Posterior cervical fusion

Last revised by Joachim Feger on 9 Jan 2022

Posterior cervical fusion refers to a surgical spinal fusion technique of the cervical spine for conditions requiring posterior stabilization. It might be done for the management of cervical spine fractures or combined with spinal decompression techniques such as laminectomy or laminotomy.

The first posterior cervical fusion was performed in the late 19th century with bone graft as scaffolds and temporary external immobilization 1-3 and the first posterior cervical fusion with a wire as hardware was reported by Hadra in the 1890s 2,3.

Posterior cervical fusion might be performed in the following situations 1,2:

The procedure and techniques and hardware used in the case of a posterior cervical fusion depend on the indication, location and the number of levels that need to be fused. A rough overview of the surgical procedure includes the following steps:

  • longitudinal incision over the targeted levels
  • exposure of the spinous processes and the posterior vertebral arches
  • variably any necessary decompression procedures
  • fixation and stabilization of the vertebral arches at the involved levels
  • variably bone graft insertion after decortication of facet joints
  • suture of the interspinous and nuchal ligament as well as the subcutaneous tissue layer and the skin

Various techniques with different spinal instrumentation hardware include 1-5:

  • spinal wiring
    • sublaminar wiring
    • interspinous wiring
    • facet wiring
    • posterior atlantoaxial fixation
      • Gallie technique: wire cerclage connecting the C1 posterior arch with the C2 spinous process
      • Brooks technique: two paired wires connecting the C1 posterior arch with the C2 laminae
  • interlaminar clamps
  • posterior cervical fixation systems
    • plate-screw interfaces
    • rod-screw interfaces
  • screws
    • pars screws (typically C2)
    • lateral mass screws (C3-C6 and variably C7)
    • pedicle screws (T1 and variably C2 and C7)
    • laminar screws (possibility in C2)
    • Magerl technique: transarticular screw fixation

Complications of posterior cervical fusion include complications of spinal surgery and the following 6,7:

CT can be used to detect and characterize the location of implants as well as complications.

MRI can be used to evaluate the spinal canal in particular in the setting of suspected complications. Depending on the implanted hardware, MRI evaluation might be impaired by artifacts.

The postoperative radiological report should include a description of the following features:

  • implanted hardware
  • position of screws especially to the following structures
    • spinal canal
    • intervertebral foramen
    • foramina transversarium
  • bone grafts if present
  • complications

Lateral mass screws can be used at multiple levels combined with rods and/or plates and feature a low complication rate, and better stability than wiring or translaminar screws. The use of cervical pedicle screws is technically more challenging, but offer potentially higher stability and a lower risk of screw back out. They have a higher risk of a spinal cord, nerve root or vertebral artery injury and are usually used at the T1 level and variably at C2 and C7 1,2.

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