electrocoagulation (1), or open Five patients
The final control of (3), direct exposure
to be safe, quick and reliable. Careful particularly in pathologically weakened
by a thorough
as in infection avoided
All had been for spondylitic
ligament (1), nonunion of a (1). The use of an air drill had
placement of a haemostatic clip (3). had postoperative neurological deficits,
use of the air drill,
been responsible for most injuries. haemorrhage had been by tamponade and
is essential. knowledge
of the anatomical canal,
1993; 75-B :410.-S. Accepted3O
The anterior spinal cord neoplastic,
approach and nerve infective,
due to (Smith
for decompression roots is widely used or post-traumatic
reported include vocal cord to the carotid artery, Homer’s
perforation, acute and 1989;
S. E. Emery, MD Department of Orthopaedics, Abington Road, Cleveland, A. Dudley, Four East Baltimore,
MD Madison Maryland
exposure or nerve relief
M. Leventhal, MD Department of Orthopaedics, Clinic, 869 Madison Avenue, Correspondence ©I993 British 030l-620X/93/3522
Editorial Society $2.00
University Memphis, to Dr M. of Bone
of Tennessee and Campbell Tennessee 38103, USA. D. Smith. and
of the dura or manipulation of the spinal cord roots. It results in little epidural fibrosis. Direct
of anterior The
of a transverse
Sepic 1984; In contrast
the uncertain accounts control little
arthrodesis a cosmetic
and often imperceptible scar, and most of the complications of the anterior approach do not detract from the excellent long-term clinical results (Williams, Allen and Harkess 1968; White et al 1973; Bohlman 1977; Gore and
Case Western Reserve Ohio 44106, USA.
Orthopaedic 2121 1, USA.
K. J. Murray, MD, PhD NeurosurgicalOncology, Maryland 21204, USA.
Despite these theoretical complications, anterior procedures have been successful and are popular. The approach allows for anterior discectomy and thorough
McAfee to this,
et al 1987). laceration of the
Vertebral artery because of the difficulty 24th
retropharyngeal oedema Robinson 1958 ; Whitecloud
during an anterior decompression complication. Such injuries have in the literature, probably because
M. D. Smith, MD Minnesota Spine Centre, 606 ohs, Minnesota 55454, USA.
of the cervical for spondylitic, problems. The
J Bone Joint Surg [Br] Received 18 June 1992;
iatrogenic injury to a vertebral decompression were rethe mechanisms of injury, their operative
posterior longitudinal (2), or osteomyelitis
of the fracture
a partial vertebral
the avoidance injury. Spinal decompressions inadvertent We sources
or intraoperative surgeons who should be
grave and are good
exposure of the artery and of the to penetrating neck injuries, but
laceration have reviewed who
of the surgical of bleeding due
is a very serious received little attention they are infrequent.
laceration is of controlling
of the ten iatrogenic
artery. We aimed to controlling haemorrhage,
artery. from a variety
determine to discover
risk factors, and to develop guidelines for the avoidance
management of such an perform anterior cervical prepared to manage an
the best means the mechanism
anatomical of such injuries. OF BONE
vertebral of and
of ten patients
to a vertebral
C3, C4, CS
Old nonunion Spondylosis
of a dens fracture with myelopathy
C4, CS, C6
exposure vascular exposure,
Upper airway tracheostomy. later
Immediate embolisation None
OPLL* dural absence, dural patch and graft
Emergency fusion Cl to CS one week angiography
CSF fistula. reinsertion
dysphagia circulation at 6 months
CS root damage None
CS root damage which resolved
No pain difficulty
at 2 months
due to unrelated
No. 3, MAY
lost to follow-
weakness : disseminated
Drug abuser, left hospital against advice, up Overhead activities increase vertigo meet
of the posterior
Persistent Vocal cord
and dysarthria. insufficiency.
No pain, Nurick with dialysis
Collateral flow present, fossa intact
Transient posterior resolved
by vertebrectomy, sponge
by separate clips
cancer at 33 months
M. D. SMITH,
S. E. EMERY,
K. J. MURRAY,
provided prompt temporary control, but in case 6, severe hypovolaemia led to cardiac arrest before temporary control of the haemorrhage allowed adequate restoration
the authors’ four medical centres, all being referral centres for complex and tertiary spinal care, and identified ten patients who had had vertebral artery
of blood volume. Methods of definitive
laceration during an anterior operation of the cervical spine (C2 to C7). We with congenital vascular malformations,
an extended waiting period. In these bleeding had ceased, but blood loss had (2300 ml and 4500 ml) and the operations
injuries or aneurysmal the details of the ten
surgeons surgeons). of one patients
on the lower part excluded patients post-traumatic
(three neurosurgeons, of the authors had
lesions. Table I There were nine
six orthopaedic personal experience
by four other associates with this paper.
the operations had been similar technique with anterolateral the common carotid neurovascular the trachea nine right the surgeon.
performed using exposure, medial sheath and lateral
a to to
and oesophagus. The side of the approach, and one left, was based on the preference of During the study period from January 1986
to May 1990, about 1 195 tions had been performed were unable to determine
anterior cervical spine operaby the five authors, but we the other four surgeons’ case
loads. The approximate incidence was 0.5%. The first author (MDS) studied records and the operative notes
case each ; the fifth of two cases. Thus, six of the were under the direct care of one of the authors;
the other four were managed who did not wish to be involved
radiographs for risk factors, intraoperative errors, and neurological sequelae. Follow-up reports were obtained at the various centres, usually by the responsible operating surgeon, and included a physical examination and radiographs.
never returned for patient (case 8) died metastases. Neither apparent complication.
abuser (case 4) at two months and
removal of halo fixation, and one after two months from disseminated of these had paralysis or any other The other eight patients were
followed for at least one year, and none needed further operations for the cervical spine disorder that prompted the index operation. None had late worsening of any neurological complications at the time of discharge, and all with
least some recovery. Findings. In all cases, unaware vertebral unexpected gelatin (Avitene
artery : the first indication and profuse bleeding. sponges, ; Medchem
severe postoperative of arterial control
two patients the been considerable were prolonged
haemorrhage, and been undertaken,
probably caused later. A separate necessary There
the spinal longitudinal
in case were
5 to provide no
patients one alone.
of them Because
after the operation. postoperative neurological
3 suffered a Wallenberg’s and bulbar dysfunction al
postoperative haemorrhage, this an uncomplicated prophylactic
diagnosed had been
adequate exposure. of recurrent bleeding
angiography, but treated by tamponade
possibility of had undergone
of the patient Five
nerve root left-sided
syndrome (lower cranial with cerebellar findings: MRI
infarction (Fig. 1), but the patient’s speech, swallowing have improved over the 18-month One patient (case 5) had persistent ataxia and
vertigo with positional changes of the head, which were thought to be due to impaired posterior circulation; resolution has been slow and incomplete. Cases 7 and 9 had root injuries due to blind suture placement, and had rapid and nearly complete recovery. The fifth patient, case 6, had a severe quadraparesis, which is still dense but recovering slowly one year later. This patient had ossification of the posterior longitudinal ligament and a grade 4 myelopathy (Nurick 1972). She had absence ofthe dura and a postoperative cerebrospinal fluid fistula. postoperative
These other problems quadraparesis.
been to the
of trouble Tamponade
and fibrillated Woburn, Mass)
by suture ligation in cases 7, 8 and 9, by metallic clips in cases 3, 5 and 6 and by exposure and electrocoagulation in case 2. In cases 7 and 8 the sutures had been passed blindly through bone using a stout curved needle above and below the area of the arterial injury ; these sutures
cerebellar gait and follow-up.
less than one year. One intravenous-drug left hospital against medical advice
8 hours). immediate
had postoperative (case 4) had been
in detail the medical with all pertinent
the bleeding. another seven
recurred about direct
this patients occurred
Most spinal JOINT
Case 3. A 52-year-old man with an old upper cervical spine fracture and progressive myelopathy. During decompression of the lateral aspect ofthe spinal canal with a motorised burr, the left vertebral artery was lacerated. A haemorrhagic cerebellar infarction resulted. Axial MRI of the skull shows an ischaemic area in the distribution of the posterior inferior cerebellar artery.
three common reasons for the apparent : the motorised dissection width of the bone and disc removal bone of the pathologically
through the base
of the infection
of C7, but usually The
foramina until it reaches level it curves posteriorly to
enter the foramen transversarium part of the ring of the atlas and
in the perforates
posterolateral the posterior
membrane to pass through the foramen It then joins the opposite vertebral artery to basilar artery, which supplies most of the and cerebellum. The artery is most vulnerable C7, laterally at C3 to C7, and posteriorly at
Cl andC2. Operative
anatomy must wide.
be performed To deviate
the midline or to remove bone wider than is necessary risks a laceration, particularly if there is ectasia of the vertebral artery (Fig. 2). The location of the insertions of longus colli may help to maintain orientation. SubperiosVOL.
No. 3, MAY
the anterior posteriorly.
cervical spine of a patient injury. It is apparent that The corpectomy defect is of the fibular strut graft.
defect needed 3). The bone and straight anteroposterior tomy
surface of the vertebral body The width between the two
atlantoaxial magnum. form the brainstem anterior to
removal of bone and disc material the midline and not be excessively
Case 2. Anteroposterior radiograph of the who sustained a right-sided vertebral artery the surgeon lost his midline orientation. eccentric as shown by the lateral placement
from the the foramen
a series of transverse of the axis. At this
spinal canal or tumour.
to the transverse
lacerations became was off midline ; the was excessive ; or the
it is anterior
for spinal canal decompression (Fig. disc material is then removed in a direction. The posterior vertebral and
using a diamond burr, punches as needed.
needed, using The vertebral
begins to curve dissected flaps
small diamond artery should
(Raynor 1983). We verified the safety by studying 25 preoperative, axial CT scans of patients
curettes, and decompression
burrs or Kerrison be above this
ofthis technique of dissection myelographically enhanced, who were about to undergo
anterior decompression and fusion. We measured the distances from the floor of the spinal canal to the artery, from the anticipated lateral wall of the decompression to the artery, and the necessary width of through the middle portion of the vertebral CS and
decompression bodies at C4,
of the spinal
M. D. SMITH,
S. E. EMERY,
K. J. MURRAY,
Diagram of the landmarks used to measure the width of the corpectomy needed for adequate spinal canal decompression. The vertical lines are based on the medial borders of the longus colli muscles. The horizontal line is at the most anterior aspect of the dissection on the floor of the canal showing the lateral position of the arterial foramina.
at these levels was The average lateral needed
1 3.7, 1 3.8 and 1 3.3 mm respectively. dissection ofthe longus colli insertion
decompression at all levels,
ical landmarks margin of safety.
motorised burr. can be performed
that we A small
foramina. Preoperatively, the
artery is prophylactic
as its exposure for of encircling vascular
precautions (Fig. 4). In the exposure difficult exposure effective, inflatable compression
in cases the
of the vertebral artery presents a serious and problem. Our best results were with direct of the artery ; blind placement of sutures was but caused nerve root palsies. The use of an balloon catheter of the vessel
to provide temporary within the foramen
foramen or complete allow the muscles ; retracted
1 4 and
severe of the
haemorrhage interferes artery (Hatzitheofilou
the arterial injury is on the same side as the original approach, exposure may be facilitated by further lateral dissection of the longus colli and longus capitus beyond the transverse process to expose the
transversarium. In these circumstances partial transection of the sternocleidomastoid may surgeon easier retraction laterally of the other the carotid sheath could also be mobilised and medially or laterally as necessary (Riley 1989).
Partial removal ofthe rim of the foramen
the proximal and loops or sutures.
in the Burkus Fig. 4).
tortuous, or may be needed
sarium is possible when with the orderly exposure
safely used to perform a of the lateral recesses of the risk of entering the arterial
cyst extends after the anteriorly.
Axial preoperative CT scan. An aneurysmal bone around the foramen transversarium. An angiogram revealed that the artery was tortuous and displaced
with a 5 mm with continuous
determine if the arteries are ectatic or are involved tumour or infection (Lindsey, Piepmeier and 1985; Bohlman et al 1986; Born et al 1988: Preoperative
This shows that using the anatom-
have described, diamond burr,
generous decompression canal with very small
of the central canal was less than 3 mm leaving at least S mm of bone between
the artery and the central corpectomy
longus colli transversarium exposure
muscle and the anterior with rongeurs will
the cosmetic results should be acceptable (Southwick and Robinson 1957). If the injury is on the contralateral side and adequate visualisation is not obtained through the initial incision, the operating surgeon could either extend the present incision beyond the midline and expose the artery beyond the contralateral sternocleidomastoid (as described Some one
or make published artery THE
a separate incision. work supports the
ligated OF BONE
patients had circulation.
neurological This rate
deficits is greater
that reported by Golueke et al (1987) (six of 23) or Hatzitheofilou et al (1988) (four of 20). These authors were reporting the results of traumatic lacerations in
DECOMPRESSION Golueke P,Sclafani and management. Gore
who were more likely to be able to ligation. An additional factor is arterial
sided artery part of the
is usually the blood supply
larger and provides to the hindbrain.
the greater Ligation or
S, PhilllpsT, J Trauma
DR, Sepic SB. Anterior protruded discs : a review 1984; 9:667-71.
et al. Vertebral artery 1987; 27:856-65.
C, Demetriades approaches
cervical fusion for of one hundred forty-six
Graham JJ. Complications of cervical spine. Second ed. Philadelphia, etc: Hatzitheofilou Surgical
spine injury. J. B. Lippincott, injuries.
7:234-7. Lindsey RW, PiepmeierJ, BurkusJK. an adventitious finding after [Am] 1985; 67-A :806-8.
Tortuosityofthe cervical trauma.
McAfee PC, Bohlman HH, Riley LH Jr, retropharyngeal approach to the upper part J BoneJoint Surg[Am] 1987; 69-A:1371-83.
vertebral artery: J Bone Joint Surg et al. The of the cervical
We would prefer repair rather than ligation artery (Perry 1989 ; De Los Reyes et al 1990), and
Nurick S. The natural history and results of surgical treatment spinal cord disorder associated with cervical spondylosis.
Reyes absence vein
et al (1990) of the left grafting
a patient with a congenital artery who required bypass right vertebral lacera-
tion. This was not possible in any of our patients. anterior exposure does not allow for direct repair laceration of the posterior or posteromedial arterial No benefits commercial article.
in any party
form have been related directly
An of a wall.
received or will be received or indirectly to the subject
from a of this
Br J Surg
occlusion by retraction ofa left vertebral artery in patients with this vascular pattern increases the likelihood ofcerebellar or brainstem infarction (Bohlman and Eismont 1981 ; Berguer 1985; Bohlman et al 1986). of the De Los
In : The cervical 1989 :831-7.
Trauma. In : Rosenberg New York, etc : Churchill
RN, ed. Livingstone,
anterior spine. clinical 1983 III:
24 1-4. of the Brain
1972; 95:101-8. Perry
MO. Injuries of the ed. Vascular surgery. Saunders, 1989:604-12.
brachiocephalic Vol. 2. Third
RB. Anterior or posterior anatomical and radiographic surgery 1983; 12:7-13. LH
vessels. In : Rutherford Philadelphia, etc:
approaches Second ed.
to the cervical and comparison.
to the lower Philadelphia,
cervical etc : J.
spine : an Neuro-
spine. In : The B. Lippincott,
Schellhas KP, Latchaw injuries following
Vertebrobasilar 1980; 244:
vertebral and potential
Bohlman HH. Cervical spondylosis Spine 1977; 2:151-62. Bohlman HH, sion and 57-67.
bypass : technique, J Vascular Surgery with
Eismont FJ. Surgical techniques fusion for spinal cord injuries.
the “occipital 1985 ; 2:621-6.
to severe of anterior C/in Orthop
myelopathy. decompres1981 ; 154:
Southwlck bodies 1957;
Whitecloud American lectures,
De Los Reyes
Klippel-Feil 1988; 70-A:14l2-S.
an extra cranial vertebral review ofthe literature. Emery
: a case
No. 3, MAY
DP, Boehm FH. Direct repair of artery pseudoaneurysm : case report and Neurosurgery 1990; 26 :528-33.
SE, Smith MD, Bohlman HH. Upper airway multi-level cervical corpectomy for myelopathy. [Am] 1991 ; 73-A :544-51.
J Bone Joint Surg
WO, Robinson in the cervical 39-A :631-43.
of the intervertebral [Am]
1958 ; 40-A
RA. Surgical approaches to the vertebral and lumbar regions. J Bone Joint Surg [Am]
Verbiest H. Anterolateral operations for fractures and dislocations in the middle and lower parts of the cervical spine : report of a series of forty-seven cases. J Bone Joint Surg [Am] 1969; 51-A :1489-530.
by the anterior
Bohlman HH, Sachs BL, Carter J, Riley L, RObinSOn RA. Primary neoplasms ofthe cervical spine : diagnosis and treatment of twentythree patients. J Bone Joint Surg [Am] 1986 ; 68-A :483-94.
AA, Southwick pain by anterior sixty-five patients. iS.
WO, Deponte cervical-spine
J Bone Joint
Complications of Academy ofOrthopaedic 1978:223-7.
RJ, Gainer JW, Hardy fusion for spondylosis Surg [Am] 1973 ; 55-A anterior
R. Relief : a report :525-34.
cervical fusion. Surgeons : instructional
Whitecloud iS III. Management of radiculopathy the anterior approach. In : The cervical spine. phia, etc: J. B. Lippincott, 1989:644-58.
Williams JL, Allen MB Jr, Harkess JW. Late results of cervical discectomy and interbody fusion : some factors influencing the results. J Bone Joint Surg [Am] 1968 ; 50-A :277-86.