PPT Ilmiah Spine

Posterior Cervical Laminectomy and

Fusion Surgery C3-C7
Present By : Rita Trisnawati Sugianto

Departemen Ilmu Bedah Saraf

Faculty of Medicine – Universitas Padjajaran
Bandung - 2022
 Introduction
● The posterior approach to the cervical spine : effective
for multilevel central canal decompression and for
providing access for posterior instrumentation.
● A properly performed laminectomy includes

○ lateral mass to lateral mass decompression that

fully decompresses the posterior aspect of the
spinal canal

Posterior cervical foraminotomies can also

be performed in conjunction with this
technique for nerve root decompression Preoperative MRI in a patient with
cervical myelopathy

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
Posterior cervical laminectomy and fusion is most effective in cervical alignments
that are either lordotic, neutral, or kyphotic but flexible.

• This technique have some ability to correct fixed kyphotic deformity

• But more often it is performed in conjunction with an anterior approach when significant
anterior pathology prevents adequate decompression from a posterior approach alone.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
● Stand-alone cervical laminectomy has generally fallen out of favor due to a relatively high incidence of
post-laminectomy kyphosis.
● Laminoplasty (covered elsewhere in this text) or laminectomy and fusion procedures are typically chosen
instead of laminectomy without fusion
● Techniques :

wiring
plating system subaxial
techniques
(past) instrumentation
(past)

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
● Currently, subaxial instrumentation is most often performed via lateral mass screw fixation.
● Pedicle screw fixation in the subaxial cervical spine is sometimes used at C7 because of the
small lateral mass and the absence of the vertebral artery

this presentation will focus on lateral mass fixation techniques

The Resident’s Guide to Spine Surgery. Springer Publishing

 Introduction
Pre- and postoperative lateral
radiographs in a patient who underwent
C3–C7 laminectomy and fusion for
cervical myelopathy.

A: Preoperative lateral cervical

radiograph.

B : Postoperative lateral cervical

radiograph

The Resident’s Guide to Spine Surgery. Springer Publishing

 Exposure
The incision should start at
the cranial aspect of C2 and
Landmark : inion (external extend down 1 cm past the
occipital protuberance) spinous process of C7 in
most patients and can be
lengthened as necessary
Careful exposure of the
medial inferior border of the
lamina-lateral mass junction
The Resident’s Guide to Spine Surgery. Springer Publishing
The dissection is carried
down through the midline
raphe  down to the
spinous processes
The dissection is carried out
to the lateral aspect of the
lateral mass at each level.
The fascia is incised at the
midpoint of the spinous
process at each level from
C2 to T1, and then these
“dots” are connected to form
a complete fascial incision.
subperiosteal dissection of
the deep posterior cervical
musculature is performed
 Laminectomy Technique
Identification midline raphe in
Open The interlaminar space
the ligamentum flavum with
with narrow Leksell Rongeur
micro-curved curette
A 2-mm Kerrison Rongeur is
used to open the length of the
The lamina should be
trough in order to remove the
circumferentially freed at this
thin shell of bone at the lamina-
point
lateral mass junction any
remaining ligamentum flavum
The Resident’s Guide to Spine Surgery. Springer Publishing
A high-speed burr with a 4-mm
non-end-cutting attachment is
Kerrison Rongeur is then used
then used to create a near full
to remove the ligamentum out
thickness trough in the lamina
to the lateral mass
at the lamina-lateral mass
junction.
The trough is examined and/or
palpated as necessary with a
The trough is created with the
micro-curette in order to
burr
determine whether or not the
trough is full thickness
 Laminectomy Technique
The laminae are gently removed by pulling up with a pituitary rongeur and a small curved
curette is used to gently sweep along the undersurface of the lamina, freeing any adhesions.

A 2–3- mm Kerrison Rongeur can be used to bite away any remaining lamina to the level of the
lateral mass.

A small nerve hook should easily pass lateral to the dura once the decompression is complete.

Once the cord is centrally decompressed, foraminotomies (described elsewhere in this text)
may be performed to treat any areas of foraminal stenosis, which will not be adequately
treated by central decompression alone.

The Resident’s Guide to Spine Surgery. Springer Publishing

 C3–C6 Instrumentation
The vertebral artery most commonly traverses the foramen transversarium from C1 to
C6
The lateral mass can be divided into three anatomic zones :

The first extends from the superior border of the superior articular process to the top of the
transverse process.

The second zone is between the superior and inferior margins of the transverse process.

The third zone extends from the caudal aspect of the transverse process to the caudal aspect
of the inferior articular process.

The Resident’s Guide to Spine Surgery. Springer Publishing

 C3–C6 Instrumentation

The three most

common methods in
use today are those
described by :

An Magerl Roy-Camille

The Resident’s Guide to Spine Surgery. Springer Publishing

 C3–C6 Instrumentation

The Resident’s Guide to Spine Surgery. Springer Publishing

 C3–C6 Instrumentation
The exiting nerve root lies within zone two and each of the above
techniques is designed to land the tip of the screw in zone 1 (an & magerl)
or zone 3 (roy-camille), which may be important if the screw is bicortical
and penetrates the ventral cortex of the lateral mass.

The most important technical point is to anchor the screw in solid bone
while minimizing danger to neurovascular structures.

The Resident’s Guide to Spine Surgery. Springer Publishing

 C7 Instrumentation
C7 may be instrumented either with lateral mass screws or pedicle screws

● the transverse foramen of C7 usually lies empty without vertebral artery  This along with the
larger size of the C7 pedicle makes it an easier target for pedicle screw fixation

If pedicle screws are chosen,

the start point
should be 2-mm
lateral and 2-mm
superior to the
center of the lateral
mass.
The laminectomy
In the sagittal
The C7 pedicle has allows palpation or
plane, the
approximately 30 even visualization
trajectory of the
degrees of medial of the pedicle to
screw should
angulation in the facilitate placement
parallel the
axial plane. of the C7 pedicle
superior endplate.
screw.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Fusion/Decortication Technique
Following Once the
Once the screw decortication, fusion bed has
The lateral
start points and any bone taken been
masses should
trajectories as part of the sufficiently
be decorticated
have been decompression prepped, the
lateral to the
identified, the is thoroughly graft is placed
screw hole and
fusion bed is debrided of soft both within the
the appropriate
then prepped tissue, decorticated
facets should
and grafted morselized, facet joints as
be decorticated
prior to and recycled well as lateral
as well.
instrumentation as local to the screw
autograft. start sites

The Resident’s Guide to Spine Surgery. Springer Publishing

 Final Steps
The set screws and rods
The screw start points
are placed and final
and trajectories are then Optional : place 1 g of
tightened. Final A drain is placed deep to
reidentified using a ball vancomycin powder
radiographs confirm the fascia.
tip probe and are deep to the fascia
hardware position and
sequentially inserted.
cervical alignment

The skin is closed with

The dermis is closed The fascia is closed with
3–0 monocryl and
with interrupted 2–0 interrupted #1 vicryl in a
dermabond. A sterile
vicryls. figure-of-8 fashion.
dressing is applied

The Resident’s Guide to Spine Surgery. Springer Publishing

 Complications
● Surgical site infection : 1–3% of all cases

● Risk factor :

The use of
immunomodulatory
Smoking Obesity Malnutrition
drugs and/or
steroids

Powered vancomycin powder applied directly to the wound at closure has shown
promise in reducing the rate of postoperative infection

The Resident’s Guide to Spine Surgery. Springer Publishing

 Complications
Other complications :

Neck pain and Adjecent

Pseudoarthrosis stiffness segment disease Spinal cord injury
complaints at C7-T1

Vertebral artery
Nerve root injury
injury

The Resident’s Guide to Spine Surgery. Springer Publishing

 Summary

The posterior cervical

laminectomy and fusion
The posterior approach
can be used alone, or
to the cervical spine is
in conjunction with
effective for central This procedure
anterior procedures for
canal decompression generally safe and
effective neurological
as well as for providing effective
decompression,
access for posterior
restoration of cervical
instrumentation.
alignment, and high
union rates

The Resident’s Guide to Spine Surgery. Springer Publishing

THANK YOU