, Inc.)

J Bone Joint Surg Am. 2011;93:780-8


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approaches for radiculopathy may be


associated with complications, includ-
ing recurrent laryngeal nerve palsy,
dysphagia, dysphonia, and adjacent-
segment degeneration. The incidence of
symptomatic adjacent-segment degen-
eration after anterior cervical discec-
tomy and fusion is 2.9% per year (26%
in a group of patients seen at ten years
postoperatively)9. Posterior foraminot-
omy avoids the complications of ante-
rior surgery and may also reduce the risk
of adjacent-segment degeneration post-
operatively. In a study of 303 patients
followed for an average of 7.2 years after
a single-level posterior foraminotomy,
4.9% developed symptomatic adjacent-
segment degeneration10. The ten-year
rate of adjacent-segment degeneration
Fig. 1 was calculated to be 6.7%. Furthermore,
Axial cross-sectional view of a cadaveric upper cervical spine with facet joint arthrosis (F) and unlike anterior fusion, posterior de-
uncovertebral hypertrophy (VB), causing encroachment on the exiting nerve root (N). VA = vertebral compression maintains cervical spine
artery. (Reprinted, with permission, from: Papadopoulos SM, editor. Manual of cervical spine motion. In patients with multilevel
internal fixation. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2004.) pathological involvement, a posterior
approach can lead to outcomes that
microscopic techniques have been lateral to the pedicle to ensure a com- are comparable with those of the ante-
described to aid visualization during plete decompression. rior approach without limiting neck
this procedure. After a preoperative When a soft disc herniation is motion6.
localization radiograph identifies the present, a partial pediculectomy is done Some authors have suggested that
cervical spine location, an incision is to minimize nerve root retraction. Once a C5 foraminotomy with a decompres-
made 1.5 cm off of the midline at the the medial third of the pedicle is re- sive procedure, such as a laminoplasty,
appropriate level. Sharp dissection is moved with an oscillating burr, the would lead to a decreased incidence of
then performed through the fascia, traversing nerve root can be gently C5 nerve root palsy. Patients with this
with either a self-retaining McCullough mobilized with a nerve hook to expose complication can have severe deltoid
retractor or a tube retractor docked the disc fragment. Since this space is weakness, preventing them from per-
onto the lateral mass and the facet joint. quite limited, an arthroscopic grabber or forming some activities of daily living.
A localizing lateral radiograph is ob- micro-pituitary rongeur from a tympa- Although the exact cause of C5 nerve
tained to confirm the cervical spine noplasty set can facilitate free disc frag- root palsy is unclear, many authors have
level. ment removal. suggested an ischemic etiology from
The medial third of the facet joint Posterior foraminotomies provide nerve root stretch after decompression.
is identified, and the overlying inferior excellent clinical outcomes when used No treatment modalities have been
articular facet is then removed (at the C5 for the treatment of cervical radicu- successful in improving the outcome if
level for a C6 foraminotomy) with a lopathy5,6. Of 736 patients with a iatrogenic C5 nerve root palsy occurs,
high-speed oscillating burr (Fig. 2). The ‘‘posterior-lateral foraminotomy,’’ 91.5% but most patients regain functional
superior articular facet is well visualized were reported to have a good or excellent deltoid strength within six to nine
and is removed to unroof the foramen result at an average of 2.8 years postop- months after surgery11. Even though a
and expose the traversing nerve root. An eratively 5, a finding that has been sup- posterior foraminotomy would theo-
oscillating burr, micro-Kerrison ron- ported by other reports7,8. Factors that retically decrease nerve root tension
geurs, and angled curets are used to contribute to worsening sagittal align- after posterior drift of the spinal cord, it
remove up to the medial 50% of the ment after posterior foraminotomy is unclear whether this would decrease
facet joint. To ensure adequate decom- include an age over sixty years and the incidence of this difficult postoper-
pression once the nerve root is exposed, preoperative cervical lordosis of <107. ative complication.
a nerve hook can be utilized to carefully A posterior cervical foraminot-
palpate the caudad pedicle (at the C6 omy provides a number of advantages Laminectomy
level for a C6 foraminotomy) (Fig. 2, D). over anterior approaches in properly Posterior cervical laminectomy has pri-
The procedure must be carried out selected patients. Anterior surgical marily been used to treat central cervical
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Fig. 2
Posterior foraminotomy procedure. After the medial third of the corresponding facet joint is identified, the
inferior articular facet is removed with either micro-Kerrison rongeurs (A) or an oscillating burr (B) to expose the
overlying superior facet. Decompression of the facet is continued to the level of the nerve root (C). A nerve hook
can be used to palpate the pedicle inferiorly and ensure adequate lateral decompression (D). (Reprinted, with
permission, from: An HS, Xu R. Posterior cervical spine procedure. In: An HS, Riley LH 3rd, editors. An atlas of
surgery of the spine. 1st ed. London: Martin Dunitz; 1998.)

spine stenosis caused by spondylosis, ina removal is done with symmetric rigidity and result in higher fusion rates
neoplastic conditions, or ossification upward traction with use of a towel than spinous process wiring12.
of the posterior longitudinal ligament. clamp at both ends of the decompres-
Preoperative positioning is similar to sion (Fig. 3, B). Care must be taken to Subaxial Cervical Spine
that for a foraminotomy, but a more avoid rotation of the fragments and A number of techniques for subaxial
extensive soft-tissue dissection is re- subsequent impingement on the cervical screw fixation of the lateral mass have
quired to expose the posterior cervical cord. Remaining ligamentum flavum been described. First described in
spine. attachments to the lamina during this 197913, the Roy-Camille technique uti-
Bilateral exposure of the lamina- part of the procedure can be removed lizes a starting point at the midpoint of
lateral mass junction is required for a with a Kerrison rongeur. the lateral mass. With use of the neutral
full laminectomy. One of several tech- alignment of the cervical spine (plumb
niques that have been described is use of Posterior Cervical Fusion line), the screw trajectory is perpen-
a high-speed oscillating burr to remove Posterior fusion is indicated for cervical dicular in the superior-inferior plane
this osseous bridge bilaterally (Fig. 3, spine instability resulting from trau- with a 10 lateral orientation (Fig. 4).
A). After removal of the outer osseous matic, iatrogenic, or degenerative causes; The primary risk with this technique is
cortex, the burr tip can be switched to an pseudarthrosis after a prior arthrodesis; a breach of the facet joint in the area of
extra-rough diamond-tip drill bit to or multilevel anterior procedures re- both the vertebral artery and the nerve
avoid catching soft tissue and dural quiring enhanced fixation. Surgeons can root (Fig. 5). The Magerl (transarticular
tears. Excision of the ligamentum fla- choose between wiring and screw fixa- screw) technique14 utilizes a starting
vum is performed both cephalad and tion techniques. Recent studies have point just medial and superior to that
caudad to the laminectomy sites. Lam- shown screw constructs to have greater used with the Roy-Camille procedure
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length drill guide is used to optimize screw


lengths at each cervical level. Advance-
ment of drilling in 2-mm increments
ensures the strongest bone purchase
without violation of the traversing nerve
root. This screw trajectory appears to be
the most reliable for avoiding critical
neurovascular structures.
Stemper et al. demonstrated the
variations in the anatomy of the subaxial
cervical lateral mass in an in vivo CT
study of the cervical spine16. Bicortical
screw paths created with use of the
Roy-Camille and Magerl techniques
were drawn on sagittal CT images of
ninety-eight asymptomatic volunteers.
Standard open posterior cervical laminectomy.
Although there was a moderate amount
After adequate soft-tissue exposure of the
of variation in screw lengths, no corre-
lamina-lateral mass junction bilaterally, a high-
lation was found between screw length
speed oscillating burr can be used to separate and stature, body weight, or neck length.
this junction (A). Once the inner cortical bone is At C3-C6, Magerl screw trajectories were,
adequately separated on each side, symmetric on average, at least 2 mm longer than
traction is necessary to safely remove the bone Roy-Camille screw trajectories. The
from the underlying cervical cord (B). Final in- screw lengths were the shortest (aver-
spection of the laminectomy site should dem- age, 9.8 mm in males and 8.5 mm in
onstrate retention of the facet joint capsules females) at the C7 lateral mass.
and wide exposure of the cervical dura (C).
(Reprinted, with permission, from: Cooper PR, Atlantoaxial Junction
Ratliff JK. Cervical laminectomy. In: Herkowitz Atlantoaxial fusions are indicated for
HN, editor. The cervical spine surgery atlas. 2nd patients showing >5 mm of instability
ed. Philadelphia: Lippincott Williams & Wilkins; on flexion-extension views; those with
2003.) severe cervical cord compression; and
those with traumatic injuries, such as
a Jefferson or unstable hangman frac-
ture. Historically, the use of sublaminar
wiring alone to stabilize this junction
with the modified Gallie17 or Brooks18
technique has led to acceptable clinical
outcomes, but the development of safe
and efficient protocols with lateral mass
and pedicle screw fixation in the upper
cervical spine has increased fusion rates
and often obviates the need for halo
vest immobilization postoperatively.
Patients with concomitant subaxial
cervical fracture or osteoporotic bone
Fig. 3 leading to poor bone purchase may
require a halo postoperatively, but the
and orients the screw in a cephalad techniques if they are not performed potential for complications with halo
angle of 30 and a laterally directed properly. use must be carefully considered, es-
angle of 25 (Fig. 4). A broad or Anderson et al. modified the pecially in elderly patients12.
prominent spinous process can inter- lateral-mass screw technique by using a The Magerl technique utilizes a
fere with the screw trajectory with the starting point slightly medial to the mid- cancellous screw that crosses the C1-
Magerl technique, which may increase point of the lateral mass and a 35 to 40 C2 facet joint (Fig. 6). Percutaneous
the risk of lateral screw cutout. There is superior and 10 lateral orientation15. I starting points are made as caudad
a risk of nerve root injury with both prefer this method, in which a variable- as T1 to obtain the proper angle for
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Fig. 4
Cervical lateral mass fixation with use of either a Magerl or a Roy-Camille technique. While both techniques utilize a starting
point at the midpoint of the lateral mass in both the cephalad-caudad and the medial-lateral plane, the Magerl screw is
inserted in a 30 superior and 25 lateral orientation. The Roy-Camille screw takes a more perpendicular trajectory (0) and
10 lateral approach. (Reprinted, with permission, from: Stemper BD, Marawar SV, Yoganandan N, Shender BS, Rao RD.
Quantitative anatomy of subaxial cervical lateral mass: an analysis of safe screw lengths for Roy-Camille and Magerl
techniques. Spine [Phila Pa 1976]. 2008;33(8):893-7.)

adequate fixation. Biplanar fluoroscopy greater insertional torque and pullout screw size is 3.5 · 28 mm. With this
is often required to identify the correct strength than either laminar or pars procedure, the surgeon should try not
trajectory of 0 in the medial-lateral interarticularis screws in cadaveric to violate the C2-C3 interspinous
plane and 45 in the cephalad-caudad spines20. The C2 pedicle screw is in- space, and to leave as many muscle
plane. With a starting point in the serted with a starting point that is just attachments as possible to reduce
inferomedial quadrant of the C2 lateral superior and medial to the center of the postoperative pain and increase sta-
mass, the trajectory is aimed toward the lateral mass (Fig. 7). A small laminot- bility. Any bleeding from the venous
anterior tubercle of C1 on a lateral omy and palpation with a nerve hook plexus between C1 and C2 should be
fluoroscopy view. Either cannulated or can often assist with the medial-lateral controlled with FloSeal Hemostatic
noncannulated screws can be used, but orientation (10), while lateral fluo- Matrix (Baxter Healthcare, Fremont,
the placement and control of the initial roscopy can guide the cephalad-caudad California); cottonoids; or a combina-
Kirschner wire can be challenging. One direction (15). The C1 entry point is tion of Avitene (microfibrillar collagen)
advantage of this technique is that a identified at the junction of the lateral (Devol, Warwick, Rhode Island), Gel-
standard set of fracture repair screws is mass and the inferior aspect of the foam (Upjohn, Kalamazoo, Michigan),
sufficient for adequate fixation. A pre- posterior arch (Fig. 7). Often, the and thrombin.
operative CT scan of the cervical spine overhang of the C1 arch should be Although the C1 lateral mass
is required to track the course of the removed with an oscillating burr at the screw is ideally placed with bicortical
vascular structures at this level. The level of the lateral mass in order to purchase, anterior structures such as
presence of an anomalous vertebral identify the landmarks and provide the internal carotid artery must be
artery precludes the use of this screw. room for the screw head. A Penfield avoided. In a study of 149 CT recon-
The Harms technique utilizes retractor can be used to palpate the struction images of the cervical spine,
axial pedicle or pars interarticularis medial aspect of C1 to guide a 10 Murakami et al. defined the variation of
and atlas lateral mass screws19. Pedicle medial and 20 cephalad trajectory. the anatomy of the internal carotid
screws have been found to have a The most commonly used titanium artery anterior to the C1 anterior arch21.
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with the proper entry point can avoid


injury to the internal carotid artery. This
ideal trajectory was confirmed with an
anatomic study of atlas specimens that
demonstrated less variability in C1 lat-
eral mass measurements compared with
those of other levels22.
When it is not possible to use C2
pedicle or pars interarticularis screws
because of anatomic variations, lami-
nar fixation can be considered. With an
entry point 5 mm lateral to the mid-
line of the spinous process and 6 mm
caudad to the cranial border of the
lamina, a 3.5 · 26-mm screw can often
be inserted2 (Fig. 8). In a biomechanical
analysis of C1 lateral mass-C2 pedicle
screw fixation, C1 lateral mass-C2
intralaminar screw fixation, and C1-C2
Fig. 5
sublaminar wire fixation techniques,
Sagittal cross section of a cadaveric specimen of a lateral mass (LM) in a man operated on with Elgafy et al. demonstrated that all three
3.5-mm cancellous screws when he was seventy-two years old. The lateral mass screw (S) is seen instrumentation systems were equally
violating the inferior articular process of C5 with its tip just short of the vertebral artery (VA) in
stable in flexion-extension and lateral
between the C5 nerve root and C6 ganglion. F = facet joint. (Reprinted, with permission, from:
bending23. While both screw constructs
were superior to the wiring technique in
Papadopoulos SM, editor. Manual of cervical spine internal fixation. 1st ed. Philadelphia:
axial rotation, there were no significant
Lippincott Williams & Wilkins; 2004.)
differences between the lateral mass-
In 64% of patients, the internal carotid cases, it was over the lateral third. The intralaminar and lateral mass-pedicle
artery was directly anterior to the mid- authors concluded that a 10 medial constructs in flexion-extension. In an
dle of the C1 lateral mass, and in 55% of orientation of the C1 lateral mass screw anatomic study of the axis in an Asian

Fig. 6
Transarticular screw fixation at C1-C2. The entry point for the transarticular screw is located in the inferomedial quadrant
of the lateral mass (B) with a neutral trajectory in the medial-lateral plane (A). Identification of the vertebral artery and the
C2 nerve root can aid in the drilling of this screw (B). (Reprinted, with permission of Elsevier, from: Feiz-Erfan I,
Klopfenstein JD, Vougioukas VI, Dickman CA. Surgical therapy for fractures and dislocations of the craniocervical
junction and upper cervical spine. In: Kim DH, Henn JS, Vaccaro AR, Dickman CA, editors. Surgical anatomy &
techniques to the spine. New York: Elsevier; 2006.)
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Fig. 7
C1-C2 fixation with use of the Harms technique. The entry point for the C2 pedicle screw is the superomedial quadrant of
the lateral mass (A) directed in a 15 cephalad and 10 medial trajectory. The C1 lateral mass screw is started in the
midpoint of the lateral mass just below the arch and oriented in a 10 medial direction for bicortical purchase (B).
(Reprinted, with permission, from: Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation.
Spine [Phila Pa 1976]. 2001;26(22):2467-71.)

population, Ma et al. demonstrated that Occipital-Cervical Junction instrumentation. The external occipi-
83% of patients had anatomic parame- Posterior fixation for occipital-cervical tal protuberance is a palpable uprising
ters that allowed for a 3.5-mm screw, fusion is required for clinical conditions that marks the thickest portion of the
while only a unilateral screw was suit- such as atlanto-occipital dissociation/ bone (Fig. 9, A). The superior and
able in 12% of cases2. In 5% of the cases instability or basilar invagination. Depend- inferior nuchal lines are ridges that
examined, the laminae were too thin ing on the associated condition, a decom- extend in the medial-lateral direction
to accommodate screws on either side. pression of the opisthion (the hindmost from the external occipital protuber-
This and other studies highlight the point on the posterior margin of the ance. The path from the external
importance of preoperative CT planning foramen magnum) may be needed as well. occipital protuberance to the foramen
when either C2 pedicle or C2 laminar It is important to identify a magnum marks a sharp anterior trajec-
screws are considered. number of landmarks prior to formal tory that can make plate contouring a
substantial challenge. All screw fixation
should be caudad to the external occip-
ital protuberance to ensure good bone
quality and adequate soft-tissue cover-
age. At the external occipital protu-
berance, 12 to 18-mm-thick bone is
expected. However, the identification of
this point is important since a starting
point just 1 cm lateral and inferior to
it provides only 5 to 7 mm of bone
thickness. Although some authors have
advocated bicortical screw purchase,
unicortical screws at the external oc-
cipital protuberance provide adequate
pullout strength as the inner table has
only 10% of the overall thickness. A
wide array of occipital-cervical plate-
Fig. 8 screw constructs that allow contouring
Entry points for C2 laminar screws. (Reprinted, with permission, from: Ma and flexibility in this articulation are
XY, Yin QS, Wu ZH, Xia H, Riew KD, Liu JF. C2 anatomy and dimensions available. Regardless of the instrumen-
relative to translaminar screw placement in an Asian population. Spine tation system, the construct should
[Phila Pa 1976]. 2010;35(6):704-8.) allow adequate soft-tissue coverage,
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Fig. 9
Occipital-cervical fixation. The identification of anatomic landmarks (A) is essential to providing the optimum screw fixation in the occiput. Instru-
mentation systems should provide for screws in the midline of the occiput and a plate-rod interface that is secure and can be contoured to fit the skull (B
and C). (Fig. 9, A, reprinted, with permission, from: Herkowitz HN, editor. The cervical spine surgery atlas. 2nd ed. Philadelphia: Lippincott Williams &
Wilkins; 2003.)

avoid hardware prominence, and pro- tomy site can provide an osteoinductive involvement, and patient preference.
vide a stable plate-to-screw interface stimulus necessary for bone-healing Recent advances in spine surgeons’ un-
to avoid postoperative complications in this environment24. Bone graft ex- derstanding of anatomy and technique
(Fig. 9). tenders such as ceramic scaffolds, used have increased their level of comfort
in conjunction with local bone graft, with using instrumentation in the upper
Bone Graft also can increase osseous healing, and and subaxial cervical spine. Further-
The choice of bone graft to be used in this is the method that I prefer. The more, the use of concomitant minimally
conjunction with posterior cervical use of bone morphogenetic protein invasive techniques with these proce-
fusion depends on a number of factors, (BMP) has led to high fusion rates in dures leads to faster recovery times with
including fusion rates, the volume the posterior cervical spine, but its use equivalent outcomes. Awareness of the
required, complications, comorbid- may lead to wound complications and strengths and limitations of posterior
ities, and cost. Historically, structural local seroma formation25. At the pres- cervical techniques can greatly enhance
and cancellous autologous iliac crest ent time, use of BMP in this surgical the surgeon’s ability to achieve excellent
bone-grafting has been successfully setting has not been approved by the clinical outcomes.
utilized in Brooks and Gallie as well Food and Drug Administration in the
as subaxial fusion constructs. Because United States. The complications ap-
the posterior cervical spine is a more pear to be linked to the dose of growth
favorable biologic milieu for bone- factor utilized.
healing than is the posterior lumbar Wellington K. Hsu, MD
spine, iliac crest bone-grafting can Overview Departments of Orthopaedic Surgery and
Neurological Surgery, Feinberg School
often be avoided. Just as important as In properly selected patients, posterior of Medicine, Northwestern University,
the bone graft choice is the preparation cervical decompression and fusion can 676 North St. Clair Street, Suite 1350,
of the fusion surfaces, which should successfully treat cervical myelopathy Chicago, IL 60611.
include a subtotal facetectomy in the and radiculopathy. The choice of a E-mail address: whsu@nmff.org
subaxial spine and thorough prepara- posterior approach versus an anterior
tion of the lamina, facet joint, and approach depends on a number of Printed with permission of the American
occiput surfaces in the upper cervical factors, including sagittal alignment, the Academy of Orthopaedic Surgeons. This
spine. Local bone graft from a laminec- type and extent of the pathological article, as well as other lectures presented at
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the Academy’s Annual Meeting, will be Course Lectures, Volume 61. The complete www.aaos.org, or by calling 800-626-6726
available in February 2012 in Instructional volume can be ordered online at (8 A.M.-5 P.M., Central time).

References
1. Liu J, Napolitano JT, Ebraheim NA. Systematic 9. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, 18. Brooks AL, Jenkins EB. Atlanto-axial arthrodesis
review of cervical pedicle dimensions and projections. Bohlman HH. Radiculopathy and myelopathy at seg- by the wedge compression method. J Bone Joint Surg
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