Operative Techniques: Spine Surgery - E-Book

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Spine Surgery, 2nd Edition delivers step-by-step, multimedia guidance to help you master the must-know techniques in this field. Part of the popular and practical Operative Techniques series, this orthopaedics reference focuses on individual procedures, each presented in a highly visual, easy-to-follow format for quick reference.

  • Consult this title on your favorite e-reader with intuitive search tools and adjustable font sizes. Elsevier eBooks provide instant portable access to your entire library, no matter what device you're using or where you're located.
  • Access the entire text, fully searchable, online at www.expertconsult.com.
  • Concentrate on precisely the information you need with brief, highly illustrated coverage of each surgical technique, complemented with just the right amount of relevant science.
  • Find the answers you need quickly and easily with a strictly templated format for consistent and rapid visual reference.
  • View 12 surgical videos at www.expertconsult.com demonstrating how to perform state-of-the-art procedures such as C1-C2 Posterior Cervical Fixation, Minimally Invasive Deformity Correction and Fusion, and Lumbar Disc Arthroplasty.
  • Learn today's hottest techniques with new chapters on C2 translaminar fixation, vertebroplasty/kyphoplasty, internal laminectomy, and interbody fusion.
  • See exactly what to do using step-by-step intraoperative photos demonstrating each technique, and radiographs showing presenting problems and post-surgical outcomes.
  • Achieve optimal results using minimally invasive surgery whenever possible.
  • Contain costs by using new implants related to pedicle screws and interbody devices, as well as new biologics such as BMP (bone morphogenetic protein).
  • Benefit from the latest evidence-based information from randomized trials and retrospective studies.

Subjects

Books
Savoirs
Medicine
Médecine
Alar
Spinal stenosis
Surgical incision
Spinal fracture
Plethora
Proximal subungual onychomycosis
Spinal cord
Screw
Laminotomy
Surgical suture
Neck pain
LMNA
Rongeur
Radiculopathy
Body of vertebra
Spondylolysis
Spinal fusion
Electrocoagulation
Arthrodesis
Undershirt
Dedication
Spondylolisthesis
Decompression
Thoracotomy
Spinal cord injury
Acute pancreatitis
Spondylosis
Electromyography
Orthopedics
Stenosis
Laminectomy
Review
Osteotomy
Discectomy
Vertebroplasty
Pedicle
Lumbar
Osteoarthritis
Physician assistant
Pleural effusion
Laparotomy
Biopsy
Lesion
Congenital disorder
Cauterization
Health care
Tetralogy of Fallot
Wrench
Pulmonary embolism
Endoscopy
Evoked potential
Human skeleton
Paste
Fixative
Back pain
Bleeding
Scoliosis
Operant conditioning
Cementation
Pneumonia
X-ray computed tomography
Philadelphia
Surgery
Address
Tool
Radiation therapy
Rheumatoid arthritis
Osteoporosis
Neutral
Neurology
Mechanics
Magnetic resonance imaging
General surgery
Engineering
Brain abscess
Fractures
Pneumothorax
Pathology
Mandrillus leucophaeus
Oblique
Dissection
Tong
Lombalgie
Fracture
Torque
Ring
Thorax
Accent
Compression
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Operative Techniques: Spine
Surgery
Second Edition
Alexander R. Vaccaro, MD, PhD
The Everrett J. and Marion Gordon Professor of Orthopaedic
Surgery, Professor of Neurosurgery, Co-Director of the
Delaware Valley Spinal Cord Injury Center, Co-Chief Spine
Surgery, Co-Director Spine Surgery, Thomas Jefferson
University and the Rothman Institute, Philadelphia,
Pennsylvania
Eli M. Baron, MD
Attending Spine Surgeon, Attending Neurosurgeon,
CedarsSinai Institute for Spinal Disorders, Los Angeles, California
S a u n d e r sCopyright
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
OPERATIVE TECHNIQUES: SPINE SURGERY, SECOND EDITION ISBN:
978-14377-1520-0
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
All rights reserved. No part of this publication may be reproduced or
transmitted in any form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with
organizations such as the Copyright Clearance Center and the Copyright Licensing
Agency, can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this Aeld are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identiAed, readers are
advised to check the most current information provided (i) on procedures featured
or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Spine surgery / [edited by] Alexander R. Vaccaro, Eli M. Baron.—2nd ed.
p. ; cm.—(Operative techniques)
Includes bibliographical references and index.
ISBN 978-1-4377-1520-0 (hardcover : alk. paper)I. Vaccaro, Alexander R. II. Baron, Eli M. III. Series: Operative techniques.
[DNLM: 1. Spinal Diseases—surgery—Atlases. 2. Spine—surgery—Atlases.
3. Orthopedic Procedures—methods—Atlases. WE 17]
617.5′6059–dc23
2012006062
Executive Content Strategist: Dolores Meloni
Content Development Specialist: Taylor Ball
Publishing Services Manager: Anne Altepeter
Project Manager: Louise King
Design Manager: Steven Stave
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedications
To my previous fellows, who inspire me more than I can ever teach them To Eli
Baron, who typi es a physician of honor and dedication to patient care, and who
possesses a relentless drive for truth in spinal care research To the graduates of the
Thomas Je erson spine fellowship—may they continue to teach and inspire their
teachers for years to come
Alexander R. Vaccaro
To my spine surgery instructors, colleagues, students, residents, and fellows, who
enlighten me on a daily basis regarding nuances in surgical decision making and
technique, and who also are my inspiration for continued self improvement
Eli M. BaronContributors
Kuniyoshi Abumi, MD
Professor, Spinal Reconstruction, Hokkaido University
Graduate School of Medicine, Sapporo, Japan
Cervical Pedicle Screw Fixation
Frank L. Acosta, Jr. , MD
Assistant Professor and Director of Spinal Deformity,
Neurological Surgery, Cedars-Sinai Medical Center, Los
Angeles, California
Surgical Treatment of High-Grade Spondylolisthesis
Todd J. Albert, MD
Richard H. Rothman Professor and Chair, Professor of
Neurosurgery, Department of Orthopaedic Surgery, Thomas
Jefferson University Hospital and The Rothman Institute,
Philadelphia, Pennsylvania
Posterior Far Lateral Disk Herniation
Christopher P. Ames, MD
Associate Professor, Department of Neurosurgery,
CoDirector, Spine Center, University of California San
Francisco, San Francisco, California
Surgical Treatment of High-Grade Spondylolisthesis
Howard S. An, MD
The Morton International Endowed Chair, Professor of
Orthopaedic Surgery, Director, Division of Spine Surgery
and Spine Fellowship Program, Rush University Medical
Center, Chicago, IllinoisHalo Placement in the Pediatric and Adult Patient
Neel Anand, MD
Co-Director, Institute for Spinal Disorders, Cedars-Sinai
Medical Center, Los Angeles, California
Posterior Cervical Osteotomy Techniques
Transforaminal Lumbar Interbody Fusion
The Transpsoas Approach for Thoracolumbar Interbody Fusion
Lumbar Internal Laminectomy
David T. Anderson, MD
Resident, Orthopaedic Surgery, Thomas Jefferson
University Hospital, Philadelphia, Pennsylvania
Anterior Cervical Corpectomy/Diskectomy
D. Greg Anderson, MD, PhD
Associate Professor, Department of Orthopaedic Surgery,
Thomas Jefferson University, Philadelphia, Pennsylvania
Posterior Far Lateral Disk Herniation
Minimally Invasive Exposure Techniques of the Lumbar Spine
Ronald I. Apfelbaum, MD, FAANS
Professor Emeritus, Department of Neurosurgery,
University of Utah, Salt Lake City, Utah
Odontoid Screw Fixation
Hyun Bae, MD
Co-Director Fellowship, Division of Orthopaedic Surgery,
Cedars Sinai Spine Center, Los Angeles, California
Posterior Cervical Laminoplasty
Eli M. Baron, MD
Attending Spine Surgeon, Attending Neurosurgeon,Cedars-Sinai Institute for Spinal Disorders, Los Angeles,
California
Anterior Odontoid Resection: The Transoral Approach
Anterior C1-C2 Arthrodesis: Lateral Approach of Barbour and Whitesides
Transforaminal Lumbar Interbody Fusion
The Transpsoas Approach for Thoracolumbar Interbody Fusion
Lumbar Internal Laminectomy
Edward C. Benzel, MD
Chairman, Department of Neurosurgery, Center for Spine
Health, Cleveland Clinic, Cleveland, Ohio
Lateral Extracavitary Approach for Vertebrectomy
John K. Birknes, MD
Attending Pediatric Neurosurgeon, Division of
Neurosurgery, Children’s Hospital of the King’s Daughters,
Norfolk, Virginia
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
Oheneba Boachie-Adjei, MD
Chief of the Scoliosis Service, Hospital for Special
Surgery, New York, New York
Hemivertebrae Resection
Keith H. Bridwell, MD
Professor, Orthopaedic Surgery, Professor, Neurological
Surgery, Chief, Adult/Pediatric Spine Surgery, Orthopaedic
Surgery, Washington University School of Medicine, St.
Louis, Missouri
Osteotomy Techniques (Smith-Petersen and Pedicle Subtraction) for Fixed
Sagittal Imbalance
Robert M. Campbell, Jr. , MD
Professor of Orthopaedic Surgery, University ofPennsylvania; Director, The Center for Thoracic
Insufficiency Syndrome, Division of Orthopaedics, The
Children’s Hospital of Philadelphia, Philadelphia,
Pennsylvania
VEPTR Opening Wedge Thoracostomy for Congenital Spinal Deformities
Wilsa Charles, MD
Research Fellow, Montefiore Medical Center, Albert
Einstein College of Medicine, Bronx, New York
Operative Management of Scheuermann Kyphosis
David Choi, MB ChB, PhD, FRCS
Consulting Neurosurgeon, The National Hospital for
Neurology and Neurosurgery, Queen Square, London,
United Kingdom
Anterior Odontoid Resection: The Transoral Approach
Murat Cosar, MD
Department of Neurosurgery, Faculty of Medicine,
Canakkale 18 March University, Canakkale, Turkey
Minimally Invasive Presacral Retroperitoneal Approach for Lumbosacral
Axial Instrumentation
H. Alan Crockard, MB, DSc, FRCS, FDSRCS, FRCP
Professor of Neurosurgery, The National Hospital for
Neurology and Neurosurgery, Queen Square, London,
United Kingdom
Anterior Odontoid Resection: The Transoral Approach
Michael D. Daubs, MD
Assistant Professor, Orthopaedic Surgery, University of
Utah, Salt Lake City, UtahAnterior Lumbar Interbody Fusion
Timothy Davis, MD, DABNM
Physical Medicine and Interventional Pain, Cedars-Sinai
Spine Center, Los Angeles, California
The Transpsoas Approach for Thoracolumbar Interbody Fusion
Rick B. Delamarter, MD
Vice Chairman, Department of Surgery, Co-Director,
Spine Center, Cedars Sinai Medical Center, Los Angeles,
California
Anterior Cervical Disk Arthroplasty
Michael F. Duffy, MD
Orthopaedic Spine Surgeon, Texas Back Institute,
Mansfield, Texas
Lumbar Total Disk Arthroplasty
Mostafa H. El Dafrawy, MD
Research Fellow, Orthopaedic Surgery-Spine Division,
Johns Hopkins University, Baltimore, Maryland
Sacropelvic Fixation
Thomas J. Errico, MD
Associate Professor of Orthopedic and Neurological
Surgery, New York University School of Medicine; Chief,
Division of Spine Surgery, New York University Hospital
for Joint Diseases, New York, New York
Operative Management of Scheuermann Kyphosis
Daniel R. Fassett, MD
Interim Head of Neurosurgery, University of Illinois
College of Medicine Peoria; Director of Spinal Surgery,
Illinois Neurological Institute, Peoria, IllinoisOdontoid Screw Fixation
Michael A. Finn, MD
Assistant Professor of Neurosurgery, University of
Colorado School of Medicine, Aurora, Colorado
Odontoid Screw Fixation
Ernest Found, MD
Associate Professor of Orthopaedics, The University of
Iowa, Iowa City, Iowa
Spondylolysis Repair
Peter G. Gabos, MD
Assistant Professor of Orthopaedic Surgery, Jefferson
Medical College of Thomas Jefferson University,
Philadelphia, Pennsylvania; Co-Director, Division of
Scoliosis and Spine Surgery, Alfred I. duPont Hospital for
Children, Nemours Children’s Clinic, Wilmington,
Pennsylvania
Anterior Thoracolumbar Spinal Fusion via Open Approach for Idiopathic
Scoliosis
George M. Ghobrial, MD
Resident, Neurological Surgery, Thomas Jefferson
University Hospital, Philadelphia, Pennsylvania
Anterior Odontoid Resection: The Transoral Approach
Colin B. Harris, MD
Syracuse Orthopedic Specialists, Spine Center, Dewitt,
New York
Closed Cervical Skeletal Tong Placement and Reduction Techniques
Christopher C. Harrod, MDOrthopaedic Surgery Chief Resident, Harvard Combined
Orthopaedic Residency Program, Harvard University,
Boston, Massachusetts
Anterior Thoracic Diskectomy and Corpectomy
James S. Harrop, MD
Associate Professor, Neurological Surgery, Jefferson
Medical College, Philadelphia, Pennsylvania
Anterior Odontoid Resection: The Transoral Approach
Occipital-Cervical Fusion
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
Alan S. Hilibrand, MD
Professor of Orthopaedic Surgery, Director of
Orthopaedic Medical Education, Professor of Neurological
Surgery, Jefferson Medical College of Thomas Jefferson
University/The Rothman Institute, Philadelphia,
Pennsylvania
Anterior Cervical Corpectomy/Diskectomy
Yoshihiro Hojo, MD
Department of Orthopedic Surgery, Kushiro Rosai
Hospital; Japan Labour Health and Welfare Organization,
Kashiro, Japan
Cervical Pedicle Screw Fixation
Jonathan A. Hoskins, MD
Research Associate, Department of Orthopedic Surgery,
Rush University Medical Center, Chicago, Illinois
Anterior Resection of Ossification of the Posterior Longitudinal Ligament
Cervical Spine: Lateral Mass Screw Fixation
Manabu Ito, MD
Department of Advanced Medicine for Spine and SpinalCord Disorders, Hokkaido University Graduate School of
Medicine, Sapporo, Japan
Cervical Pedicle Screw Fixation
George Jallo, MD
Associate Professor, Neurosurgery, Pediatrics, and
Oncology, Clinical Director, Pediatric Neurosurgery,
Department of Neurosurgery, Johns Hopkins University,
Baltimore, Maryland
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
(Video)
Jack I. Jallo, MD, PhD
Professor, Thomas Jefferson University, Philadelphia,
Pennsylvania
Occipital-Cervical Fusion
Sunil Jeswani, MD
Department of Neurosurgery, Cedars-Sinai Medical
Center, Los Angeles, California
Lumbar Internal Laminectomy
Avrum Joffe, MD
Resident, Orthopaedic Surgery, St. Luke’s and Roosevelt
Hospitals, New York, New York
Thoracoplasty for Rib Deformity
Ian T. Johnson, MD
Director of Spinal Care, Neurological and Orthopedic
Institute of Florida, Delray Beach, Florida
Minimally Invasive Presacral Retroperitoneal Approach for Lumbosacral
Axial InstrumentationJ. Patrick Johnson, MD
CEO and Chairman, The Spine Institute Foundation;
Attending Neurosurgeon/Spine Specialist, Neurosurgery,
Cedars-Sinai Medical Center, Los Angeles, California
Anterior Odontoid Resection: The Transoral Approach
Endoscopic Thoracic Diskectomy
Stepan Kasimian, MD
Attending Spine Surgeon, Orthopaedic Surgery,
CedarsSinai Medical Center, Los Angeles, California; Attending
Spine Surgeon, Glendale-Adventist Spine
Institute/Orthopaedic Surgery, Glendale-Adventist Medical
Center, Glendale, California
Endoscopic Thoracic Diskectomy
Manish K. Kasliwal, MD, MCh
Spine Fellow, Rush University Medical Center, Chicago,
Illinois
Spondylolysis Repair
Khaled Kebaish, MD
Associate Professor, Orthopaedic Surgery, Johns
Hopkins University, Baltimore, Maryland
Sacropelvic Fixation
Michael P. Kelly, MD
Assistant Professor of Orthopaedics, Assistant Professor
of Neurological Surgery, Washington University School of
Medicine, St. Louis, Missouri
Osteotomy Techniques (Smith-Petersen and Pedicle Subtraction) for Fixed
Sagittal Imbalance
Christopher K. Kepler, MDSpine Surgery Fellow, Orthopaedics, Thomas Jefferson
University/Rothman Institute, Philadelphia, Pennsylvania
Minimally Invasive Exposure Techniques of the Lumbar Spine
Larry T. Khoo, MD
Director of Spinal Surgery, The Spine Clinic of Los
Angeles at Good Samaritan Hospital, A Teaching Affiliate
of the University of Southern California, Los Angeles,
California
Minimally Invasive Presacral Retroperitoneal Approach for Lumbosacral
Axial Instrumentation
Paul Dohyung Kim, MD
Orthopaedic Spine Surgeon, Spine Institute of San Diego,
San Diego, California
Anterior Cervical Disk Arthroplasty
Posterior Cervical Laminoplasty
Paul Kraemer, MD
Orthopaedic Spine Surgeon, Indiana Spine Group;
Assistant Professor, Orthopaedic Surgery, Indiana
University, Indianapolis, Indiana
Complete Vertebral Resection for Primary Spinal Tumors
Steven K. Leckie, MD
Resident, Orthopedic Surgery, University of Pittsburgh
Medical Center, Pittsburgh, Pennsylvania
Posterior C1-C2 Fusion: Harms and Magerl Techniques
Joon Y. Lee, MD
Associate Professor of Orthopaedic Surgery, University
of Pittsburgh Medical Center, University of Pittsburgh,
Pittsburgh, PennsylvaniaPosterior C1-C2 Fusion: Harms and Magerl Techniques
Howard B. Levene, MD, PhD
Assistant Professor of Neurological Surgery, University
of Miami Miller School of Medicine, Miami, Florida
Occipital-Cervical Fusion
Isador H. Lieberman, MD
Director, Scoliosis and Spine Tumor Center, Texas Back
Institute, Plano, Texas
Kyphoplasty
Neil A. Manson, MD
Staff Surgeon, Spine, Sports Medicine, and Orthopaedic
Surgery, Canada East Spine Centre and Horizon Health
Network, Saint John, New Brunswick, Canada; Assistant
Professor, Department of Surgery, Dalhousie University,
Halifax, Nova Scotia, Canada
Halo Placement in the Pediatric and Adult Patient
Mark M. Mikhael, MD
Reconstructive Spine Surgeon, Illinois Bone and Joint
Institute, Glenview, Illinois
Interspinous Process Motion-Sparing Implant
Rani Nasser, MD
Resident, Neurological Surgery, Montefiore Medical
Center, Bronx, New York
Hemivertebrae Resection
Alpesh A. Patel, MD, FACS
Associate Professor, Department of Orthopaedic Surgery
and Rehabilitation, Loyola University, Chicago, IllinoisAnterior Resection of Ossification of the Posterior Longitudinal Ligament
Brian Perri, DO
Institute for Spinal Disorders, Cedars-Sinai Medical
Center, Los Angeles, California
Posterior Cervical Osteotomy Techniques
Matias G. Petracchi, MD
Orthopaedics and Traumatology, Hospital Italiano de
Buenos Aires, Buenos Aires, Argentina
Hemivertebrae Resection
Daniel Raphael, PA-C
Division of Neurosurgery, The Spine Clinic of Los
Angeles, Good Samaritan Hospital, University of Southern
California Medical School, Los Angeles, California
Minimally Invasive Presacral Retroperitoneal Approach for Lumbosacral
Axial Instrumentation
John K. Ratliff, MD
Department of Neurosurgery, Stanford University
Medical Center, Stanford, California
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
Hemivertebrae Resection
Coleen S. Sabatini, MD
Assistant Professor of Clinical Orthopaedic Surgery,
Department of Orthopaedic Surgery, University of
California San Francisco, San Francisco, California
Posterior Thoracolumbar Fusion Techniques for Adolescent Idiopathic
Scoliosis
Rick C. Sasso, MDProfessor, Clinical Orthopaedic Surgery, Indiana
University School of Medicine; Indiana Spine Group,
Indianapolis, Indiana
Complete Vertebral Resection for Primary Spinal Tumors
Suken A. Shah, MD
Chief, Division of Spine and Scolosis, Department of
Orthopaedics, Nemours/Alfred I. duPont Hospital for
Children, Wilmington, Delaware; Assistant Professor of
Orthopaedic Surgery, Department of Orthopaedic Surgery,
Thomas Jefferson University, Philadelphia, Pennsylvania
Thoracoplasty for Rib Deformity
Arya Nick Shamie, MD
Associate Professor, Orthopaedic Surgery, Associate
Professor, Neurosurgery, University of California Los
Angeles, Los Angeles, California; Medical Director, Spine
Surgery, UCLA/Santa Monica Medical Center, Santa
Monica, California
Interspinous Process Motion-Sparing Implant
Alok D. Sharan, MD
Chief, Orthopedic Spine Service, Orthopedic Surgery,
Montefiore Medical Center/Albert Einstein College of
Medicine, Bronx, New York
Operative Management of Scheuermann Kyphosis
Ashwini Sharan, MD, FACS
Associate Professor of Neurosurgery, Program Director,
Department of Neurosurgery, Jefferson Medical College of
Thomas Jefferson University, Philadelphia, Pennsylvania
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
Andrew K. Simpson, MDOrthopaedic Surgery Resident, Harvard Combined
Orthopaedic Residency Program, Harvard University,
Boston, Massachusetts
Anterior Thoracic Diskectomy and Corpectomy
Harminder Singh, MD
Assistant Professor of Neurosurgery, Stanford University
School of Medicine, Stanford, California
Anterior Odontoid Resection: The Transoral Approach
Kern Singh, MD
Associate Professor, Orthopedic Surgery, Rush University
Medical Center, Chicago, Illinois
Anterior Resection of Ossification of the Posterior Longitudinal Ligament
Cervical Spine: Lateral Mass Screw Fixation
David L. Skaggs, MD
Professor, Orthopaedic Surgery, University of Southern
California; Chief, Orthopaedic Surgery, Children’s Hospital
Los Angeles, Los Angeles, California
Posterior Thoracolumbar Fusion Techniques for Adolescent Idiopathic
Scoliosis
Zachary A. Smith, MD
Assistant Professor of Neurosurgery, Northwestern
University Feinberg School of Medicine, Chicago, Illinois
Minimally Invasive Presacral Retroperitoneal Approach for Lumbosacral
Axial Instrumentation
John Christos Styliaras, MD
Resident, Department of Neurological Surgery, Thomas
Jefferson University Hospital, Philadelphia, PennsylvaniaOccipital-Cervical Fusion
Resection of Intradural Intramedullary or Extramedullary Spinal Tumors
Ishaq Syed, MD
Assistant Professor, Department of Orthopaedic Surgery,
Wake Forest University Baptist Medical Center,
WinstonSalem, North Carolina
Posterior C1-C2 Fusion: Harms and Magerl Techniques
Chadi Tannoury, MD
Orthopaedic Spine Fellow, Rush University Medical
Center and Midwest Orthopaedics at Rush, Chicago, Illinois
Posterior Far Lateral Disk Herniation
Issada Thongtrangan, MD
Orthopedic Spine Surgeon, Orthopaedic and Spine
Institute, San Antonio, Texas
Kyphoplasty
Vincent C. Traynelis, MD
Professor, Department of Neurosurgery, Rush University
Medical Center, Chicago, Illinois
Spondylolysis Repair
Per D. Trobisch, MD
Spine Surgeon, Orthopädische Klinik Berlin, Vivantes
Klinikum im Friedrichshain, Landberger Allee, Berlin,
Germany
Operative Management of Scheuermann Kyphosis
Kene T. Ugokwe, MD
Associate Staff Neurosurgeon, Surgery, St. Elizabeth
Health Center, Youngstown, OhioLateral Extracavitary Approach for Vertebrectomy
Alexander R. Vaccaro, MD, PhD
Everett J. and Marion Gordon Professor of Orthopaedic
Surgery, Professor of Neurosurgery, Thomas Jefferson
University and The Rothman Institute; Co-Director,
Delaware Valley Spinal Cord Injury Center, Philadelphia,
Pennsylvania
Anterior Odontoid Resection: The Transoral Approach
Anterior C1-C2 Arthrodesis: Lateral Approach of Barbour and Whitesides
Anterior Resection of Ossification of the Posterior Longitudinal Ligament
Occipital-Cervical Fusion
Cervical Spine: Lateral Mass Screw Fixation
Anterior Thoracic Diskectomy and Corpectomy
Posterior Far Lateral Disk Herniation
Transforaminal Lumbar Interbody Fusion
Michael J. Vives, MD
Associate Professor and Chief of Spine Surgery,
Orthopedics, University of Medicine and Dentistry-New
Jersey Medical School, Newark, New Jersey
Closed Cervical Skeletal Tong Placement and Reduction Techniques
Brian Walsh, MD
Staff Neurosurgeon, Madison, Wisconsin
Spondylolysis Repair
Christopher F. Wolf, MD
Orthopaedic Spine Surgeon, Christiana Spine Center LLC,
Newark, Delaware
Interspinous Process Motion-Sparing Implant
Kamal R.M. Woods, MD
Chief Resident, Neurosurgery, Loma Linda University
Medical Center, Loma Linda, CaliforniaTransforaminal Lumbar Interbody Fusion
Neill M. Wright, MD
Herbert Lourie Professor in Neurological Surgery,
Neurological Surgery, Washington University School of
Medicine, St. Louis, Missouri
C2 Translaminar Screw Fixation
Vamshi Yelavarthi
Medical Student, Boston University School of Medicine,
Boston, Massachusetts
Anterior Resection of Ossification of the Posterior Longitudinal Ligament
Cervical Spine: Lateral Mass Screw Fixation
Joseph M. Zavatsky, MD
Staff Orthopaedic Surgeon, Ochsner Medical Center,
Baton Rouge, Louisiana
Posterior C1-C2 Fusion: Harms and Magerl Techniques
Lukas P. Zebala, MD
Associate Professor, Orthopedic Surgery, Washington
University School of Medicine, Saint Louis, Missouri
Osteotomy Techniques (Smith-Petersen and Pedicle Subtraction) for Fixed
Sagittal Imbalance
Jack E. Zigler, MD
Orthopaedic Spine Surgeon, Co-Director of Fellowship
Program, Texas Back Institute, Plano, Texas
Lumbar Total Disk Arthroplasty=
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Foreword to the First Edition
It seems fair to say that the development of spine surgery over the past 50
years has been nothing short of breathtaking. Advances in mechanical engineering
and biomaterials as well as increasing anatomic sophistication have led to a surge
of surgical treatment options for patients with spinal disorders. During this period,
the care of spinal disorders has matured from a peripheral possibility requiring
some improvisational management skills to a highly diversi ed specialty in its own
right. On the publications side, there has been a similar increase in the number of
textbooks and journals dealing with spinal disorders. Several of the classic
textbooks on the spine have blossomed into multivolume tomes containing highly
di erentiated discussions on the many complex issues surrounding this subject.
The result, borrowing the words of Thomas De Quincey (1785-1859), is that
“Worlds of ne thinking lie buried in the vast abyss…, never to be disentombed or
restored to human admiration” (from Coleridge’s “Reminisces of the English Lake
Poets”). Indeed, the somewhat overwhelming plethora of spine publications has
led to frequently heard inquiries to the tune of “What should I read rst?” and
“Where can I find a quick description of …?” by many involved in spine care.
It certainly is a privilege to have been asked to provide introductory words to
a refreshingly novel yet thorough approach toward presenting this increasingly
large body of knowledge in the world of spinal surgery to a widely di ering
audience. The editors of Operative Techniques: Spine Surgery, Alexander Vaccaro
and Eli Baron, draw from an extensive clinical background across surgical
specialty lines and have a nearly unparalleled research background, as any
Medline search will readily demonstrate. They have taken the challenge of
information over ow head-on by providing a meaningful condensation of the
myriad surgical techniques available and presenting it in a well-structured and
meaningful fashion. The reader will nd helpful the organization of each
procedure into sections on Surgical Anatomy, Positioning, Portals and Exposures,
and step-by-step surgical plans, accompanied by subsections on Pearls and Pitfalls.
The open-ended questions of spine surgery are addressed in straightforward
fashion in the subsections on Controversies. The latter will pique the interest of
even seasoned spine surgeons as they invite thought-provoking deliberations on
how to further develop the eld of spine surgery. Key references are listed in an
evidence-based bibliography, with brief synopses of some of the most relevant
publications. The quality of the state-of-the-art illustrations are in a way
emblematic of this book, with their concise yet eminently detailed depictions of
anatomy providing meaningful assistance for a brief review of a speci c area of
interest.
Undoubtedly this book will be an asset to a wide array of health providers
associated with spine care for the eminently approachable and resource-rich
material that it provides.
Jens R. Chapman
ProfessorHansJörg Wyss Endowed Chair
Chief of Spine Service
Departments of Orthopaedic and Neurologic Surgery
University of Washington School of Medicine
Seattle, Washington




Preface
A plethora of textbooks on spinal surgery is available today. Most provide an
overview of the general science of spinal care or are intended as a reference text for
speci c spinal procedures. They include the background on a particular topic, its
clinical presentation, treatment options, and outcomes. Alternatively, they may
provide a review of the nuances of a pathologic condition, including a discussion of
the nonoperative and operative treatments with case examples.
This book is intended to serve a much di erent purpose. Although some atlases
of spine surgery exist, none are meant to serve as an operating room companion.
We envision this text to function as an indispensable tool for spinal surgeons who
want to accent their knowledge and exposure to interesting and commonly
performed surgical procedures encountered in daily practice. Within the pages of
this book, highly experienced practitioners present 40 of the most commonly
performed spinal procedures. Each chapter includes step-by-step illustrations of
spinal procedures, along with practical expert advice. Many pearls of wisdom are
conveyed by the authors to assist in the learning curve and avoid the commonly
experienced pitfalls encountered by many practitioners.
We believe this text represents a source of information that will be used
repeatedly by the busy spinal clinician. Surgeons will nd they want to consult
with this text routinely before embarking on a particular procedure, to feel
comfortable and con dent regarding their chosen techniques. A collection of videos
that illustrates master practitioners performing their trademark surgical procedures
as they counsel and guide the reader through each surgical step is available at
expertconsult.com. This addition wonderfully complements the overall appeal of
this learning aid.
We hope this text serves as a valuable resource, not only to orthopaedic
surgeons, neurosurgeons, and surgical trainees such as residents and fellows, but
also to physician assistants, nursing sta personnel, and anyone involved in the
operative care of patients undergoing spinal surgery.
Alexander R. Vaccaro, MD
Eli M. Baron, MDVideo Contents
Section I CERVICAL SPINE
Procedure 3Anterior Odontoid Resection: The Transoral Approach
Video 3-1 Anterior Odontoid Resection—David Choi, H. Alan Crockard
Procedure 4Odontoid Screw Fixation
Video 4-1 Odontoid Screw Fixation—Ronald I. Apfelbaum, Daniel R. Fassett
Procedure 8Anterior Cervical Disk Arthroplasty
Video 8-1 Lumbar Disk Arthroplasty—Rick B. Delamarter
Procedure 14Posterior Cervical Osteotomy Techniques
Video 14-1 Cervicothoracic Deformity Correction—Neel Anand, Brian Perri
Section II THORACIC SPINE
Procedure 18Operative Management of Scheuermann Kyphosis
Video 18-1 Correction of Scheuermann Kyphosis—Thomas J. Errico
Procedure 19Resection of Intradural Intramedullary or Extramedullary
Spinal Tumors
Video 19-1 Intramedullary Tumors—George Jallo
Procedure 20Endoscopic Thoracic Diskectomy
Video 20-1 Endoscopic Thoracic Diskectomy—J. Patrick Johnson, Stepan
Kasimian
Section III LUMBAR SPINE
Procedure 28Osteotomy Techniques (Smith-Petersen and Pedicle
Subtraction) for Fixed Sagittal Imbalance
Video 28-1 Smith-Petersen Osteotomy and Lumbar Pedicle Subtraction
Osteotomy—Keith H. Bridwell, Lukas P. Zebala
Procedure 33Transforaminal Lumbar Interbody Fusion
Video 33-1 Transforaminal Lumbar Interbody Fusion—Neel Anand, Kamal
R.M. Woods, Eli M. Baron
Procedure 39Lumbar Internal Laminectomy
Video 39-1 Unilateral Laminotomy with Bilateral Microdecompression—Neel
Anand, Sunil Jeswani, Eli M. Baron
MISCELLANEOUS
C1-C2 Posterior Cervical Fixation—Christopher Ames, Jae Taek Hong
Minimally Invasive Deformity Correction and Fusion—Neel Anand, Eli M.
BaronTable of Contents
Instructions for online access
Cover
Copyright
Dedications
Contributors
Foreword to the First Edition
Preface
Video Contents
Section I: Cervical Spine
Procedure 1: Closed Cervical Skeletal Tong Placement and Reduction
Techniques
Procedure 2: Halo Placement in the Pediatric and Adult Patient
Procedure 3: Anterior Odontoid Resection: The Transoral Approach
Procedure 4: Odontoid Screw Fixation
Procedure 5: Anterior C1-C2 Arthrodesis: Lateral Approach of Barbour
and Whitesides
Procedure 6: Anterior Cervical Corpectomy/Diskectomy
Procedure 7: Anterior Resection of Ossification of the Posterior
Longitudinal Ligament
Procedure 8: Anterior Cervical Disk Arthroplasty
Procedure 9: Occipital-Cervical Fusion
Procedure 10: C2 Translaminar Screw Fixation
Procedure 11: Posterior C1-C2 Fusion: Harms and Magerl Techniques
Procedure 12: Cervical Spine: Lateral Mass Screw Fixation
Procedure 13: Cervical Pedicle Screw Fixation
Procedure 14: Posterior Cervical Osteotomy Techniques
Procedure 15: Posterior Cervical Laminoplasty
Section II: Thoracic Spine
Procedure 16: Anterior Thoracic Diskectomy and Corpectomy
Procedure 17: Anterior Thoracolumbar Spinal Fusion via Open Approach
for Idiopathic Scoliosis
Procedure 18: Operative Management of Scheuermann Kyphosis
Procedure 19: Resection of Intradural Intramedullary or Extramedullary
Spinal TumorsProcedure 20: Endoscopic Thoracic Diskectomy
Procedure 21: VEPTR Opening Wedge Thoracostomy for Congenital
Spinal Deformities
Procedure 22: Posterior Thoracolumbar Fusion Techniques for
Adolescent Idiopathic Scoliosis
Procedure 23: Thoracoplasty for Rib Deformity
Procedure 24: Complete Vertebral Resection for Primary Spinal Tumors
Section III: Lumbar Spine
Procedure 25: Sacropelvic Fixation
Procedure 26: Posterior Far Lateral Disk Herniation
Procedure 27: Lateral Extracavitary Approach for Vertebrectomy
Procedure 28: Osteotomy Techniques (Smith-Petersen and Pedicle
Subtraction) for Fixed Sagittal Imbalance
Procedure 29: Spondylolysis Repair
Procedure 30: Surgical Treatment of High-Grade Spondylolisthesis
Procedure 31: Interspinous Process Motion-Sparing Implant
Procedure 32: Anterior Lumbar Interbody Fusion
Procedure 33: Transforaminal Lumbar Interbody Fusion
Procedure 34: The Transpsoas Approach for Thoracolumbar Interbody
Fusion
Procedure 35: Lumbar Total Disk Arthroplasty
Procedure 36: Kyphoplasty
Procedure 37: Minimally Invasive Exposure Techniques of the Lumbar
Spine
Procedure 38: Hemivertebrae Resection
Procedure 39: Lumbar Internal Laminectomy
Procedure 40: Minimally Invasive Presacral Retroperitoneal Approach
for Lumbosacral Axial Instrumentation
IndexSection I
Cervical SpineProcedure 1
Closed Cervical Skeletal Tong Placement and
Reduction Techniques
Michael J. Vives, Colin Harris
Indications
Subaxial cervical fractures with malalignment
Unilateral and bilateral subaxial cervical facet dislocations
Displaced odontoid fractures, selected types of hangman’s fractures, and C1-2
rotary subluxations
Pitfalls
• Patient must be awake, alert, and cooperative.
• Coexistence of skull fractures in the areas of pin placement may contraindicate
tong placement.
Controversies
• Magnetic resonance imaging (MRI) before closed reduction of dislocated facets,
to exclude an associated disk herniation, is advocated by some.
• For awake, alert patients, closed reduction may be attempted without MRI. If
closed reduction fails, MRI should be obtained before operative reduction under
general anesthesia.
Treatment Options
• Open reduction by anterior or posterior approach
• Anterior (or combined anterior-posterior) approach is commonly recommended if
MRI shows large associated disk herniation at the level of the dislocation.
Examination/Imaging
A thorough neurologic examination should be documented before the procedure.
High-quality imaging of the cervical spine (including visualization of the
occipital-cervical and cervical-thoracic junctions) should be obtained before the
reduction attempts (Figure 1-1).FIGURE 1-1
Surgical Anatomy
Correct pin placement site is 1 cm above the pinna, in line with the external
auditory meatus and below the equator of the skull (Figures 1-2 and 1-3).
The temporalis muscle and super3cial temporal artery and vein are at risk if pins
are placed too anterior.
FIGURE 1-2FIGURE 1-3
Anatomy Pearls
• Posterior pin placement will apply a flexion moment to the cervical spine.
• Anterior pin placement will apply an extension moment to the cervical spine.
Anatomy Pitfalls
• Placement of the pins too superior (above the equator) increases risk of pullout.
• Placement of the pins too anterior may result in injury to the super3cial
temporal vessels.
Positioning
The patient is positioned supine on the operative table, Stryker table, or
RotoRest bed.
Positioning Pearls
• Reverse Trendelenburg position or the use of arm and leg weights can help
prevent the patient from sliding to the top of the bed as weights are added.
Positioning Pitfalls
• Frequent radiographs and close monitoring are necessary during reduction
attempts; thus the emergency room (trauma bay), the operating room, or an
intensive care unit are preferred settings.
Portals/Exposures
• The skin is prepped with a povidone-iodine solution.
• Shaving or skin incisions are not necessary with the use of tapered Gardner-Wells
pins. Hair, however, can get wrapped around the pin during insertion.
Thoroughly soaking the area with the preparation solution facilitates parting
long hair in the area and helps prevent this.
• Local anesthetic is used to infiltrate the skin and down to the skull periosteum.
Procedure
Step 1
The pins are angled upward slightly and simultaneously tightened until the
spring-loaded force indicator (found on one of the two pins) protrudes 1 mm
above the flat surface of the pinhead (Figure 1-4).FIGURE 1-4
Step 1 Pearls
• Standing at the head of the bed during tong placement facilitates symmetric
positioning of the tongs.
Step 1 Pitfalls
• Overtightening can result in penetration of the inner table of the calvarium,
leading to cerebral abscess or hemorrhage.
• Check for all proper components before starting the procedure. Occasionally, the
spring-loaded pin may be missing from the set!
Equipment
• MRI-compatible graphite tongs and titanium pins have lower failure loads
because of deformation. Stainless steel tongs are therefore recommended if
greater than 50 lb of traction are anticipated.
Step 2
An initial weight of 10 lb is applied.
The neurologic examination is repeated and a lateral radiograph is taken.
Step 2 Pearls
• Small doses of intravenous diazepam can be administered to aid in muscle
relaxation. The patient should, however, be kept awake and conversive<
throughout.
Step 2 Pitfalls
• A small amount of weight (10 lb) is used initially to avoid overdistraction of
unstable injury patterns, such as occult instability at the occipital-cervical
junction.
Step 3
Weights are increased at 5- to 10-lb increments at intervals of 20 to 30 minutes
to overcome muscle spasm and to obtain a soft tissue creep effect.
Serial neurologic examinations and radiographs are obtained after each increase
in weight.
Step 3 Pearls
• To reduce a facet dislocation that is not associated with a fracture, a exion
moment helps unlock the dislocated facet(s) (Figures 1-5 and 1-6).
• This can be achieved by posteriorly placed pins or by raising the height of the
pulley.
FIGURE 1-5FIGURE 1-6
Step 3 Pitfalls
• If overdistraction or neurologic deterioration occurs, the weights should be
immediately removed.
Equipment
• In general, the amount of weight required depends on the level of the injury
(5 kg per level).
• More weight is generally required to reduce a unilateral facet dislocation than a
bilateral facet dislocation.
Controversies
• Some authors have recommended weight limits of 66 to 70 lb. Other authors have
reported use of up to 140 lb.
Step 4: Reduction of Unilateral Facet Dislocation
Manipulation may assist in the final reduction of dislocated facets.
An axial load is applied to the normal facet while the head is rotated 30 to 40
degrees past midline in the direction of the dislocated facet (Figure 1-7).
Stop the reduction once resistance is felt, and verify the reduction
radiographically.FIGURE 1-7
Step 4 Pearls
• Facets should be distracted to a perched position before attempting manipulative
reduction.
Step 5: Reduction of Bilateral Facet Dislocation
An anteriorly directed force is applied just caudal to the level of the dislocation,
which is usually palpable as a stepoff in the spinous processes (Figure 1-8).
The head is rotated 30 to 40 degrees beyond midline toward one side, then the
maneuver is repeated toward the opposite side if successful.
FIGURE 1-8
Step 5 Pearls• Facets should be distracted to a perched position before attempting manipulative
reduction.
Step 5 Pitfalls
• An irreducible bilateral facet dislocation is unstable and should be treated with
urgent open reduction (after MRI evaluation is performed).
Postoperative Care and Expected Outcomes
After reduction is achieved, traction weight typically can be reduced to about 10
to 20 lb.
After removal of the tongs, the pin sites should be cleaned with a saline-soaked
gauze. In rare cases where signi3cant bleeding is encountered, stapling the pin
site can achieve hemostasis.
Postoperative Pearls
• A Rota-Rest bed can be useful at this stage, while the patient awaits de3nitive
treatment.
Postoperative Pitfalls
• Tongs should be retightened 24 hours after initial application until the indicator
again protrudes 1 mm from the flat surface of the pinhead.
Evidence
Cotler HB, Miller LS, DeLucia FA, Cotler JM, Davne SH. Closed reduction of cervical
spine dislocations. Clin Orthop Rel Res. 1987;214:185-199.
A cadaver study was performed to delineate the anatomy of pin placement, in
addition to a review of 24 patients with cervical facet dislocations treated with closed
reduction and traction. Ninety percent of patients improved at least one Frankel grade, and
71% were treated successfully with closed reduction.
Cotler JM, Herbison GJ, Nasuti JF, et al. Closed reduction of traumatic cervical spine
dislocation using traction weights to 140 pounds. Spine. 1993;18:386-390.
This review of 24 cases demonstrates that traction weights of up to 140 lb can be used
safely in the reduction of facet dislocations without associated fractures. Seventeen
patients in this series required more than 50 lb for successful reduction, with total time to
successful reduction ranging from 8 to 187 minutes. None of the patients had worsening
neurologic status during or after the procedure.
Grauer JN, Vaccaro AR, Lee JY, et al. The timing and influence of MRI on the
management of patients with cervical facet dislocations remains highly variable:
a survey of members of the Spine Trauma Study Group. J Spinal Disord Tech.
2009;22:96-99.Questionnaire study presented to 25 fellowship-trained spine surgeons. Substantial
variability in the timing and utilization of magnetic resonance imaging (MRI) and closed
reduction techniques for patients with cervical facet dislocations was demonstrated.
Neurosurgeons were signi4cantly more likely than orthopedic surgeons to order an MRI
before open or closed treatment.
Hadley MN. Initial closed reduction of cervical spine fracture-dislocation injuries.
Neurosurgery. 2002;50:S44-S50.
Qualitative review of English language citations until 2001 found insu6 cient evidence
to support formal treatment standards or guidelines on initial closed reduction of cervical
fracture dislocations. Patients who cannot be examined during attempted closed reduction
or open reduction by posterior approach should undergo MRI before the procedure.
Littleton K, Curcin A, Novak V, Belkoff S. Insertion force measurement of cervical
traction tongs: a biomechanical study. J Orthop Trauma. 2000;14:505-508.
Biomechanical study on cadaver specimens that demonstrated that overtightening of
pins can result in substantial increases in force exceeding that needed to penetrate the
skull. In addition, the possible complications of tong placement are discussed.
Vaccaro AR, Falatyn SP, Flanders AE, et al. Magnetic resonance evaluation of the
intervertebral disc, spinal ligaments, and spinal cord before and after closed
traction reduction of cervical spine dislocations. Spine. 1998;24:1210-1217.
Prospective study utilizing MRI to evaluate the incidence of intervertebral disk
herniations and ligamentous injuries before and after closed traction reduction of facet
dislocations. Of 11 patients in the study, nine had successful closed reduction, two had
disk herniations on pretraction MRI, and 4ve had disk herniations on post-traction MRI.
None of the patients who sustained disk herniations during the reduction developed
neurologic deficits.
Vital J, Gille O, Sénégas J, Pointillart V. Reduction technique for uniarticular and
biarticular dislocations of the lower cervical spine. Spine. 1998;23:949-954.
This is a review of 168 consecutive cases of lower cervical facet dislocations treated
with gradual traction, followed by closed reduction under anesthesia and, 4nally, open
reduction when necessary. Fifty-nine percent of unilateral dislocations and 73% of bilateral
dislocations were treated successfully with closed reduction techniques or traction alone.Procedure 2
Halo Placement in the Pediatric and Adult Patient
Neil A. Manson, Howard S. An
Indications
Jefferson fracture
Odontoid fracture: type III or specific type II
Hangman’s fracture: type II
One-column bony cervical spine fracture
Fracture in ankylosing spondylitis
Preoperative traction or stabilization
Postoperative stabilization of arthrodesis, infection, tumor resection
Indications Pitfalls
• Skull injury
• Skin injury
• Sensory loss (spinal cord injury)
• Associated injury: thoracic, abdominal, musculoskeletal
Treatment Options
• Consider rigid collar immobilization in a compliant, young, healthy patient with
a minimally displaced, stable fracture.
• Consider surgical intervention in an elderly or noncompliant patient with an
unstable or displaced fracture, a fracture of high nonunion potential,
ligamentous injury, or associated injury.
• Move to surgical intervention for failure of halo , xation: loss of fracture
alignment, symptomatic nonunion, neurologic deterioration.
Examination/Imaging
Computed tomography (CT) is required to de, ne fracture morphology and
stability and rule out adjacent or noncontiguous injuries (Como et al, 2009)
(Figure 2-1, A-C).
Radiographs con, rm fracture reduction and cervical alignment following halo
application, and maintenance of these parameters during treatment (Figure 2-2).
FIGURE 2-1, A-C
Courtesy Dr. G. Kolyvas.
FIGURE 2-2
Courtesy Dr. G. Kolyvas.
Surgical Anatomy
Relevant anatomy pertains to pin placement. Correct placement prevents direct
neural or vascular injury, inner calvarial plate penetration, and pin migration,
while providing adequate strength of fixation.
Anterior pins
• Safe zone of placement: anterolateral skull, 1 cm superior to the orbital rim(eyebrow), above the lateral two-thirds of the orbit, and below the greatest
circumference of the skull
• Structures to avoid (medial to lateral): frontal sinus, supratrochlear nerve,
supraorbital nerve, zygomaticotemporal nerve, temporal artery, temporalis
muscle (Kang et al, 2003) (Figure 2-3, A and B)
Posterior pins
• Placement: posterolateral skull, at 4 o’clock and 8 o’clock positions or
approximately diagonal to the corresponding contralateral anterior pins,
below the greatest circumference of the skull and above the upper helix of the
ear.
• There are no specific structures to avoid.
FIGURE 2-3 A, Anterolateral view. B, Posterolateral view.Pearls
• It is preferable if the patient is awake and responsive to report any progression
of pain or neurologic loss. Light sedation (midazolam) may be provided for
comfort.
• Crash-cart access should be assured during halo application.
Equipment
• Ensure that all necessary equipment is available before halo application
(adapted from Botte et al, 1995):
• Sterile halo ring/crown in preselected size
• Sterile halo pins
• Halo torque screwdrivers or breakaway wrenches
• Halo-pin locknuts
• Halo vest in preselected size
• Halo upright post and connecting rods
• Headboard
• Spanners or ratchet wrenches
• Iodine solution
• Iodine ointment
• Sterile gloves
• Syringes
• Needles
• Lidocaine for injection
• Crash cart (including airway supplies, endotracheal tube)
• Three people are recommended during application.
• Measure head and chest circumference and obtain appropriate size halo and vest
before halo application.
Positioning
Typical halo application is performed in the supine position utilizing in-line
cervical stabilization by a knowledgeable care provider while two providers
apply the apparatus.
For stable fractures or nonfracture treatment, halo application in the upright
position is preferred to optimize cranial-cervical-thoracic alignment and patient
comfort.
A cervical collar can provide additional stability until the halo construct is
completed.
Positioning Pearls
• Before supine halo application, consider positioning the vest’s posterior shell
under the patient to minimize movements during the application process. This
could take place, for example, when transferring the patient to an operatingroom table for the application process.
Positioning Pitfalls
• The patient’s eyelids should be closed and relaxed during application. Pin
malposition or sliding during insertion may tent the periorbital tissues and limit
eyelid closure. This should be avoided.
Controversies
• The traditional construct utilizes four pins of 8 inch-pounds torque each. Cadaver
and clinical studies have demonstrated improved stability and decreased pin-site
complications with six- and eight-pin constructs.
Procedure: Halo Application
Step 1: Crown and Pin Placement
Identify proper crown size: small for 48- to 58-cm head circumference, large for
58- to 66-cm head circumference. Choose the smallest crown size that allows at
least 1 cm of space between head and crown.
Identify proper pin sites as previously described in the “Surgical Anatomy”
section of this chapter.
Shave hair at posterior sites and cleanse skin at all sites with Betadine or alcohol
preparation.
Instruct patient to keep eyes closed and face musculature relaxed.
Utilize positioning pins to align and maintain halo position: 1 cm above eyebrow
and top of ear and below largest circumference of the head.
Inject 1% lidocaine with epinephrine at the intended pin sites. Pass the needle
through the pin holes of the halo ring to optimize anesthetic positioning. Inject
from skin though to periosteum for patient comfort during pin placement.
Traditionally, four pins provide halo fixation.
Initial skin incision at the pin sites is not necessary and does not inDuence scar
formation.
Placement of all pins should occur simultaneously to maintain halo position and
balance pin forces. Simultaneous advancement to the skin, through the soft
tissue, and to the skull should occur, with , nal security achieved with release of
the breakaway torque-limiting caps (Figure 2-4) (Depuy Spine Bremer Halo
Systems technical monograph).
Confirm torque to 8 inch-pounds utilizing a torque wrench.
With pins secure to the skull, tighten the locking nuts to secure the pins to the
halo ring.
Areas of tethered or tented skin surrounding the pins can be released using a
scalpel as needed.FIGURE 2-4
Step 2: Vest Application
Identify proper vest size based on chest circumference 5 cm below the xiphoid
process and patient height: short vest for circumference of 70 to 97 cm and
height less than 170 cm, large vest for circumference up to 112 cm and height
greater than 170 cm.
In-line cervical stabilization is maintained as required.
Logrolling or trunk elevation allows placement of the posterior shell of the vest
(Magnum and Sunderland, 1993) (Figure 2-5).
The anterior shell is positioned and secured to the posterior shell. The vertical bars are secured on the vest and positioned for fixation to the crown.
FIGURE 2-5
Step 2 Pitfalls
• Patient obesity may necessitate custom vest sizing or preclude halo management
altogether.
Step 3: Construct Alignment
Each posterior vertical bar is attached to its ipsilateral anterior bar by the
horizontal crown connector. Loosen all joints within the construct to allow
appropriate alignment of the bars relative to the crown.
Time spent in optimizing bar position before attachment to the crown will
minimize patient discomfort and risk of loss of cervical alignment, which can
occur when adjustments are made with the construct secured to the crown
(Magnum and Sunderland, 1993) (Figure 2-6).
Ensure symmetry between left and right bar constructs.
Final tightening of all joints of the crown and vest construct should provide
security with no concern for loosening.
Only when , nal stability is obtained may the rigid collar be removed and in-line
stabilization released.
Final cranial-cervical-thoracic alignment is crucial to: (1) maintain fracture
alignment, (2) provide patient comfort, and (3) optimize patient function,
specifically concerning normal vision and swallowing ability.FIGURE 2-6
Step 3 Pitfalls
• A linear correlation has been demonstrated between increased cervical extension
and increased risk of laryngeal penetration and aspiration, secondary to
swallowing dysfunction. Optimizing sagittal alignment can limit this signi, cant
complication.
Step 3 Pearls• Application tools should be kept at the bedside or taped to the vest in case
emergency removal of the vest is required.
Step 4: Follow-up
Immediate follow-up
• Imaging is required to confirm cervical alignment and/or fracture alignment.
Lateral radiograph is standard.
• If possible, sit patient upright to assess cervical alignment, construct security,
and patient comfort.
Short-term follow-up
• Further imaging (radiographs or computed tomography) is obtained as
needed.
• Retightening of pins is performed at 24 hours after halo application. Locking
nuts are first loosened and each pin is retightened to 8 inch-pounds utilizing
the torque wrench. Locking nuts are retightened. All joints of the crown-vest
construct are retightened.
Procedure: Halo Application in the Child or Infant
Relevant diHerences in halo application in the pediatric population pertain to
skull thickness, skull hardness, and the presence of open cranial sutures. Cranial
penetration must be avoided.
Consider general anesthesia depending on age and diagnosis. Although an
anesthetized patient cannot provide feedback regarding neurologic status, this
may be irrelevant in the very young child or infant.
A custom crown and vest may be necessary, although pediatric sizes are
available.
Consider preapplication computed tomography to identify cranial sutures and
plan pin placement (Mubarak et al, 1989) (Figure 2-7).
Eight to 10 pins are utilized to provide stable fixation at lower torque forces.
Torque to 2 inch-pounds utilizing a torque wrench. Consider torquing to , nger
tightness only in the very young child or infant.FIGURE 2-7
Pitfalls
• Beware of halo use in the extremes of ages. In the very young, skull thickness
and frequent falls during typical pediatric ambulation increase complications. In
the elderly, cardiopulmonary dysfunction leads to signi, cantly increased
morbidity and mortality. Some clinicians question the safety of this tool in the
elderly (Majercik et al, 2005).
Postoperative Care and Expected Outcomes
Long-term follow-up
• Pin retightening at 1 week after halo application
♦ Pins require removal and replacement at a new site for infection or if no
resistance is met within the first few turns during retightening.
• Pin-site care twice daily
♦ Inspection for crusting, drainage, redness, or swelling
♦ Cleansing using hydrogen peroxide (full or half strength)
♦ Reporting any changes to the care team
• Patient education regarding self-care and independence: Magnum and
Sunderland (1993) provides valuable information.
• Complications are high but manageable through meticulous care and
awareness.
Final care
• One third of patients regard their pin scars as severe. During removal of the
halo, the pin sites should be massaged with peroxide-saturated gauze to
loosen adhesions between skin and bone. The patient should move the skin
over the pin holes for several days to prevent reattachment of adhesions and
thus minimize scarring.Postoperative Pearls
• Careful halo application emphasizing pin placement, torque, and reevaluation
combined with diligent pin-site care has been proven to decrease the rate of
complications associated with halo fixation.
Postoperative Pitfalls
• Complications, although virtually ensured during the treatment period, are most
often minor and can be well controlled with diligent care.
• Complications related to halo application include the following (adapted from
Botte et al, 1995):
• Pin loosening: 36%-60%
• Pin-site infection: 20%-22%
• Severe pin discomfort: 18%
• Ring migration: 13%
• Pressure sores: 4%-11%
• Redislocation: 10%
• Restricted breathing from the vest: 8%
• Difficulty with arm elevation from the vest: 23%
• Pneumonia: 5%
• Nerve injury: 2%
• Bleeding at pin sites: 1%
• Dural puncture: 1%
• Neurologic deterioration: 1%
Evidence
Botte MJ, Byrne TP, Abrams RA, Garfin SR. The halo skeletal fixator: current
concepts of application and maintenance. Orthopedics. 1995;18:463-471.
Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for
identification of cervical spine injuries following trauma: update from the eastern
association for the surgery of trauma practice management guidelines committee.
J Trauma. 2009;67:651-659.
Kang M, Vives MJ, Vaccaro AR. The halo vest: principles of application and
management of complications. J Spinal Cord Med. 2003;26:186-192.
Letts M, Girouard L, Yeadon A. Mechanical evaluation of four versus eight-pin halo
fixation. J Pediatr Orthop. 1997;17:121-124.
Magnum S, Sunderland PM. A comprehensive guide to the halo brace. AORN J.
1993;58:534-546.
Majercik S, Tashjian RZ, Biffl WL, Harrington DT, Coiffi WG. Halo vest
immobilization in the elderly: a death sentence? J Trauma. 2005;59:350-357.
Manthey DE. Halo traction device. Emerg Med Clin North Am. 1994;12:771-778.
Morishima N, Ohota K, Miura Y. The influence of halo-vest fixation and cervical
hyperextension on swallowing in healthy volunteers. Spine. 2005;30:e179-e182.
Mubarak SJ, Camp JF, Vuletich W, Wenger DR, Garfin SR. Halo application in theinfant. J Pediatr Orthop. 1989;9:612-614.
Nemeth JA, Mattingly LG. Six-pin halo fixation and the resulting prevalence of
pinsite complications. J Bone Joint Surg Am. 2001;83:377-382.
Polin RS, Szabo T, Bogaev CA, Replogle RE, Jane JA. Nonoperative management of
types II and III odontoid fractures: the Philadelphia collar versus the halo vest.
Neurosurgery. 1996;38:450-457.
Product monograph. Bremer Halo Crown Traction Set. Bremer Halo Systems,
Raynham, Mass., 2003.
Procedure 3
Anterior Odontoid Resection
The Transoral Approach
George M. Ghobrial, Eli M. Baron, David Choi, Harminder
Singh, James S. Harrop, J. Patrick Johnson, Alexander R.
Vaccaro, H. Alan Crockard
Indications
Generally, for the correction of irreducible, ventral compression of the
cervicomedullary junction.
Speci cally, for ventral extradural, midline pathology from the lower clivus to the C2-3
disk. Anticipated dissection should not extend laterally more than 11 mm on either side
of the midline, as this may result in damage to the eustachian tubes, hypoglossal
nerves, or vertebral arteries.
Commonly used to decompress neural elements, typically in patients with rheumatoid
arthritis. Cervicomedullary neural compression may be due to
• Craniovertebral settling resulting from rheumatoid or degenerative disease
• Pseudotumor or rheumatoid pannus
• Extradural primary bone or soft tissue tumors
• Congenital basilar invagination
• Irreducible chronic nonunion of a fractured odontoid process causing neural
compression
As part of a staged procedure, may be used to excise a chordoma or other midline
extradural tumor at the craniocervical junction
May very occasionally be used for midline intradural pathology, such as meningiomas
and schwannomas, usually as part of a staged procedure.
Examination/Imaging
Neurologic and musculoskeletal examination
• Rotary subluxation is a relative contraindication to this procedure, as is irreducible
torticollis.
• Careful examination of the oral and pharyngeal region
♦ The relationship of the hard palate to the pathology must be studied: a hard
palate located above the level of pathology allows for good access.
♦ The mouth should be able to be opened more than 25 mm. This is required to
obtain adequate visualization of the pathology, and provide adequate access for
surgical instruments.
♦ Close attention must be paid to the patient’s teeth: Root abscesses and
periodontal sepsis may be significant risk factors for postoperative infection. Any
irregularities in dentition should be noted, as they may make retractor placement
difficult.
♦ A gum guard, which fits both the irregular dentition and the retractors, can be


fashioned before surgery.
♦ Temporomandibular pathology should be taken into consideration as this may
limit mouth opening and hinder a transoral approach.
• Good neck extension is required. Fixed flexion deformities of the neck can prevent
sufficient mouth opening, and limit surgical access.
• A preoperative otorhinolaryngologic assessment should be performed to rule out any
lower cranial nerve dysfunction. If there is vocal cord, pharyngeal, or brainstem
dysfunction, then a preoperative tracheostomy should be considered.
Preoperative imaging should include multiplanar radiographs of the cervical spine,
computed tomography (CT) with sagittal and coronal reformatting, and magnetic
resonance imaging (MRI) to clearly de ne any soft tissue pathology and the degree of
neural compression (Figure 3-1).
CT reformatted images provide detailed information about the bony elements and can
be beneficial in planning posterior instrumentation procedures.
Image guidance has been used as an adjunct for anterior odontoid resection, including
frameless stereotaxy and intraoperative MRI. However, frameless stereotaxy may be
inaccurate because of the mobility of the craniocervical junction.
Magnetic resonance angiography (MRA) may be bene cial in de ning the vascular
anatomy and relationship of the vertebral arteries to the midline, as well as dominance
of one vessel.
In the treatment of patients with rheumatoid arthritis, it is suggested that anti-tumor
necrosis factor be held 2 to 4 weeks before surgery and up to 2 weeks after. There is no
definitive evidence to suggest methotrexate should be discontinued perioperatively.

FIGURE 3-1, A-B
Treatment Options
• Anterior odontoid resection through the transoral approach (transoral-transpharyngeal,
with or without palatotomy)
• Combined anterior odontoid resection through the transoral approach, followed by
posterior stabilization with possible decompression
• Standalone posterior stabilization with possible decompression
• Adjunctive traction reduction (in setting of reducible basilar invagination or
atlantoaxial subluxation), followed by posterior stabilization
Surgical Anatomy
Understanding the ligaments of the craniovertebral junction is vital when operating in
this region.
The atlas is united to the occipital bone by the anterior and posterior atlanto-occipital
membranes.
The atlantoaxial joint consists of four articulations and two key ligaments. Two
synovial joints for each lateral mass and two odontoid joints, on the anterior and
posterior aspects.
The alar ligament arises laterally from the odontoid to attach to the occipital condyles.
The apical ligament runs from the odontoid process to the anterior margin of the
foramen magnum. Disruption of any of the aforementioned ligamentous structures runs
an increased risk for basilar invagination.
The cruciate ligament runs from the atlas to the axis anteriorly. Atlantoaxial
dissociation results from damage to this ligament, requiring surgical intervention.
Below the foramen magnum, the oropharynx is separated from the prevertebral fascia
by a well-de ned areolar plane (Figure 3-2). The oropharyngeal mucosa heals
remarkably well after surgical incision and repair.
The most important bony anatomic landmarks for the transoral approach are the
midline structures: rostrally, the septal attachment to the sphenoid, the pharyngeal
tubercle on the clivus; and caudally, the anterior tubercle of the C1 arch. The longus
colli muscles ; ank the dens on each side and, more laterally, the longus capitis
muscles.
The anterior longitudinal ligament extends caudally in the midline.
• Knowledge of the location of the vertebral arteries is requisite before performing a
transoral procedure.
• The vertebral arteries are located 24 mm laterally from the midline at the level of
the arch of C1, and approximately 11 mm from the midline at the C2-3 disk space
as well as the level of the foramen magnum.
• Pathology such as atlantoaxial rotary subluxation can significantly distort the
relationship of the vertebral arteries to the midline.
• Visually, the anatomic midline can be accurately defined by examining the
symmetry of the anterior longitudinal ligament and the longus colli muscles.

FIGURE 3-2, A-C
Positioning
Neurophysiologic monitoring electrodes for somatosensory-evoked potential and
transcranial motor-evoked potential monitoring are placed first.
Fiberoptic nasotracheal intubation is then performed.
A nasogastric tube should also be placed for intraoperative gastric drainage and
postoperative feeding.
The patient’s head can be xed in a three-pin xation system with slight extension.
Alternatively, a horseshoe with Gardner-Wells traction or the head resting on a circular
headrest can be used.




Extension should not be used in patients with xed cervical kyphosis. Rather, they
should be placed in slight Trendelenburg position to assist in the rostral extent of the
dissection. One caveat to this would be the limitations in positioning caused by cervical
instability or cervicomedullary compression; in this case, positioning is done cautiously
with neuromonitoring.
Positioning Pearls
• Because many patients have inherent spinal instability, perisurgical neck
immobilization may be required. Halo immobilization, however, will limit neck
extension and surgical exposure.
• The placement of topical 1% hydrocortisone on the oral mucosa, before and after
surgery, may reduce the incidence of lip and tongue swelling.
Positioning Pitfalls
• Inability to widely open the mouth is a relative contraindication to this procedure. As a
general rule, in the adult population, if you cannot place three ngers into the mouth
of a patient with his or her mouth fully opened, the transoral approach should be
avoided. Otherwise, splitting the mandible and tongue may be needed for adequate
exposure.
• Alternatively, patients may be positioned laterally in a May eld clamp (Figure 3-3).
The advantages of this position are that blood and washings drain out of the operative
eld. The head is placed in slight extension, which improves exposure. The table may
be tilted laterally, allowing optimal positioning for the patient and surgeon. After the
initial procedure, a posterior stabilization can be performed after reversing the lateral
tilt.
• A ; uoroscopy unit is then brought in following positioning to con rm adequate
positioning and spinal alignment.
FIGURE 3-3
Portals/Exposures
Oral swabs can be obtained for culture to identify bacterial colonization before
preparation of the mouth and oropharynx with 1% Betadine or cetrimide.
The upper esophagus should be packed with a collagen sponge or gauze to minimize
the ingestion of saline and blood.
The midlines of the oropharyngeal mucosa and soft palate are in ltrated with 1%
lidocaine with epinephrine (1:100,000). A Crockard transoral retractor system
(Codman, Raynham, Mass.) is used to maintain adequate exposure of the posterior oral
cavity and to keep the nasotracheal and nasogastric tubes to one side, out of the
surgeon’s way (Figures 3-4 and 3-5).
A tongue blade and soft palate retractors maximize the exposure.
To extend superior and lateral exposure, the soft palate may be split at the midline
from hard palate to the uvula.
The uvula may be secured with a red rubber catheter and retracted along with the soft
palate through the nares to avoid problems with swallowing and phonation
postoperatively. After incision of the posterior pharyngeal wall, a Crockard toothed
self-retaining retractor is inserted for lateral retraction to expose the underlying
anterior longitudinal ligament and longus colli muscles.
With or without the aid of lateral fluoroscopy, the extent of the incision is from the base
of the clivus to the upper border of the C3 vertebra.
Alternative techniques
• Another technique is to use endotracheal intubation with the Spetzler-Sonntag
retractor system (Aesculap, San Francisco). This system protects and retracts the
endotracheal tube and tongue, whereas the Crockard system displaces the
nasotracheal tube out of the way.
• The soft palate may also be retracted using sutures through the soft palate, which
are brought out via the nares after they are secured to vessel loops that were passed
through the nostrils into the nasopharynx (Spetzler technique) (Hadley et al, 1988).
Alternatively, the soft palate may be divided in the midline (offset to avoid the
uvula) and retracted with sutures hanging out of the mouth (Crockard, 1995).

FIGURE 3-4, A-B
FIGURE 3-5
Procedure
Step 1
The anterior ridge or tubercle of the atlas is palpated. At this point, a con rmatory
lateral localizing image may be taken. An operating microscope can then be used, or a
surgeon may choose loupe magnification with directed illumination.
A vertical incision is made extending approximately 2.5 cm superiorly and 2.5 to
3.0 cm inferiorly along the midline of the posterior oropharynx (Figure 3-6).
The extent of the exposure obtained with this incision will be approximately 15 to
20 mm bilaterally from the midline incision.
Dissection is taken through the posterior pharyngeal mucosa, the superior constrictor

muscles of the pharynx, and the anterior longitudinal ligament.
Incising the soft (and sometimes hard) palate can provide additional visualization of
the lower clivus if needed.
Using periosteal elevators and electrocautery, a subperiosteal dissection exposes the
arch of C1, as well as the anterior bodies of C2 and C3.
The longus colli and longus capitis muscles are detached medially to laterally from the
cervical vertebra.
In the presence of instability, there may be a large amount of granulation tissue at the
level of the inferior margin of the atlas and its junction with the anterior odontoid peg.
Toothed retractor blades are then used to retract the dissected soft tissues laterally. This
allows excellent visualization of the midline inferior clivus, the atlas, and the axis.
FIGURE 3-6
Step 1 Pitfalls
• Great care should be taken to avoid cerebrospinal ; uid (CSF) leakage in order to
minimize the risk of postoperative meningitis. A preoperative lumbar drain should be
placed when an intradural approach is anticipated. In such procedures, fat, muscle,
fascia lata, or a dermal fat graft should be used in the repair of any dural opening,
followed by the application of fibrin glue.
• With an incision from the inferior clivus to the superior border of C3, an operating eld
of 15 to 20 mm bilaterally can be exposed. Beyond that, there is an increased risk of
trauma to the eustachian tube, hypoglossal nerve, vidian nerve, and vertebral artery
at the C1-2 interspace.
• Given the large vascular channels and venous sinusoids in this region, postoperative
hematoma formation may be a problem. This can be minimized by meticulous
hemostasis, using Avitene, Surgicel, Gelfoam, or brin glue, and postoperative nursing
in the head-up position. Bleeding from the rheumatoid pannus or small arterial feeders
can be controlled with bipolar electrocautery. If an intradural procedure is performed,
watertight dural closure is very important to minimize the risk of infection. Suturing or
clipping the dura will rarely close the defect completely. A free dermal fat graft,
pharyngeal mucosal rotation ; aps, or nasal septal mucosal ; aps help provide a
watertight closure, and a lumbar drain may also be used.
Step 2
A match-head burr is used to remove the anterior arch of the atlas out laterally
approximately 1 cm to each side of the midline (about two thirds of the arch, exposing
the shoulder of the dens bilaterally) (Figure 3-7). The odontoid mass and pannus (if
present) are then resected in a rostrocaudal direction (starting at the top of the
odontoid process) using a combination of drilling and curetting.
Alternatively, the odontoid process may be initially drilled at its base and disarticulated
from the C2 body. The odontoid peg is hollowed out gradually with a 3-mm cutting
burr down to the cortical bone, which is then thinned and removed with a match-head
or diamond burr. The alar and apical ligaments are sharply divided, taking care not to
cause a CSF leak. The proximal peg is then removed after circumferentially elevating
oF all soft tissue attachments. This is facilitated by grasping the odontoid peg with
special forceps and pulling it down from the foramen magnum while elevating the dura
oF it. This allows complete removal of the dens. This technique has a greater potential
for durotomy, particularly in the pediatric population, in whom the odontoid process
may have a hook at its apex that can tear the dura during peg removal.
The posterior longitudinal ligament is seen behind the dens, which has now been
removed. The bers of the transverse ligament are also visualized at the level of the
removed C1 anterior arch. With division of these ligaments, the dura should be clearly
seen. Ligament and soft tissue removal can be accomplished with a series of small
angled curettes, transsphenoidal punches, and transoral bayoneted forceps. Typically,
a gap exists between the ligaments and dura. Decompression is considered adequate
when the dura pulsates freely and the lateral curvature of the dura is seen bilaterally.
Fluoroscopy may be used to confirm adequate decompression.
Any venous bleeding can be controlled with Surgicel and fibrin glue (Figure 3-8, A).
Extended approaches
• In addition to the standard transoral technique, extended approaches can be
performed to widen the surgical exposure of the craniocervical junction.
• A mandibulotomy can be made to increase the cervical exposure by first incising the
lip in the midline, then more inferiorly through the gingival, mandible, and finally
the hyoid. The mucosa is divided beneath the tongue, sparing the submaxillary
ducts, with retraction of the mandible laterally to allow for the depression of the
tongue to maximize the exposure of the craniocervical junction superiorly and
inferiorly.
• A mandibuloglossotomy extends the above approach to include the middle clivus to
the C3-4 vertebral bodies inferiorly.
• A palatotomy can be made by extending the midline incision of the soft palate,
sparing the uvula. The posterior connection of the vomer can be disconnected, as
well as the hard palate separated then retracted laterally.
• A more extensive bilateral mucogingival extension can be performed along the
maxilla, with a subperiosteal dissection, effectively degloving the face. The superior
limit of muscle and mucosa dissection off of the maxilla is the infraorbital nerve.
Bilateral osteotomies are made from the piriform aperture to the maxillary alveolus.
The maxilla is disarticulated from the pterygomaxillary fissure. An inferior
turbinectomy is made. The nasal mucosa is reflected off of the nasal septum as well
as the sphenoid bone for a superior exposure. Concern for this extensive approach is
preservation of the vascular supply namely via the palatine arteries.
FIGURE 3-7, A-B


FIGURE 3-8, A-B
Step 3
The posterior pharyngeal wall is then closed with a two-layered closure using 3-0 Vicryl
sutures (Figure 3-8, B).
Despite the presence of bacterial ; ora in the oral cavity, a low infection rate of less
than 3% is to be expected if the dura is not breeched. In the presence of a durotomy,
great efforts should be made to close the dura in a watertight manner.
A double layer closure of both the pharyngeal musculature and mucosa is less
susceptible to dehiscence.
In the presence of durotomy, a watertight closure may be aided with the application of
fat, fascia, dermal fat graft, and brin glue. Additionally, a lumbar drain should be
used for about 5 days with regular drainage of CSF (10 to 15 mL/hr).
Postoperative Care and Expected Outcomes
Postoperatively, the nasotracheal tube is left in place for 24 to 48 hours. It should only
be removed if there is no evidence of significant labial or lingual swelling.
The patient should be left in a halo vest, Minerva jacket, rigid collar, or traction if a
posterior stabilization has not been performed at the initial procedure.
The patient should be encouraged to sit up and to ambulate, if possible, to minimize
saliva pooling in the pharynx and the potential for breakdown of the incision.
The patient should take nothing by mouth for 5 days after the operation. Nasogastric
feeding may commence after 5 hours.
Hydrocortisone ointment should be applied to the tongue and mucosa for the rst 48
hours.
In the event of a durotomy, lumbar drainage should be maintained for 5 to 10 days.
Prophylactic antibiotic therapy directed against gram-positive, gram-negative, and
anaerobic oral ; ora may be administered by some surgeons. For example, Menezes
(1991) recommended CSF cultures for the initial 5 days, at which point, if the cultures
remain negative, antibiotics may be stopped. Occasionally, a lumbar-peritoneal shunt
may be required for persistent CSF leakage.
The main predictor of outcome is the degree of preoperative neurologic impairment.
Rheumatoid patients who are unable to walk due to myelopathy (Ranawat
classification IIIb) have a much higher mortality.


Complications
• Airway complications are always a concern with the transoral approach. It is the
practice of the senior author to leave the endotracheal tube in place for a minimum of
24 hours following surgery. If after this time there is evidence of swelling of the
tongue or oral cavity, the endotracheal tube is left in situ until the swelling subsides.
The occurrence of lingual swelling may be minimized by intermittent intraoperative
release of the retractor, and ensuring the tongue is not trapped between the retractor
blade and the lower teeth.
• Delayed complications may include tongue swelling, meningitis, palatal/pharyngeal
dehiscence, neurologic deterioration, retropharyngeal abscess, late pharyngeal
bleeding, and velopalatine incompetence. Pharyngeal dehiscence may occur either
early or late. Early dehiscence (during the rst 7 days after surgery) is typically due to
inadequate closure or starting oral feeding too early. This can be minimized by
encouraging the patient to sit up and walk as soon as possible to prevent pooling of
saliva at the apex or weakest point of the pharyngeal incision. If early dehiscence
occurs, closure should be attempted (with the assistance of head and neck specialists if
required), followed by hyperalimentation and intravenous antibiotics. In cases of late
dehiscence, infection needs to be ruled out. The diFerential diagnosis of late
dehiscence includes osteomyelitis, retropharyngeal abscess, and poor nutrition.
Management of retropharyngeal abscess includes lateral drainage (rather than
transoral), followed by appropriate intravenous antibiotics, hyperalimentation
through a nasogastric feeding tube, and neck immobilization.
• Neurologic deterioration after transoral odontoid resection is most likely to be due to
craniocervical instability. The vast majority of patients who undergo this procedure
require a posterior stabilization procedure.
• In patients with altered mental status following the transoral approach, meningitis
must be kept at the forefront of the diFerential diagnosis. This is particularly true in
the elderly population with rheumatoid arthritis, in whom this diagnosis may be
overlooked because confusion in this age group can be common in the critical care
setting.
• Late retropharyngeal bleeding may indicate an underlying infection. Osteomyelitis and
pseudoaneurysm of the vertebral artery must also be ruled out. MRI/MRA evaluation
of the craniovertebral junction should be performed in addition to angiography to rule
out vascular involvement. This diagnostic process also allows for potential therapeutic
endovascular treatment in cases of vertebral artery compromise.
• Velopalatine incompetence (incorrect closure of the soft palate muscle during speech
resulting in a nasal voice) occurs more commonly in children than in adults. It
typically occurs 4 to 6 months after the transoral procedure and probably occurs
secondary to contracture of the soft palate and nasopharynx. This requires
otorhinolaryngologic evaluation. Usually it is treated with pharyngeal retraining, but
a palatal prosthesis or a pharyngeal flap may also be used.
Evidence
Although little evidence exists as to the long-term efficacy of anterior odontoid resection, with
proper indications, diligent planning, and an understanding of the anatomy of the craniovertebral
junction, the procedure appears to be a highly e ective and safe method of addressing anterior
compressive pathology at the craniocervical junction. A few small studies support the di erent
steps outlined in this technique.
5
4
Apuzzo ML, Weiss MH, Heiden JS. Transoral exposure of the atlantoaxial region.
Neurosurgery. 1978;3:201-207.
This paper reviews the positioning, surgical technique, and postoperative care related to
transoral odontoid resection (Level V evidence [expert opinion]).
Crockard HA. Transoral surgery: some lessons learned. Br J Neurosurg. 1995;9:283-293.
Reviews the author’s experience with the transoral approach and discusses its use in relation
to di erent pathologies. Reviews technical pearls of preoperative patient evaluation and selection,
intraoperative techniques, and postoperative management (Level V evidence).
Crockard HA, Calder I, Ransford AO. One-stage transoral decompression and posterior
fixation in rheumatoid atlanto-axial subluxation. J Bone Joint Surg Br. 1990;72:682-685.
Illustrates how the lateral position can be used for anterior odontoid resection and for
posterior stabilization in the same setting (Level IV evidence [case series]: retrospective series of
68 patients undergoing a combined procedure).
Crockard HA, Sen CN. The transoral approach for the management of intradural lesions at
the craniovertebral junction: review of 7 cases. Neurosurgery. 1991;28:88-97. discussion
97-8
A study examining the transoral approach for intradural pathology, including meningiomas
and schwannomas. Reviews the advantages and disadvantages of this approach in this clinical
setting (Level IV evidence).
Fang HSY, Ong GB. Direct anterior approach to the upper cervical spine. J Bone Joint Surg
Am. 1962;44:1588-1604.
Fang and Ong published a series of patients who underwent transoral decompression of the
spinal cord and brainstem for irreducible compressive atlantoaxial pathology. The high
complication rate with this approach tempered their enthusiasm for the procedure (Level IV
evidence).
Frempong-Boadu AK, Faunce WA, Fessler RG. Endoscopically assisted
transoraltranspharyngeal approach to the craniovertebral junction. Neurosurgery. 2002;51(5
Suppl):S60-S66.
A review of the endoscopic transoral approach (Level IV evidence [case series of 7
patients]).
Hadley MN, Martin NA, Spetzler RF, Sonntag VK, Johnson PC. Comparative transoral dural
closure techniques: a canine model. Neurosurgery. 1988;22:392-397.
This animal study demonstrated the superiority of a brin glue augmented dural closure over
other methods (Level I study: prospective study).
Hsu W, Wolinsky J, Gokaslan Z, Sciubba DM. Transoral approaches to the cervical spine.
Neurosurgery. 2010;66(Suppl. 3):119-125.
A review article highlighting the transoral-transpharyngeal approach to the cervical spine as
well as more recent use of the endoscopic endonasal and endoscopic transcervical approach as an
alternative.
Kaibara T, Hurlbert RJ, Sutherland GR. Transoral resection of axial lesions augmented by
intraoperative magnetic resonance imaging: report of three cases. J Neurosurg Spine.
2001;95:239-242.
Small case study supporting alternative intraoperative imaging in addition to uoroscopy
(Level IV evidence).
Krauss WE, Bledsoe JM, Clarke MJ, Nottmeier EW, Pichelmann MA. Rheumatoid arthritis
of the craniovertebral junction. Neurosurgery. 2010;66(Suppl. 3):83-95.
Review of rheumatoid arthritis at the craniovertebral junction, including the evaluation,
diagnosis, and surgical management.
Menezes AH. Complications of surgery at the craniovertebral junction—avoidance and
management. Pediatr Neurosurg. 1991;17:254-266.