Journal of Neurosurgery: Spine Preview for October 2000: Single-Stage Anterior-Posterior Decompression and Stabilization for Complex Cervical Spine Disorders

Karl D. Schultz, Jr., M.D., Mark R. Mclaughlin, M.D., Regis W. Haid, Jr., M.D., Christopher H. Comey, M.D., Gerald E. Rodts, Jr., M.D., Joseph Alexander, M.D., Department of Neurosurgery, The Emory Clinic, Atlanta, Georgia; Neurosurgical and Neurological Group, Inc., Springfield, Massachusetts; and Mayo Clinic Jacksonville, Jacksonville, Florida

Neurosurg Focus. 2000;9(2) 

In This Article

Abstract and Introduction

Object. To evaluate the applicability and safety of single-stage combined anterior-posterior decompression and fusion for complex cervical spine disorders, the authors retrospectively reviewed 72 consecutive procedures of this type performed at their respective institutions.
Methods. The indications for decompression and stabilization included: postlaminectomy kyphosis (15 patients), trauma (19 patients), spondylosis and congenital stenosis (32 patients), and ossification of the posterior longitudinal ligament (six patients). All patients underwent anterior cervical corpectomies in which allograft fibula and plates were placed, with 89% of patients undergoing two- or three-level procedures (range one-four levels). Lateral mass plating with autograft (morselized iliac crest) fusion was performed in all patients while the same anesthetic agent was still in effect. A hard cervical collar was used postoperatively in all patients (mean 13 weeks). All patients were followed for a minimum of 2 years (mean 29 months).
Fusion was determined to be successful in all 72 patients (100%). Although the short-term morbidity rate reached 32%, the significant long-term morbidity rate was only 5%. At the 2-year follow-up examination, anterior cervical plate dislodgment was seen in one patient, and 16 of the 516 lateral mass screws implanted were observed to have partially backed out. However, there were no cases of nerve root injury, strut graft extrusion, or anterior plate or screw fracture. There were no clinically significant hardware complications and no patient required repeated operation.
Conclusions. The combined single-stage anterior-posterior decompression, reconstruction, and instrumentation procedure represents a viable option in the treatment of a select group of patients with complex cervical spinal disorders. The technique provides immediate rigid stabilization of the cervical spine, prevents anterior plate failure or strut graft extrusion, and eliminates the need for halo immobilization postoperatively. Furthermore, a higher rate of fusion is achieved with this combined approach than with the anterior approach alone.

During the past decade there has been a growing interest in the management of complex cervical spine disorders. A better understanding of the biomechanics involved in both normal and pathological conditions of the cervical spine,[2,13,34] as well as the introduction and successful application of innovative spinal instrumentation,[1,4,28,31,35,40,44,51] have paved the way for an aggressive surgical approach to these disorders. The purpose of this study was to evaluate the applicability, safety, and radiographically observed efficacy of a combined single-stage anterior-posterior approach involving decompression, reconstruction, and stabilization procedures in select patients suffering from complex cervical spine disorders.

Controversy continues to surround the most effective method for decompression, reconstruction, and stabilization of complex cervical spine disorders such as traumatic instability, postlaminectomy kyphosis, multilevel spondylosis, and OPLL. Although it is becoming increasingly clear that anterior plating for single-level corpectomies enhances arthrodesis and diminishes graft extrusion,[7,22,24,28,47,56] the effectiveness of anterior plating in decreasing graft dislodgment or promoting fusion in multilevel corpectomies is less clear.[33,45,57] Posterior decompressive approaches without placement of instrumentation are indicated in patients with multisegmental stenosis (for example, congenital or degenerative disease) with preserved lordosis.[16,30,50,57] Decompressive laminectomy with instrumentation is used in the presence of frank instability or loss of lordosis (such as in a straight cervical spine) to prevent late kyphotic deformity (unpublished data, Gropper, et al., 1998).

In the presence of a kyphotic deformity requiring multilevel vertebrectomies, anterior reconstruction with plates and simple (nonhalo) bracing may not be the optimum treatment. When confronted with this clinical picture, a combined anterior-posterior approach may yield a very high fusion rate with few graft- or plate-related complications. In the literature, however, there are few reports of experience with a single-stage combined anterior-posterior approach.[37,38,51] To evaluate its applicability, safety, and efficacy, we reviewed outcomes in 78 patients with complex cervical spinal disorders treated with this combined approach.