Surgical Approach: Anterolateral High Cervical Approach
Anterior approach of high cervical spine particularly occipito-cervical area and atlanto-axis vertebrae remains a demanding surgery.
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Philippe Bancel
Purpose Approach of high cervical spine particularly occipito-cervical area and atlanto-axis vertebrae remains a demanding surgery. Occipito-cervical junction may be involved in different kinds of pathologies: inflammatory, tumours, malformation and degenerative alteration. Sometimes only the anterior part of the spine must be reached. Mobilization of the vertebral artery is then necessary.
Prerequisites A perfect knowledge of the anatomy is necessary. 1. Bone Anatomy. (a) The inferior part of the occiput. (b) The lateral mass of the atlas which will be a major spatial landmark during the approach. 2. Vertebral Artery Anatomy. (a) The suboccipital segment (C2-C0) coursing from C3 to C2 foramen with a first P. Bancel (*) Spine Department, Arago Institute, Paris, France e-mail: [email protected]
loop and then joining the transverse foramen of C1. Then it winds around the lateral mass and posterior arch of C1 (second loop with an horizontal trajectory). (b) Intradural segment: leaving the atlas, the artery passes through the posterior atlanto-occipital membrane into the foramen magnum.
Planning and Diagnostics Indication for approaching the anterolateral high cervical spine varies according to pathologies to be treated. Perfect assessment must be done before surgery including: –– Clinical and neurological examination. –– X-rays, CT-scan and MRI. –– Specific vascular exploration as angiogram, CT angiogram with 3D reconstruction and angio-MRI. These explorations will help to define perfect relationship between lesion and VA, diagnose congenital or acquired anomalies, identify spinal blood supply, predominant VA and realize a vascular procedure (occlusion, embolization).
© Springer Nature Switzerland AG 2019 H. Koller, Y. Robinson (eds.), Cervical Spine Surgery: Standard and Advanced Techniques, https://doi.org/10.1007/978-3-319-93432-7_10
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Patient Positioning Under general anaesthesia and endotracheal intubation, the patient is placed in supine position and in slightly reversed Trendelenburg. The head and the intubation are turned away from the pathologic side. The ear lobe is reversed and applied on the temporomandibular joint, leaving free the mastoid process. A pillar is placed under the upper part of the thorax; the shoulder is lowered using adhesive tape.
Surgical Technique 1. A hockey-stick incision is performed : from the tip of the mastoid process, a vertical arm follow the anterior border of the sternocleidomastoid muscle (SCM) caudally, an horizontal arm follows the upper rim of the mastoid , then the superior occipital line to the external occipital protuberance. The greater auricular nerve is identified and retracted cephalad. The platysma muscle is divided. The deep cervical fascia is incised along the anterior border of the SCM. 2. Detached of the SCM: all the SCM including the anterior tendon from the tip of the mastoid and nuchal muscles are detached from the occiput to the fat tissue. Conversely the digastric muscle is respected. 3. Opening of the space ante
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