With increased choice of implants and gadgets and development of better surgical approaches & techniques, surgery is playing a greater role in management of cervical injuries as compared to earlier times.
Timing of Surgery
There is still controversy about the optimal time to perform surgery, particularly in patients with neurologic deficits. Advocates of early surgery point at the two benefits of earlier surgery
- Neurological recovery
- Improved ability to mobilize the patient without concern of spinal displacement.
Studies have pointed out that surgery performed within first 72 hours to 5 days have better outcome but surgery performed within first 24 hours may not.
But specific and substantial evidence that early surgery produces better neurological recovery is yet to come.
The other school of thought believes that surgery should be delayed to allow for optimal medical stabilization of the patient and resolution of initial spinal cord swelling. This school hypothesizes that early surgery may be potentially detrimental due to spinal cord edmea and it is worthwhile to wait for stabilization of the patient.
Surgery can be done with anterior or posterior approach
Anterior Surgery
Approach
The subaxial spine is reached by the interval plane between the sternocleidomastoid (lateral) and medial muscles.Following options are available with anterior approach
Decompression
This is done by removal of disc [discectomy] or removal of vertebra[corpectomy or vertebrectomy] depending upon the extent of bony injury and comminution and cause of compression as decide preoperatively with help of imaging studies.
Anterior Reduction of Dislocated Facets
If there is additional disc herniation, an anterior discectomy and decompression may be performed before reduction. he dislocation is reduced by maneuvering the dislocated facets by leverage on vertebral body so as to unlock the vertebrae.
A lateral intraoperative x-ray should be obtained to confirm reduction.
If the dislocation is not reducible an additional posterior surgery might be done.
Reconstruction
Reconstruction is done for replacement of the removed vertebra or disc. Autograft or allograft bone can be used to reconstruct the anterior column. Another alternative is insertion of a titanium mesh cage.
Stabilization
Following reconstruction, anterior stabilization should be performed spanning discectomy or corpectomy defects.
Posterior Surgery
Approach
The posterior approach to the cervical spine is a midline extensile approach that can be used to access as many spinal levels as necessary.
Decompression
In the majority of acute, traumatic, injuries, posterior decompression is not necessary.In rare cases of anteriorly displaced posterior arch fragments, a laminectomy would be indicated to directly remove the offending compressive elements.
Reduction Maneuvers
Usually, the primarily goal of posterior surgery for subaxial cervical injuries is reduction or stabilization. Open reduction of dislocated facet joints can be performed using a posterior approach.
Posterior Instrumentation
The options available are wire-based constructs, variable-angle screw-rod constructs.
Posterior Fusion
Cancellous bone harvested from the posterior iliac crest is packed inside curetted the facet joints for the purpose of fusion.
After Care
Rigid internal fixation reduces the for postoperative external immobilization which varies from individual to individual. Prophylactic antibiotics are continued for 48 hours or more if required.
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