Surgery in and around the craniovertebral junction requires a thorough understanding of the anatomy of the region, careful planning and proper technique. Spanning a wide range of pathologies such as atlanto-axial dislocation, basilar invagination, odontoid fractures and tumors of the craniovertebral junction region these surgeries are complex but at the same time rewarding if performed diligently.
We prefer use of the posterior or lateral approaches to most pathologies, reserving the anterior only for a few cases. Procedures include CV junction fusions including occipitocervical, C1-C2 lateral mass fusion with and without spacers, C1-C2 transarticluar fusion, anterior odontoid screw fixation, foramen magnum decompression and duraplasty with or without syringosubarachnoid shunting.
We take quiet pride in the fact that we have a low complication rate for these surgeries and that many patients’ lives have been changed for the better through it.
CERVICAL SPINE SURGERY
Surgery of the cervical spine encompasses a wide variety of clinical conditions including degenerative disc disease, tumors, trauma, ossified posterior longitudinal ligament and deformity.
Surgery for degenerative disease
Discectomy (with or without fusion)
One of the most common procedures performed in the cervical spine is the discectomy. The disc is approached from the front and the correct level is confirmed using intra-operative imaging. Under microscopic visualization the disc is excised and the area is reconstructed with an autologous bone graft or cage, with or without a plate.
This is similar to the discectomy except that the reconstruction is performed with a disc prosthesis which maintains the mobility of the segment (unlike in fusion where the mobility is lost). This procedure overcomes the potential longer term complication of adjacent level degeneration, which is a possibility in the previous procedure.
Corpectomy with fusion
In some instances, the degeneration can span more than one level which causes thickening of the ligament and can result in compression of the spinal cord. In these cases, a corpectomy is the preferred surgical treatment. It involves excision of the median part of the vertebral body using an operating microscope and a high speed drill. A reconstruction of the defective region is then carried out using an autologous bone graft or cage and plate.
In some cases, a cervical disc prolapse (commonly called a slipped disc but, occurring in the neck) can be addressed using a technique called a lamino-foraminotomy. In this procedure, a surgeon makes a small incision and removes the disc fragment which is compressing the nerve.
Laminectomy with or without lateral mass fusion
Where the disease process spans several segments a posterior approach (called a laminectomy) can be used to decompress neural structures. Since laminectomy has the potential, in the long run, to give rise to deformities it is usually combined with a lateral mass fusion to realign and stabilize adjacent cervical vertebra. In some cases a laminoplasty might also be a viable alternative.
This is largely performed on patients with ossified posterior longitudinal ligament (OPLL). In this procedure, the spinal canal is widened by performing osteotomies of the laminae which are retained to provide stability to the spine. We prefer the techniques of open door laminoplasty and french door laminoplasty.
Surgery for tumours
Common intradural (part of the dura) tumors include schwannomas and meningiomas. These tumors displace and compress the spinal cord and are excised using microsurgical techniques. Intra-operative neuromonitoring goes a long way towards preventing neurological complications. In a large number of cases, the tumour can be, and is, completely excised.
Intramedullary tumors are buried within the substance of the spinal cord itself. An opening (called a myelotomy) is made on the spinal cord and the tumor is decompressed (pressure on it is relieved). It is then dissected away from the surrounding neural tissue using microsurgical techniques.
Surgery for trauma
- Discectomy with fusion
- Corpectomy with fusion
- Lateral mass fusion