| | Anterolateral approaches to the cervical spine: tips and tricksAbstract The most common anterolateral approaches to the cervical spine are the low and high presternocleidomastoid approaches, which allow exposure of all levels of the cervical spine, from the base of the skull to the upper thoracic vertebrae. Proper positioning of the patient is a key point to gain good operative exposure and to prevent the potential complications of excessive pressure on neural or vascular structures. This is an important aspect of cervical spinal surgery, because of the depth and relative inaccessibility of the structures, the required accuracy for the determination of level and the inherent risks of the positions themselves. We describe the common anterolateral approaches to the cervical spine, complications, and some tips and tricks to avoid them. Introduction  The most common anterolateral approaches to the cervical spine are the low and high presternocleidomastoid approaches, which allow exposure of all levels of the cervical spine, from the base of the skull to the upper thoracic vertebrae. The low presternocleidomastoid approach is the most commonly used direct approach to the middle and low cervical spine. The high presternocleidomastoid approach, on the other hand, allows exposure of the high cervical spine all the way up to clivus. For anterolateral approaches to the cervical spine the patient is positioned supine. Proper positioning of the patient is a key point to gain good operative exposure and to prevent the potential complications of excessive pressure on neural or vascular structures. This is an important aspect of cervical spinal surgery, because the structures to be approached are deep and relatively inaccessible leading to difficulties in retraction, determination of level and the inherent risks of the position itself. The head is secured to a head rest, fixing its position with slight extension, but without excessive traction. Traction produces tension in the soft tissues of the neck that is detrimental to the exposure and the dissection. The combination of traction and excessive hyperextension of the head will in turn compact and stretch tissue planes, making dissection more difficult and dangerous because structures will be difficult to identify. A rigid support is essential for the neck. The spinous processes should be well supported by a firm pillow, which assures a good counterbalance to any surgical force applied. It is mandatory to use a nasogastric tube as a marker for the pharynx and oesophagus during dissection. The chin is taped to the table and to the head rest, maintaining the slight extension, which should be barely sufficient to stretch the skin of the neck. The arms should be extended, preferably with a wrist band used to produce sufficient traction to lower the shoulder, thereby permitting comfortable access to the surgical site.1, 2 Any excessive traction to the arms may cause stretching of the roots of the brachial plexus, with a risk of postoperative neuropathy of the brachial plexus. The wrist band is used to attach sufficient traction to arm, but it must also avoid significant compression of the wrist, which may cause median nerve symptoms. In relation to the elbow, a soft pad is required to avoid compressive damage to the ulnar nerve. The gluteal region is supported by a pillow, towel, or sheet and preparations are made for graft harvesting from the iliac crest. The legs are well padded in a position of stability on the surgical table. A reverse-Trendelenburg position is used, with elevation of the head end of the table, to favour venous drainage from the operative site.1, 2 We prefer that the patient is fitted with graduated compression stockings, as this position increases the venous pressure in the lower limbs. Should the patient be in a halo jacket, the ring can be used to manipulate the head into the position of mild hyperextension and can then be attached to the table to maintain this position. Low anterolateral approach In the low anterolateral approach, the skin incision can be either transverse or longitudinal, depending on the extent of required exposure. A transverse incision is prefered when surgery is performed at one or two levels of the cervical spine.1 The longitudinal incision is used for wide and multilevel exposures. We use a modified longitudinal incision in these circumstances, which does not follow the anterior border of the sternocleidomastoid muscle,2 but lies half-way between the mastoid process and the thyroid cartilage. The incision extends distally to the medial border of the sternocleidomastoid muscle at the level of the cricoid cartilage,3 and then follows the anterior border of the sternocleidomastoid muscle to the superior margin of the clavicle. This modification allows wider access to the anterior aspect of the vertebral bodies.4 Following the initial skin incision, bleeding vessels (usually branches of the external jugular vein) can be managed with bipolar diathermy (Figure 1). The platysma is then divided and in the plane deep to platysma, the sternocleidomastoid muscle and the superficial cervical fascia can be easily identified.5 The latter is split along the anterior margin of the sternocleidomastoid and is retracted using a hand-held retractor. Retraction of the sternocleidomastoid muscle exposes the underlying neurovascular bundle, consisting of the vagus nerve, the common carotid artery and the internal jugular vein.1 The omohyoid muscle crosses the field, embedded in the middle cervical fascia. The latter is lifted at the proximal surface of the omohyoid muscle and can be separated by blunt dissection from the underlying tissue all the way down to the distal end of the incision. Sutures are passed through the belly of the omohyoid muscle in its middle portion (Figure 2). Muscle and fascia can be transected with diathermy (Figure 3). These sutures can be used to apply traction to lift the muscle and the middle cervical fascia.6 This allows a wide visualization of the operative field, not obtainable with simple retraction. This facilitates control of possible complications by allowing good exposure and access. At the end of the surgical procedure, the omohyoid muscle is re-sutured. At this point, one of the potential pitfalls is damage to the internal jugular vein at the distal end of the incision. Injuries to the vein are difficult to control because of the tension in the tissues, which tends to retract the vessel out of the operative field, making it more difficult to reach and to ligate.7 The ends of the omohyoid muscle and the cervical fascia, once retracted, expose the neurovascular bundle in the carotid sheath.4 Blunt finger dissection will identify a plane of tissue separation between the neurovascular bundle laterally and the thyroid gland and muscles medially. The retropharyngeal region has now been reached.6 Once this blunt dissection has been completed, the deep cervical fascia is exposed3 and through this the anterior longitudinal ligament and vertebral bodies are visible. The deep cervical fascia and anterior longitudinal ligament are divided by diathermy and the periosteal surface of the vertebral bodies can be peeled off. The dissection can be continued laterally as required, but it is not usually recommended to dissect as far as the transverse processes, in order to avoid damage to the cervical sympathetic chain.1 To avoid injuries to the soft tissues of the neck, a self-retaining retractor should be applied only to the anterior longitudinal ligament, when it is present, and its arms should not include or apply any pressure to nerves or other soft tissues of the neck. In the degenerative cervical spine the anterior longitudinal ligament is usually disrupted and ragged, and it can be difficult to apply a retractor. This can also occur in young patients and particularly in inflammatory conditions. At this point, it is necessary to check the cervical levels exposed by fluoroscopy (Figure 4).1 High anterolateral approach In the high anterolateral approach,7 the skin incision starts in the submandibular region, one fingers breadth below the edge of the horizontal ramus of the mandible.6 The incision starts in the submental region and proceeds horizontally towards the mastoid, where it turns distally and medially along the anterior margin of the sternocleidomastoid muscle. In patients in which greater exposure is required, it is possible to perform a T-shaped incision: the first limb lying horizontally and the second, vertical limb, in front of the sternocleidomastoid muscle.1 The platysma is split and retracted. Once the platysma and superficial fascia are divided a nerve stimulator can be used to identify the mandibular branch of the facial nerve (seventh cranial nerve), which should be preserved.8 The mandibular nerve is the first branch of the cervicofacial division of the facial nerve. It passes posterior to the angle of the mandible to supply the muscles of the corner of the mouth and lower lip.1, 5 It is easy to injure this nerve with retractors, because it can become pinched between the retractor and the hard mandibular bone.1, 8 The retromandibular vein is a landmark for identification of the mandibular nerve. In more than 90% of cases it courses above the retromandibular vein within the substance of the parotid gland. In the other 10% it passes medial to the vein. The retromandibular vein is formed by the confluence of the superficial maxillary and temporal veins, descends in the substance of the parotid gland, superficial to the external carotid artery but beneath the facial nerve, and near the angle of the mandible divides into two branches; namely anterior and posterior. The anterior branch unites with the anterior facial vein to form the common facial vein. The posterior branch unites with the posterior auricular vein and becomes the external jugular vein.1 The facial artery, a branch of the external carotid artery, crosses the parotid gland posteriorly and passes over the mandible, always lying under the platysma. To expose the upper levels of the cervical spine it is often necessary to ligate the retromandibular vein adjacent to its junction with the internal jugular vein, the thyrolinguofacial trunk and the superior thyroid artery and vein. We have not encountered functional changes in the thyroid after thyroid vessels ligation.1, 8 Once the lingual and facial vessels have been controlled the posterior belly of the digastric muscle can be identified. The digastric muscle lies below the body of the mandible and extends, in a curved path, from the mastoid process to the symphysis menti. The hypoglossal nerve (12th cranial nerve) crosses the operative field from medial to lateral. It is more superior than the superior laryngeal nerve. Both should be protected by careful dissection and mobilization. The hypoglossal nerve can be retracted superiorly once it is dissected out from its exit site at the skull base to its insertion near the tongue.1, 8 It is rarely necessary to divide the tendons of the digastric and of the stylohyoid muscles to obtain better exposure. Retraction of the digastric muscle is sufficient to expose the prevertebral region. As a part of the final exposure to the operative site, it is sometimes necessary to remove the submandibular gland together with its blood supply and salivary duct.1 When the gland is resected to allow better exposure, the salivary duct must be ligated to prevent fistula formation. Complications Anterolateral approaches to the cervical spine are generally safe, even though many complications with serious life-threatening consequences have been reported.9 Potential complications of this approach include vascular, neurological, soft tissue and visceral complications Vascular injuries Jugular vein: The jugular vein may lie behind the sternocleidomastoid muscle and can therefore be difficult to visualize and identify during dissection. Its soft wall can easily be torn, particularly in older patients. When damage does occur, the resulting bleeding can be controlled by suturing the wall of the vein. The vessel must be totally accessible during suture. This may require to open the carotid sheath to expose the vein and identify the artery and the vagus nerve to avoid including these two additional structures in the sutures or ligatures.5 Carotid artery: Injuries to the carotid artery during presternocleidomastoid approaches to the cervical spine are rare, because the artery, retracted laterally, is located within the carotid sheath and covered by connective tissue. Difficult anatomy (for example in patients being treated for advanced tumours) and poor identification of the midline are risk factors for injury to the carotid artery. Injuries to the artery can be either overt, with rapid blood loss from an injury, or more insidious, presenting with an occlusive stroke. Direct injury can occur during dissection (when the artery is not adequately protected from sharp instruments such as drills and osteotomes), or because of the use of self-retaining retractors that apply direct pressure to the artery. Prolonged manual retraction may also be responsible for internal carotid artery thrombosis and stroke.10 This is the reason why we recommend intermittently release of the retractors during surgery to ensure adequate internal carotid artery flow. Embolic or occlusive strokes from the carotid artery are typically discovered post-operatively and are difficult to manage. Patients after only temporary occlusion of the internal carotid artery may develop hemorrhagic infarction in the reperfused, ischemic brain, or cerebrovascular morbidity such as cerebral oedema and herniation. Vertebral artery: Serious vascular complications can arise from the injury to the vertebral artery.11 In the high presternocleidomastoid approach injuries to the vertebral arteries can occur when the surgeon is operating at the level of the cranio-cervical junction, lateral to the axis. In patients with massive osteolysis, damage to the vertebral artery in its extraskeletal portion can occur during the exposure of the lateral masses of C2 because of the inappropriate use of retractors and surgical instruments. In the low presternocleidomastoid approach the vertebral artery can be damaged when surgery is performed in the lateral portion of the vertebral body towards the transverse processes and when bony dissection involves the transverse foramen, which contains the vertebral artery. Sometimes, extensive dissection within the vertebral body may produce a collapse of the lateral wall, compressing or injuring the vertebral artery. Fortunately, in the majority of patients, the artery is flexible enough to bend and adapt to the collapse of the surrounding bone. When injuries occur, the bleeding can be massive. Vertebral artery laceration has been reported due to a variety of causes: motorized dissection off the midline, excessive lateral bone-disc removal, excessively lateral placement of instrumentation, bone pathologically softened by tumour, infection, or irradiation and intraoperative loss of midline landmarks. The proximity of the vertebral artery to the uncovertebral joint during foraminotomy or removal of the postero-lateral quadrant of the vertebral body is a predisposing factor to arterial laceration. Endovascular management is the first therapeutic option in injuries to the vertebral artery because of its location and surgical inaccessibility. Detachable balloons, coils, stents, and haemostatic agents are successfully used to manage bleeding in expert hands. Immediate intervention with proximal and distal ligation is necessary in unstable patients with life-threatening bleeding. Soft tissue and visceral injury The thoracic duct: The thoracic duct is the main collecting vessel for the lymphatic system. Thoracic duct injury is a rare but serious complication of cervical spine surgery. It may lead to nutritional deficiencies, respiratory dysfunction and immunosuppression with a mortality up to 50%. Since the anterior approach for cervical discectomy and fusion was described in 195512 only one case of thoracic duct injury occurring during cervical discectomy and fusion via an anterior approach has been described; a consequence of an unusually cephalic location of the thoracic duct arch in the neck.13 Nine cases of thoracic duct injury occurring during thoracic and/or lumbar spine surgery have been reported. In all these nine patients, thoracic duct injury manifest as an intraoperative chyle leak, postoperative chylothorax, chyloretroperitoneum,15 or a combination of these. The variable anatomic course of the thoracic duct has been implicated as the main reason for injuries during spinal surgery.1, 14 Other factors include its small size, inconstant location, and proximity to the vertebral bodies. Chylous leakage in the thoracic cavity may complicate the primary disease and management might be prolonged. When the thoracic duct is disrupted, chylothorax may occur from leakage due to reflux within substitution collateral pathways, diverting the flow of chyle into the venous confluence of the neck. Conservative management consists of a low-fat diet with medium chain triglycerides, total parenteral nutrition, correction of electrolyte imbalance and adequate drainage by chest tube or neck drain. Somatostatin 14 and Etilefrine have been reported to be effective.16 However, it takes several weeks for the chylothorax to resolve, with an overall failure rate of up to 50% and in these cases surgical intervention may be required later. The definitive management is ligation of the thoracic duct.17 Despite excellent results, thoracotomy remains a procedure with high morbidity, postoperative pain and associated risks. For these reasons, early conservative therapy is recommended for 1–2 weeks initially. Video assisted thoracic surgery has been used in the management of chyle leaks.18 After a period of failed conservative management the duct injury can be treated by clipping, ligation of the thoracic duct and tissue glue application to the site of the leak.18 Oesophagus and pharynx: Oesophageal perforation is a recognized and potentially fatal complication of anterior cervical spine surgery. The incidence of oesophageal injury is higher in corpectomy, instrumented surgery and surgery for trauma. Oesophageal ischemic or direct injury is usually caused by excessive retraction during dissection. Injuries to the oesophagus and pharynx require immediate surgical repair.2 When the middle cervical fascia and the omohyoid muscle have been split the oesophagus and the pharynx are exposed. The walls of these structures at this level are thin and soft and, as a consequence, are easily injured by aggressive dissection. Small tears to these structures can be missed intraoperatively. A nasogastric tube passed before surgery aids in identification of the oesophagus during the surgical exposure. The hypopharynx can also be easily lacerated during dissection at higher levels of the cervical spine, particularly if dissection is not performed with great care in patients with inflammatory diseases or in patients with scarring and adhesions from previous surgery.2 The latter cases have usually lost the natural planes of cleavage and normal tissue relationships. For this reason we insist on the use of a nasogastric tube to facilitate identification of the hypopharynx and avert intraoperative injuries.5 The use of diathermy, rather than sharp dissection, to expose the prevertebral fascia during the dissection of the longus colli muscle can also lead to oesophageal injury. The oesophagus should always be protected by hand-held retractors to prevent thermal or direct injury. The morbidity and mortality of oesophageal injury, especially after delayed diagnosis, are high. With a complete perforation of the wall, oropharyngeal secretions with their contained micro-organisms are free to contaminate the visceral structures in the neck and mediastinum. The occurrence of mediastinitis, pneumonia, pleuritis, pericarditis, and systemic sepsis is well documented in the literature. Fistula formation is also a known late complication and may give away the diagnosis. Fistlulae can occur between the oesophagus and the respiratory tract. Oesophageal-bronchial and oesophageal-pleural fistulae are both complicated therapeutic dilemmas.19 The mortality of these conditions with conservative therapy has been reported in up to 65%. With accurate early diagnosis and appropriate selection criteria, mortality rates of <7% are possible. Neurological injury Laryngeal nerves: The superior laryngeal nerve can be injured during the high anterolateral approach. At this level, the nerve will be found crossing the field on its way to the pharyngeal wall. The inferior laryngeal nerve is subject to a great number of anomalous paths, arising from the vagus nerve anywhere from the middle to the inferior cervical region and often in relationship to the inferior thyroid vessels. These nerves are injured whenever the retroesophageal prevertebral space is missed, and inadvertently the surgeon enters the space between oesophagus and trachea.1 The operating surgeon's dominant hand will determine the position that is more comfortable with reference to the patient. Usually a right-handed surgeon will be more comfortable operating from the right side. All aspects of surgical operations on bone including the design of chisels, knives, or curettes favour a right-handed surgeon operating from the right side. In the past there has been much debate as to whether a right or left sided approach should be preferred, particularly with reference to complications arising from the recurrent laryngeal nerve.1 Injury to this nerve produces vocal disturbance which may be irreversible. Symptoms include hoarseness, vocal breathliness or fatigue, weak cough, dysphagia, or aspiration. Although vocal cord paralysis may be permanent, in most cases symptoms lasts for only weeks or months. The course of the recurrent laryngeal nerves differs on the right and left sides. On the left side, it has a longer course, originating more distally from the vagus within the thorax, passing under the aortic arch, and then following the space between the oesophagus and trachea in the neck. On the right side, the nerve follows a much shorter course. It arises quite proximally in the upper thorax, passes under the subclavian artery and courses between the trachea and the oesophagus. It is more superficial and, hence, more exposed. In addition, it may follow a number of differing anatomical pathways. It has been reported to arise as proximal as the inferior thyroid artery, which makes it particularly vulnerable to injury if this position is not immediately identified as a variant of normal. Injury may occur because of direct traction or retraction with excessive force if the nerve is stretched between the two planes that are separated, and may lead to neurapraxia or axonotmesis. The surgeon should keep in mind possible anatomical variations.5 Cervical sympathetic chain: The sympathetic trunk of the neck is in the prevertebral fascia, between the carotid sheath in front and the longus colli and longus capitis muscles behind. It extends above into the skull as a plexus, surrounding the internal carotid artery. It is continuous below with the sympathetic trunk of the thorax. The cervical sympathetic chain is formed by the superior, middle, and inferior ganglia. Each ganglion contributes grey rami communicante branches to the cervical nerves, a cardiac nerve, and an element of the plexus to the artery. The cervical sympathetic chain can be injured in its superior region, near the stellate ganglion, when the surgeon is dissecting the long muscles of the neck in the lateral cervical muscular plane. It is most commonly injured when the surgeon fails to remain subperiosteal during dissection of the lateral aspect of the vertebral body in the approach to the transverse processes. This injury leads to Horner's syndrome, with ipsilateral enophthalmia, myosis, and palpebral ptosis. Spinal cord and the nerve roots: Injury to the cord and to the nerve roots usually occurs during surgery directly related to these structures. Postoperative cerebrospinal fluid (CSF) leakage may occur at the dural suture line after intradural procedures or can be caused by inadvertent durotomy during discectomy. Once it has occurred, surgical repair of dural tears via an anterior approach can be difficult or impossible because of the reduced space available during single level discectomy. When possible, tears should be sutured or a dural patch can be applied. Lyophilized dura or processed bovine pericardium can be used and can be directly sutured or glued with fibrin glue. To ensure proper fixation of the patch the anesthetist should perform repeated Valsalva maneuvers to increase CSF pressure. Fascial graft covered with gelfoam, fat graft or fibrin glue can be used together with other sealant products (Duraseal Xact™) to obtain watertight sealing of dural tears. A lumbar subarachnoid drain must be always used in case of failure to secure a watertight repair or indeed if there is doubt about the adequacy of the repair. The lumbar subarachnoid drain decreases intradural pressure, contributing to dural tear healing. Drainage flow should be of 8–12 mL/h, with the flow rate to be modified on the base of clinical response. Spinal cord lesions can occur as a result of direct or indirect injury. Direct lesions can arise from contusion at the level of surgery following inadvertent surgical manoeuvres. In the immediate post-operative period, patients may experience a worsening of preoperative neurological symptoms with areas of cord damage. Indirect lesions occur following vascular ischaemic damage with subsequent postoperative neurological deficit. These lesions can occur from hypoxia from excessive retraction intraoperatively or postoperative oedema or haematoma. Decompression of the already ischemic spinal cord in spinal stenosis can lead to a segmental paradoxical infarction of the spinal cord, similar to that occurring in limb reimplantation surgery. Conclusions Although the anterolateral approaches to the cervical spine are generally safe, life threatening complications may occur and surgeons should always be prepared for these situations. Strict adherence to the surgical technique may help to avoid pitfalls during the approach. Practice points•Adequately protect the carotid artery from sharp instruments such as drills and chisels during dissection •Do not apply direct pressure to the carotid artery with self-retaining retractors •Intermittently release the retractors during surgery to restore adequate internal carotid artery flow. •Endovascular techniques are the first therapeutic option in injuries to the vertebral artery because of its location and surgical inaccessibility •When damages occur to the jugular vein the resulting bleeding can be controlled by suturing the wall of the vein. •Use a nasogastric tube, that can be palpated during dissection and can help to recognize the hypopharynx, preventing intraoperative injuries •Be always aware of the considerable anatomic variations of the thoracic duct and inferior laryngeal nerve References 1. 1Denaro V. Stenosis of the cervical spine. Berlin Heidelberg New York: Springer; 1991;. 2. 2Denaro V, Denaro L, Gulino G, Marinozzi A, Cellocco P. Complicanze nella chirurgia cervicale. Giornale Italiano di Ortopedia e Traumatologia. 1998;24:681–688. 3. 3Boni M, Denaro V. [Surgical treatment of cervical arthrosis. Follow-up review (2–13 years) of the 1st 100 cases operated on by anterior approach], Rev Chir Orthop Reparatrice Appar Mot. 1982;68:269–280. MEDLINE 4. 4Boni M, Denaro V. The cervical stenosis syndrome with a review of 83 patients treated by operation. Int Orthop. 1982;6:185–195. MEDLINE |
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17. 17Lampson RS. Traumatic chylothorax; a review of the literature and report of a case treated by mediastinal ligation of the thoracic duct. J Thorac Surg. 1948;17:778–791. 18. 18Inderbitzi RG, Krebs T, Stirneman T, Ulrich A. Treatment of postoperative chylothorax by fibrin glue application under thoracoscopic view with use of local anesthesia. J Thorac Cardiovasc Surg. 1992;104:209–210. MEDLINE 19. 19Zenone EA, Trotman BW. Boerhaave's syndrome. Spontaneous formation of an esophageal-bronchial fistula. JAMA. 1977;238:2048–2049. MEDLINE Luca Denaro MD PhD Consultant in Neurosurgery, Department of Neuroscience, University of Padua, Padua, Italy Umile Giuseppe Longo MD Resident in Trauma and Orthopaedic Surgery, Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Rome, Italy Nicola Maffulli MD MS PhD FRCS(Orth) Professor of Trauma and Orthopaedic Surgery, Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK Vincenzo Denaro MD Professor of Trauma and Orthopaedic Surgery, Department of Orthopaedic and Trauma Surgery, Campus Biomedico University, Rome, Italy PII: S1877-1327(09)00146-8 doi:10.1016/j.mporth.2009.09.002 © 2009 Elsevier Ltd. All rights reserved. | |
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