Date Published: August 14, 2012
Publisher: Hindawi Publishing Corporation
Author(s): R. G. Kavanagh, J. S. Butler, J. M. O’Byrne, A. R. Poynton.
Cervical spondylosis is a common problem encountered in modern orthopaedic practice. It is associated with significant patient morbidity related to the consequent radiculopathic and myelopathic symptoms. Operative intervention for this condition is generally indicated if conservative measures fail; however there are some circumstances in which urgent surgical intervention is necessary. Planning any surgical intervention must take into account a number of variables including, but not limited to, the nature, location and extent of the pathology, a history of previous operative interventions, and patient co-morbidities. There are many different surgical options and a multitude of different procedures have been described using both the anterior and posterior approaches to the cervical spine. The use of autograft to achieve cervical fusion is still the gold standard with allograft showing similar results; however fusion techniques are constantly evolving with novel synthetic bone graft substitutes now widely available.
Cervical spondylosis is a common problem that is increasing in incidence in our aging population. Presentation is usually with neck pain, cervical radiculopathy, cervical myelopathy, or a combination of these.
There are no strict guidelines on the indications for surgery in cervical spondylosis. The decision to proceed with surgery is taken after detailed consultation, physical examination, and imaging and is based on a number of variables including the severity of symptoms, duration of symptoms, progression of symptoms, radiological changes, and the patient’s fitness for surgery. The failure of conservative management strategies, such as physiotherapy, analgesia, nonsteroidal anti-inflammatory drugs, and epidural injections, is another indication for surgical intervention.
Both the anterior and posterior approaches can be utilised in accessing the cervical spine. The approach is dictated by a number of different variables including the location of pathology and type of procedure to be undertaken, previous surgeries to the area, extent of disease (single or multilevel), preoperative neck pain, the presence of congenital stenosis, sagittal alignment of cervical spine, and patient comobidities .
The main procedures that are performed through an anterior approach are anterior cervical discectomy and corpectomy, and those carried out through a posterior approach are laminoplasty, laminectomy, and posterior cervical discectomy.
Fusion is performed with the placement of graft between the fusion surfaces followed by a period of immobilisation to allow the fusion to occur. Bone graft can be autograft, allograft, or synthetic bone graft substitutes. Autograft is still the gold standard with its long established safety and efficacy. Bone is usually harvested from the iliac crest which introduces the risk of complications relating to nerve or arterial injury, hematoma, infection, and chronic pain at the harvest site . Allograft is usually readily available and avoids the morbidity associated with autograft harvest. Recent studies show comparable fusion rates with allograft and autograft [44, 45]. The disadvantages of using allograft include the risk of disease transmission and the increased cost. Fibular strut allografts can be used to reconstruct the defect following multilevel corpectomy. Synthetic bone graft substitutes are relatively new agents that have been used alone and in combination with autograft or allograft. When used alone synthetic graft substitutes avoid the complications of harvesting and disease transmission associated with autograft and allograft. One such agent, recombinant human bone morphogenetic protein-2 (rhBMP-2), has shown promising results in clinical trials ; however, there are still some concerns over its safety with a number of studies showing increased complications related to local and systemic inflammatory responses [47, 48] and reports of clinically significant neck swelling leading to acute airway compromise and dysphagia . Synthetic bone graft substitutes are also relatively expensive.
Cervical spondylosis is a common problem encountered by the orthopaedic surgeon. Surgical decompression can be achieved through a multitude of procedures using either an anterior or posterior approach. The type of procedure carried out is dependent on a number of different variables including extent and location of pathology, previous surgery, congenital canal stenosis, and the presence of preoperative axial neck pain. Satisfactory surgical outcome will result in long-term amelioration of cervical radiculopathic and myelopathic symptoms with few postoperative complications.