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Journal of Craniovertebral Junction and Spine
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EDITORIAL
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 1-3  

Like anterior transoral decompression, will anterior cervical spine surgery find space in history books?


Department of Neurosurgery, Seth G.S. Medical College and K.E.M Hospital, Mumbai, Maharashtra, India

Date of Submission25-Feb-2020
Date of Acceptance02-Mar-2020
Date of Web Publication4-Apr-2020

Correspondence Address:
Prof. Atul Goel
Department of Neurosurgery, Seth G.S. Medical College and K.E.M Hospital, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvjs.JCVJS_26_20

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How to cite this article:
Goel A. Like anterior transoral decompression, will anterior cervical spine surgery find space in history books?. J Craniovert Jun Spine 2020;11:1-3

How to cite this URL:
Goel A. Like anterior transoral decompression, will anterior cervical spine surgery find space in history books?. J Craniovert Jun Spine [serial online] 2020 [cited 2020 Jul 13];11:1-3. Available from: http://www.jcvjs.com/text.asp?2020/11/1/1/281910



Anterior cervical decompression and fixation, commonly named as “ACDF,” is an accepted and widely performed surgical procedure. Anterior cervical corpectomy and spinal decompression are recognized surgical procedures for the treatment of cervical myelopathy-related degenerative spinal diseases and ossification of posterior longitudinal ligament (OPLL). Artificial disc arthroplasty as a surgical technique is currently under intense clinical evaluation. Despite the undeniable fact that anterior cervical surgery has a prominent place in the treatment of cervical spinal degeneration and other related diseases, the dangers to aerodigestive tracts, carotid artery, and recurrent laryngeal nerve have been frequently identified.[1] Essentially, anterior cervical surgery has been effective but is not “easy” surgical procedure. Multiple level anterior cervical surgery and “high” cervical surgery need special surgical experience and skills. It is crucial to evaluate if anterior cervical spinal surgery is avoidable and unnecessary and if better surgical options are available.

The understanding of the spinal degeneration has been essentially disc-centric for several decades. Disc space reduction related to “old” age and loss of its water content has been identified to be the nodal point of origin of process that leads to cascade of alterations grouped under spinal degeneration. We recently proposed an alternative hypothesis of spinal degeneration and identified spinal instability related to muscle weakness due to their disuse, abuse, or injury as a primary initiating process for the entire phenomenon of spinal degeneration.[2],[3]

Human standing position places life-long stress and strain on the extensor muscles located over the posterior and lateral aspects of the spinal column. A large majority of spinal muscles act with their fulcrum point at the facets. Muscles anterior and lateral to the vertebral body and in relationship with the disc are significantly thin and “veil-like.” Intervertebral discs and odontoid process essentially have a similar function. They are the brain of all movements, the brawn being the muscles.[4] Essentially, the odontoid process and intervertebral discs, such as an opera orchestra conductor, control all spinal movements without directly handling any major muscle movement or instrument of activity. It was speculated that muscle weakness is the nodal point of initiation and propulsion of process of spinal degeneration and all the other known “pathological” spinal alterations, including disc space reduction and osteophyte formation, are secondary and probably protective natural responses.

Vertical spinal instability is a result of muscle weakness.[5] Spinal instability is first manifested at the point of the activity, namely the facets. There is telescoping of the spine and listhesis of the inferior facet of rostral vertebra over the superior facet of the caudal vertebra. More often, muscle weakness results in multi-segmental spinal instability. The lateral location of the facets away from the neural structures and their oblique profile makes radiological identification of instability difficult, if not impossible. On the other hand, consequences of instability in the form of buckling intervertebral ligaments, osteophyte formation, and disc space reduction that lead to compromise of the spinal and neural canal dimensions are starkly obvious on imaging.

In 2010, we identified that the procedure of facet distraction results in reversal of vertical spinal listhesis and has the potential for reversal of all the described “pathological” changes of spinal degeneration.[6],[7] The procedure resulted in restoration of spinal changes and arthrodesis of the treated spinal segments. For the first time in the literature, it was suggested that there was no need for spinal “decompression” by the removal of parts of the bone, ligaments, osteophytes, or disc. The process of facet distraction was identified to result in the secondary spinal decompression and assisted in the process of achieving arthrodesis. As we mature further in the field, we realize that “only spinal fixation” without any form of primary or secondary spinal decompression is an optimum form of surgical treatment for spinal degeneration.[8],[9],[10]

Our 10-year experience in the field suggests that spinal stabilization is the treatment for cervical myelopathy related to both spinal degeneration and OPLL and decompression by bone and soft tissue resection that includes buckled or ossified ligaments and disc is unnecessary.[11],[12],[13],[14],[15],[16] We also identified that both cervical and lumbar disc herniation, extrusion, or prolapse-associated cervical and lumbar radiculopathy/myelopathy are related to segmental spinal instability.[17],[18] It is unclear if spinal instability leads to disc herniation or disc herniation is the cause of spinal instability. On the basis of our ongoing experience in the field, it is apparent that only spinal segmental fixation is the treatment in cases with spinal disc herniation, and spinal bone or ligamentous resection for the purpose of decompression and direct disc removal is not necessary. As the line of muscle activity is from the posterior spinal direction and focus of muscle action is on the facets rather than the discs, attempt to stabilize the spinal segment/s is more relevant when it is done from the posterior direction. Moreover, as the disc alterations/bulges and herniation, osteophyte formation, and interspinal ligamentous buckling are all secondary events, it is not necessary to directly handle them. The facets of the spine are the strongest and thickest part of the entire spinal column. We have identified transarticular fixation using screws by the technique described by Roy-Camille and Saillant in 1972 as a safe, quick, and strong stabilization technique.[8],[19] The fixation process acts at the site of spinal movements. There is significant ease of extension of levels of spinal fixation, both rostrally and caudally. Moreover, evidence of spinal instability can be directly visualized by assessing the status of the facetal articulation. Presence of osteophytes and/or excessive or abnormal facetal movements on manual manipulation of bones and evidence of facetal listhesis are the indicators of spinal instability. Sectioning of the muscles attached to the spinous process and laminae assists in limiting all spinal movements and facilitating the process of arthrodesis.

Anterior cervical spinal surgery aims to “decompress” the spinal cord by resection of part of the disc, osteophyte, and ligamentous complex that impinges into the spinal canal. Essentially, disc bulge and osteophytes have been traditionally considered to be pathological entities that impinge or compress the neural structures. Our clinical studies have identified that it is not neural compression or deformation that is the cause of symptoms, but it is subtle instability-related repeated microtrauma to the neural structures that causes symptoms and initiates the protective bodily responses. It is obvious that disc and osteophyte resection can be avoided. Spinal stabilization and not spinal decompression is the treatment. Strong arthrodesis achieved by posterior facetal fixation results in remarkable clinical improvement and can eventually result in regression in the size of the osteophytes and disc bulges.

On the basis of our experience in the subject for over four decades, it seems that like transoral surgical decompression for craniovertebral junction, anterior transcervical decompressive surgery can soon find its place in the history books.



 
   References Top

1.
Wewel JT, Brahimaj BC, Kasliwal MK, Traynelis VC. Perioperative complications with multilevel anterior and posterior cervical decompression and fusion. J Neurosurg Spine 2019;1-6. Published online ahead of print.  Back to cited text no. 1
    
2.
Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6.  Back to cited text no. 2
    
3.
Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2.  Back to cited text no. 3
    
4.
Goel A. Treatment of odontoid fractures. Neurol India 2015;63:7-8.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Goel A. Vertical facetal instability: Is it the point of genesis of spinal spondylotic disease? J Craniovertebr Junction Spine 2015;6:47-8.  Back to cited text no. 5
    
6.
Goel A, Shah A. Facetal distraction as treatment for single-and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96.  Back to cited text no. 6
    
7.
Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2013;19:672-7.  Back to cited text no. 7
    
8.
Goel A. 'Only fixation' as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6.  Back to cited text no. 8
    
9.
Goel A. Only fixation for cervical spondylosis: Report of early results with a preliminary experience with 6 cases. J Craniovertebr Junction Spine 2013;4:64-8.  Back to cited text no. 9
    
10.
Goel A, Ranjan S, Shah A, Patil A, Vutha R. Lumbar canal stenosis: Analyzing the role of stabilization and the futility of decompression as treatment. Neurosurg Focus 2019;46:E7.  Back to cited text no. 10
    
11.
Goel A. Is instability the nodal point of pathogenesis for both cervical spondylotic myelopathy and ossified posterior longitudinal ligament? Neurol India 2016;64:837-8.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Goel A. Atlantoaxial instability associated with single or multi-level cervical spondylotic myelopathy. J Craniovertebr Junction Spine 2015;6:141-3.  Back to cited text no. 12
    
13.
Goel A. Role of subaxial spinal and atlantoaxial instability in multisegmental cervical spondylotic myelopathy. Acta Neurochir Suppl 2019;125:71-8.  Back to cited text no. 13
    
14.
Goel A, Vutha R, Shah A, Patil A, Dhar A, Prasad A. Cervical spondylosis in patients presenting with “severe” myelopathy: Analysis of treatment by multisegmental spinal fixation - A case series. J Craniovertebr Junction Spine 2019;10:144-51.  Back to cited text no. 14
    
15.
Goel A. Ossification of the posterior longitudinal ligament: Analysis of the role of craniovertebral and spinal instability. Acta Neurochir Suppl 2019;125:63-70.  Back to cited text no. 15
    
16.
Goel A, Dharurkar P, Shah A, Gore S, More S, Ranjan S. Only spinal fixation as treatment of prolapsed cervical intervertebral disc in patients presenting with myelopathy. J Craniovertebr Junction Spine 2017;8:305-10.  Back to cited text no. 16
    
17.
Goel A, Dharurkar P, Shah A, Gore S, Bakale N, Vaja T. Facetal fixation arthrodesis as treatment of cervical radiculopathy. World Neurosurg 2019;121:e875-81.  Back to cited text no. 17
    
18.
Goel A, Patil A, Shah A, Rai S, Vutha R, Ranjan S, et al. Lumbar radiculopathy: Outcome analysis following treatment by only fixation - A report of an early experience of 44 cases. J Craniovertebr Junction Spine 2019;10:203-9.  Back to cited text no. 18
    
19.
Roy-Camille R, Saillant G. Surgery of the cervical spine. 2. Dislocation. Fracture of the articular processes. Nouv Presse Med 1972;1:2484-5.  Back to cited text no. 19
    




 

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