Neurosurgery notes/Procedures/Cervical spine osteotomy

Cervical spine osteotomy

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Parent item
Cervical procedure
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Anterior Riew osteotomy
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Grade 1 osteotomy

  • Partial facet joint resection
  • Technique
    • Anterior approach OR
      • Discectomy + partial uncovertebral joint resection
    • Posterior approach
      • Facet capsule resection OR partial facet resection.
        • Offers the potential to promote fusion through cartilage removal from the facet surface
  • limited capacity for deformity correction, it may be applied over multiple levels to cumulatively assist in correcting alignment
  • Require mobility (nonfusion) of the opposite column (posterior or anterior, respectively)
 
Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure. Stage 1 entailed partial facet resections from C-5 to T-1, C6–T1 laminectomies, and posterior segmental instrumentation and fusion from C-5 to T-2. Stage 2 involved an anterior cervical discectomy and fusion with plating from C-5 to T-2. Stage 3 necessitated placement of rods, final posterior correction, and posterior spinal fusion from C-5 to T-2.
Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure. Stage 1 entailed partial facet resections from C-5 to T-1, C6–T1 laminectomies, and posterior segmental instrumentation and fusion from C-5 to T-2. Stage 2 involved an anterior cervical discectomy and fusion with plating from C-5 to T-2. Stage 3 necessitated placement of rods, final posterior correction, and posterior spinal fusion from C-5 to T-2.
 

Grade 2 osteotomy

  • Technique
    • Resection of both superior and inferior facets
      • Other soft-tissue and bony elements may also be resected, including the ligamentum flavum, lamina, and spinous process
  • Osteotomies that include any resection of the vertebral body are not included in this grade category.
  • Limited capacity for deformity correction, it may be applied over multiple levels to cumulatively assist in correcting alignment
  • Require mobility (nonfusion) of the anterior column
A: Grade 2 osteotomy, complete facet joint/Ponte osteotomy. B: Preoperative and postoperative radiographs of a patient treated with multilevel complete facet resection and posterior segmental instrumentation and fusion from C2–T2. The classification for this case is 2P (with no minor osteotomies).
A: Grade 2 osteotomy, complete facet joint/Ponte osteotomy.
B: Preoperative and postoperative radiographs of a patient treated with multilevel complete facet resection and posterior segmental instrumentation and fusion from C2–T2. The classification for this case is 2P (with no minor osteotomies).

Grade 3 osteotomy

  • Technique
    • Partial or Complete Corpectomy
      • Including adjacent disc
      • Mobility of the posterior elements is necessary to achieve optimal deformity correction with a Grade 3 osteotomy.
  • enable substantial release and correction of deformity, but may also facilitate decompression of the spinal canal and foramina.
 
A.: Grade 3 osteotomy, partial or complete corpectomy. B: Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure. Stage 1 entailed complete facet resection from C-4 to T-4, posterior segmental instrumentation from C-1 to T-6, and foraminotomies at C-2 to C-3 and C7–T1. Stage 2 involved C-4 corpectomy and anterior cervical discectomy and fusion with plating from C-3 to C-7. Stage 3 necessitated posterior rod placement, final correction, and fusion from C-1 to T-6. The classification for this case is 3PAP (with Grade 2 minor osteotomies).
A.: Grade 3 osteotomy, partial or complete corpectomy.
B: Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure. Stage 1 entailed complete facet resection from C-4 to T-4, posterior segmental instrumentation from C-1 to T-6, and foraminotomies at C-2 to C-3 and C7–T1. Stage 2 involved C-4 corpectomy and anterior cervical discectomy and fusion with plating from C-3 to C-7. Stage 3 necessitated posterior rod placement, final correction, and fusion from C-1 to T-6. The classification for this case is 3PAP (with Grade 2 minor osteotomies).

Grade 4 osteotomy

  • Technique
    • Anterior bony resection + complete unco-vertebral joints resection into the transverse foramen
      • may include skeletonization of the vertebral arteries bilaterally as a means of minimizing the risk of arterial kinking, especially at the apex in cases of severe kyphosis
Grade 4 osteotomy, complete uncovertebral joint resection to transverse foramen.
Grade 4 osteotomy, complete uncovertebral joint resection to transverse foramen.
 
Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure. Stage 1 entailed posterior instrumentation removal, exploration of fusion, C3–7 laminectomy, complete facet resections from C-3 to C-5, and segmental instrumentation from C-2 to T-1. Stage 2 involved removal of anterior instrumentation, multilevel discectomy and osteotomy through the uncovertebral joints to the transverse foramen, and plating from C-3 to C-7. Stage 3 necessitated posterior rod placement, final correction, and fusion from C-2 to T-1. The classification for this case is 4PAP (with Grade 2 minor osteotomies).
Preoperative and postoperative radiographs of a patient treated with a 3-stage procedure.
Stage 1 entailed posterior instrumentation removal, exploration of fusion, C3–7 laminectomy, complete facet resections from C-3 to C-5, and segmental instrumentation from C-2 to T-1.
Stage 2 involved removal of anterior instrumentation, multilevel discectomy and osteotomy through the uncovertebral joints to the transverse foramen, and plating from C-3 to C-7.
Stage 3 necessitated posterior rod placement, final correction, and fusion from C-2 to T-1.
The classification for this case is 4PAP (with Grade 2 minor osteotomies).

Grade 5 osteotomy

  • Technique
    • Complete resection of the posterior elements AND
      • Including lamina, spinous process, and facets
    • Osteoclastic fracture and creation of an anterior wedge in the anterior column
  • Generally performed at the level where the vertebral artery is not present
  • Grade 5 osteotomy produces an elongation of the anterior column, which has been associated with serious vascular and neurological complications, and stretching of the trachea and esophagus.
 
Grade 5 osteotomy, opening wedge osteotomy.
Grade 5 osteotomy, opening wedge osteotomy.
Preoperative and postoperative radiographs of a patient treated with posterior segmental instrumentation from C-4 to T-5, C6–T1 laminectomy, opening wedge osteotomy at C-7, rod placement, and reduction of deformity. The classification for this case is 5P (with no minor osteotomies).
Preoperative and postoperative radiographs of a patient treated with posterior segmental instrumentation from C-4 to T-5, C6–T1 laminectomy, opening wedge osteotomy at C-7, rod placement, and reduction of deformity.
The classification for this case is 5P (with no minor osteotomies).

Grade 6 osteotomy

  • Technique
    • Complete removal of the posterior elements AND
      • Including the lamina, spinous process, and facets
    • Removal of the pedicles AND
    • Creation of a closing wedge in the vertebral body
  • Generally performed at the level where the vertebral artery is not present
    • At the cervicothoracic junction (C-7 or T-1)
    • Some authors favor performing this osteotomy at C-7 rather than T-1 to avoid the necessity of deep dissection for T-1 rib removal, which can be difficult.
  • Grade 6 osteotomy may be safer than the Grade 5 osteotomy because the Grade 6 does not result in stretching of the anterior structures.
  • Similar to posterior decancellation osteotomy “eggshell” procedure or pedicle subtraction osteotomy,
 
Grade 6 osteotomy, closing wedge osteotomy
Grade 6 osteotomy, closing wedge osteotomy
Preoperative and postoperative radiographs of a patient treated with posterior segmental instrumentation from C-2 to T-4, laminectomy from C-2 to T-1, pedicle subtraction osteotomy at C-7, and Smith-Petersen osteotomies at C6–7 and C7–T1. The classification for this case is 6P (with Grade 2 minor osteotomies).
Preoperative and postoperative radiographs of a patient treated with posterior segmental instrumentation from C-2 to T-4, laminectomy from C-2 to T-1, pedicle subtraction osteotomy at C-7, and Smith-Petersen osteotomies at C6–7 and C7–T1. The classification for this case is 6P (with
Grade 2 minor osteotomies).

Grade 7 osteotomy

  • Technique
    • Complete resection of one or more entire vertebral bodies
      • including the adjacent discs, the complete uncovertebral joint, posterior lamina, and facets
    • Includes placement of anterior column support that may include custom-cut fibular allograft or an expandable cage
  • Very high risk, very limited indication
    • Not really performed. Í
 
Grade 7 osteotomy, complete vertebral column resection.
Grade 7 osteotomy, complete vertebral column resection.
Preoperative and postoperative radiographs of a patient treated with a 2-stage procedure. Stage 1 involved anterior removal of instrumentation, corpectomy through the uncovertebral joints to the transverse foramen bilaterally, and anterior fusion with cages placed from C-2 to C-6. Stage 2 entailed posterior removal of instrumentation, spinal fusion with instrumentation from the occiput to T-2, and posterior laminectomy and complete facet resection at C-3 to C-4. The classification for this case is 7AP (with no minor osteotomies).
Preoperative and postoperative radiographs of a patient treated with a 2-stage procedure.
Stage 1 involved anterior removal of instrumentation, corpectomy through the uncovertebral joints to the transverse foramen bilaterally, and anterior fusion with cages placed from C-2 to C-6.
Stage 2 entailed posterior removal of instrumentation, spinal fusion with instrumentation from the occiput to T-2, and posterior laminectomy and complete facet resection at C-3 to C-4.
The classification for this case is 7AP (with no minor osteotomies).