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Common procedures used for fixation of the cervical spine.


  • Use of traction for unstable fractures or dislocations of the c-spine.
  • UNSTABLE injuries as defined by disruption of > 2 of the 3 columns described by Denis
  • Devices: Mayfield / Gardner-Wells traction Tongs be aware of over distraction in aggressive attempts of reduction

Related Links:

Denis F: The three column spine and its significance in the classification of acute thoraco-lumbar spinal injuries. Spine 8:817-831 (click FIGURE 45 on the website-- it shows a picture of the tongs on a head)


  • Multiple surgical approaches though anterior is often safer (smaller chance of spinal cord injury).
  • Possible complications of ANTERIOR approaches:
    • injury to vessels (carotid a. /vertebral a. /jugular v.), injury to nerves (X and recurrent laryngeal, spinal cord itself), esophagus, trachea
    • other standard c-spine complications (infection, hematoma, graft collapse, non-union)

1. FIXATION OF THE C1 and C2 Special techniques needed to accommodate unusual biomechanics

a. Anterior approaches: 

  • Anterior transoral approach 
  • Anterior lateral retropharyngeal approach utilized

b. Odontoid fractures. Types I, II, III per Anderson classification 

  • Type I (odontoid tip fx) 
  • Type II (waist of odontoid fx) (Most common yet least likely to heal) 
  • Type III (extension of fracture into the base of C2) 

Look for use of partially threaded cancellous screws functioning as LAG screws (pull pieces together to aid in healing) ex. Knoringer screw (long lag screw with ends of differing pitches enabling advancement rate into bone to differà pulling of ends together)

May see plate/screws but rare. 

If at all possible utilize dynamic imaging (flexion/neutral/extension) to bring out subtle instability in this region.

Related Link

FIJACION ANTERIOR PERCUTANEA DE ODONTOIDES. Presentación de 2 casos. Autores: Enrique de Jongh Cobo; Ramiro Pereira Riverón; Susana Fernández Benítez; Esteban Roig Fabré; Ivón González Varcárcel; Alejandra Barbosa Pastor.Institución: Servicio de Neurocirugía. Hospital Universitario "Gral. Calixto García". Ciudad de La Habana, Cuba. (in Spanish)


  • Cloward fusion -- removal of the endplates (and disc) with insertion of bone grafting material.
  • Smith-Robinson fusion - removal of disc from level of PLL and laterally to joints of Lushka and bone graft placement into disc space. Incorporation at 6-12 weeks
  • PLATES: Function to aid with instability secondary to DJD, infection, tumor, trauma 
    • CASPAR plate- trapezoid like shape, 
    • MORSCHER plate /CLSP plate- H- shaped plate with recess where screw inserts (significantly reduces risk of screws 'backing out') all utilize bicortical screws (should pass anterior & posterior cortices) 
    • complications of plates: Loosening / 'backing out' / fracturing of screws / 'mass effect' on prevertbral or retropharyngeal soft tissues


    • Gallie (wiring of C1-C2 spinous processes), 
    • Brooks (C1 arch -C2 laminae wiring), 
    • McLauren fusion (wire around posterior arch of C1 and under C2 spinous process) procedures .i. Use Songer cables (cable with crimped metal collar) or cerclage wires and +/- bone grafting ii. Transarticular screws (cannulated screws (placed over K-wires) through articular pillars of C2 iii. Laminar clamps (Halifax clamps): C-shaped clamps grip lamina with assistance from screws to achive fusion C1-C2 {, page 3 of the article}
    • Laminotomy/discectiomy- used for osteophyte and disc decompression at single level 
    •  Laminectomy/Foraminotomy - window of variable size involving lamina alone or [lamina + facet joint] +/- disc removal if bulging is also present 
    • Laminoplasty- used for patients with OPLL or multisegmental spondylotic myelopathy 1. involves partial resection of spinous processes and laminae (to be used as graft material later), unroofing the posterior spinal canal (various 'open door' or other techniques) and adding 5mm of additional space posteriorly, then repacking the graft material to fill the new space. Additional fixation with wiring and/or methylmethacrylate is often used 
    • WIRES: 
      • 1. Facet wiring -drilling holes into posterior pillars with wires wrapped though the hole and the entire complex encircled with bone graft material 
      • 2. Interspinous wiring- drilling holes into spinous processes adjacent to laminae of 2 adjacent vertrebral levels and passing wire from one level to the next 
      • 3. Sublaminar wiring - Songer cables or cerclage wires wrapped in a loop around lamina (passing on the inside and outside) of the lamina. Strutted with bone graft to ensure fusion. Rarely seen in low cervical spine due to a small spinal canal diameter
    • PLATES utilized over the facet joints and attached to the spine using screws. The screws are angled out into the bone into the lateral mass.
      • Placement of the plates (or clamps) with screws involves some risk to the vertebral artery and the exiting nerve root, so there is added risk (versus wiring procedures), but better fixation of the spine is achieved.  These plates all utilize fixation of screws into the articular pillars 
      • Tubular plates- concave plate (used more commonly in extremities) sometimes used for long-segment fusions 
      • Malleable plates -main use in the pelvis, can be used in spine fusion procedures 
      • Haid Plates - proprietary plate, same function as above plates 
      • Hook plates - hook on each end to engage lamina with a hole for attachment to articular pillar 
    • CLAMPS 
      • Halifax clamps - proprietary laminar clamps, with hook curves on either end to wrap around lamina. Screw tightens the 2 ends together to engage posterior compression forces. Bone graft often used to facilitate posterior fusion 
    • RODS 
      • CD instrumentation - use reserved typically for very long segment fusion or cervico-thoracic fixation


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