Anterior Cervical Discectomy and Fusion JKBC Parthiban
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1Neuro Spinal Surgery Operative Techniques Anterior Cervical Discectomy and Fusion2
3Neuro Spinal Surgery Operative Techniques Anterior Cervical Discectomy and Fusion
JKBC Parthiban MCh (Neurosurgery) FNS Japan (Fujita) Senior Consultant (Neurosurgeon and Spine Neurosurgery) Kovai Medical Center and Hospital Coimbatore, Tamil Nadu, India Editor-in-Chief Journal of Spinal Surgery (JOSS) Past President Neuro Spinal Surgeons’ Association (NSSA) of India Founder Member, NSSA Teaching Faculty, AO Spine Forewords KR Suresh Bapu RR Ravi
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Neuro Spinal Surgery Operative Techniques
Anterior Cervical Discectomy and Fusion
First Edition: 2016
9789352501304
Printed at
5Dedicated to
Professor PS Ramani and
My dearest wife Harini6
7Foreword
Degenerative cervical disc disease with radiculopathy and/or myelopathy is a very common clinical scenario requiring surgical management. Anterior cervical discectomy with fusion (ACDF) continues to be the gold standard for cervical disc prolapse. Movement-preserving surgeries such as anterior and posterior microforaminotomy and artificial disc have less applicability in practice. Though minimally invasive endoscopic techniques and use of robots are available, but open microsurgical technique continues to be the most preferred one by neurosurgeons.
Personal preferences by individual surgeons are many:
  • Surgeon standing on the side of approach versus standing on the right of the patient yet approaching the cervical spine through a left-sided incision.
  • Use of freehand large blade (LB) retractors versus self-retaining blade retractors
  • Use of vertebral spreaders inserted into disc space versus distractors with pins in the vertebral body
  • Use of high-speed drill versus only curettes
  • Anterior cervical plating in all patients after insertion of bone graft or metal spacer.
Whatever technique is used, it should be safe with consistent good outcome achieving the purpose of the operation, namely adequate neural decompression, good bony fusion with restoration of normal cervical lordosis.
In institutional practice, standardization of the surgical techniques is recommended and Dr JKBC Parthiban has brought out the safe techniques of Anterior Cervical Discectomy and Fusion in 8 chapters. With basic anatomy and approaches described in the first 2 chapters, the technique of microdiscectomy and bone grafting are detailed with illustrative operative pictures. His technique of ‘sinking’ the graft in the disc space bed has been found to be very important in prevention of graft migration. His vast knowledge and experience is evident in the book and will be of great practical guide for all young spinal surgeons.
KR Suresh Bapu MCh (Neurosurgery)
Director and Senior Consultant Neurosurgeon SIMS Hospital, Chennai
Professor of Neurosurgery
SRM Medical College, Chennai, Tamil Nadu, India
Member, Neurological Society of India
Member, Neuro Spinal Surgeons’ Association (NSSA) of India
Member, Congress of Neurological Surgeons
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9Foreword
About 32 years ago, a neurosurgical neophyte showed unmistakable signs of precocity. Later years saw, the tiny spark evolving into a dazzling effulgence. It was given unto me to be a catalyst in this metamorphosis.
During the year 1984, in the temple town of Madurai in South India—the hallowed abode of learning and wisdom, in walked to the portals of the Neurosurgery Department of Madurai Medical College, a young cherubic man. The Department was already the coveted destination for many aspiring youngsters—next only to Vellore and Chennai. I was at that time an Assistant Professor in the Department. He told me that he has been posted for 15 days to the unit. So be it, I thought. Many had already come and gone.
I was proved wrong within a few days. Beneath the smile on his lips and the spring in his steps, I perceived a steely determination. He had dreams in his eyes. He carved a niche in my mind.
When the season arrived, I suggested to him to consider neurosurgery as a career option. The ambience was picture perfect. Diffident as he was, I collected the application form for MCh (Neuro) myself and persuaded him to fill them up and submit. The rest needs no reiteration. Looking back through the corridors of time, I experience a sense of satisfaction that those early glimpses of talent were not wasted by the way side. The opportunity of a lifetime has to be seized during the lifetime of the opportunity.
Today, JKBC Parthiban is a shining star in the firmament of Spinal Surgeons in the country. He has now authored a treatise on Neuro Spinal Surgery Operative Techniques: Anterior Cervical Discectomy and Fusion and has asked me to pen the Foreword. Obviously, I am filled with a pardonable pride—as only a ‘mentor’ can ever have. This is the saga of his experience- consummated through years of toil, struggle and hard work. Needless to say, it contains precious nuggets.
Continued innovation in surgery requires a knowledge and understanding of historical advances with recognition of successes and failures. Current surgical approaches for treating cervical spine disc diseases have developed through the continuous innovations in surgical approaches, bone grafting techniques, and instrumentation. Rapid advances in imaging and minimally invasive techniques suggest that we are at a threshold for a new era in patient care.10
Anterior Cervical Discectomy arrived as a whiff of fresh air in the spinal surgical scenario in the late 1950s which heralded a new era popularized by Cloward and Smith-Robinson. Neurosurgeons began to shift from using posterior to anterior techniques. Continuous refinements in techniques and instruments and implants along with the arrival of high magnification micro- scopes resulted in breath-taking changes. At present, anterior percutaneous endoscopic cervical discectomy (APECD) is popularizing itself in the ever- improving quest for new and minimally invasive techniques. All these have resulted in the procedure becoming extremely patient friendly, reducing the hospital stay dramatically. The day is not far off when this will become an outpatient procedure.
It has been wisely said that dreams get transcended during the lifetime of the dreamer. Many of the techniques now in vogue are certain to be relegated to the relics of history soon.
It is against this backdrop that the book of Dr JKBC Parthiban assumes special significance. The book deals in detail about anterior cervical discectomy and fusion (ACDF) in 8 brilliantly carved chapters. I am confident that it will not only adorn the shelves of the bibliophiles but also shall be a reference guide to the practitioners.
RR Ravi
Senior Consultant Neurosurgeon and HOD
Medical Trust Hospital, Kochi, Kerala, India
Member, Neurological Society of India
Member, Neuro Spinal Surgeons’ Association of India
Registered Member General Medical Council, UK Faculty
DNB-Neurosurgery, India
11Preface
As far as anterior cervical discectomy and fusion (ACDF) is concerned, I always recollect two incidences in my life. First one in 1991 that surprised Dr AN Subbarao, my senior consultant in Medical Trust Hospital in Kochi, Kerala, who got stunned, when I reached the prevertebral space in 10 minutes time from skin incision. He could not believe that since I used to take an hour to reach the disc space in ACDF. My dissection was slow and meticulous due to less or no experience at all, then until I observed in close range Dr PS Ramani's dissection. The reason for quick perfection was simple and straightforward. My training under him for 30 days at Lokmanya Tilak Municipal Medical College (LTMMC), Sion, Mumbai, Maharashtra, changed the fortune in my life in spinal surgery. The wet glove finger dissection technique of PS Ramani was fabulous though I was scared to do so, but I still managed to click my finishing time quicker after observation training. This stunned Dr Subbarao, a great man who gave me free hands to do all spine work wayback in 1991. Since then, there was no stopping in advancing this technique to next level.
The second incidence, when Dr Ramani was assisted by my scrub assistance Mrs Usha Kumari, Kovai Medical Center and Hospital, Coimbatore, in 2006 during Spine conference live workshop. It was interesting to note that neither Dr Ramani nor Mrs Usha understood each others language. No words exchanged during ACDF and the procedure got over without any hitch. Highly impressed by my staff who understood each one of his steps in ACDF, Dr Ramani said that he never uttered a word to ask for the instruments at each step since everything was coming as per his expectations. He mentioned this in the inaugural function and said, ‘My student has followed and done ACDF step by step like the way, I followed in my practice. That's why I never needed a chance to ask for instrument in a different operative set-up!.’ The Guru Shisya Parampara was well appreciated by this incidence.
Days have gone where technology has changed for better. Osteotomes are not used now. High-speed drills are handy and effective. Microscopes are fabulous and provide beautiful vision and depth. We do not need cadaver allografts since tricalcium phosphate impregneted in polyethylene ethylene ketone (PEEK) cages are now available. Though ‘Counter sink’ method in placing the tricortical graft-needed repeated practice nowadays simple low profile titanium grafts with spikes are available. To an extent today's younger surgeons are lucky to get all surgeons friendly systems though, in fact, they really do not test the finer technical skills of these younger surgeons.12
Anterior migration of bone grafts were common in cases where the graft beds were not prepared well. Even today, we see low-profile titanium grafts slip out in a few cases. It is so intriguing to see PEEK cages come out with screws to fix them to adjacent vertebral bodies and plates being recommended for augmenting cages. Young surgeons should know the art of interbody fusion. The ACDF is a microsurgical procedure and a good neural decompression can be achieved only by microsurgical technique using microscope. I do not recommend and favor ACDF being done with naked eye surgery.
This book is written with all these in mind. I do know many surgeons ponder over the surgical flaws in their career. Of course, continuous reading and observation shape our results.
Books are not written to be followed blindly. Surgeons are requested to go through it leisurely but at the same time cautiously and then practice with care and guidance. In case of doubt, no time should be wasted to communicate with me for clarification. My best wishes to all who are going to be benefitted by this small book.
Finally, we live to transfer our knowledge to others for the benefit of mankind.
JKBC Parthiban13
Acknowledgments
Nothing is possible without my patients who had faith in me. This book is no exception. I am greatly indebted to all of them who extended their co-operation for this venture.
I thank the staff and management of Medical Trust Hospital, Kochi, Global Hospital, Chennai, and Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, for their support.
My special thanks to my nursing staff and theater technicians for their whole-hearted involvement.
I thank my junior colleague Dr Shanthanam and my Secretary Sajini for helping me during data collection.
Mr Samuel Williams, Gesco-Chennai, was instrumental in arranging the instruments and implants for the project. Many thanks to him. I also appreciate the cooperation of Medtronics Spine, Depuy-Synthese and Elacons.
I am grateful to Shri Jitendar P Vij (Group Chairman) and Mr Ankit Vij (Group President) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India. My special thanks to Mr Tarun Duneja (Director–Publishing) and Mrs Samina Khan (Executive Assistant to Director–Publishing) for their kind cooperation in helping us to publish this edition in time. Finally, my sincere thanks to all the associates of the company with special mention to Mr KK Raman (Production Manager).
Mr Sabarish Menon (Commissioning Editor—Mumbai Branch), M/s Jaypee Brothers Medical Publishers (P) Ltd, was in constant touch until the last moves were made to get the book completed.
My special thanks to Mrs Chetna (Associate Director–Content Strategy) for her immense help in shaping and bringing out the book in this present shape. I also thank all the other staff involved in designing and printing.
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17Introduction
Anterior Cervical Discectomy and Fusion (ACDF) is the most common surgery done by spinal surgeons. The surgeon must have clear knowledge of anatomy and the plane of cleavage to reach the pre-vertebral space in cervical spine. Subsequently, a steady hand is essential in using long instruments such as knife handle, curets, Kerrison punches, hooks and high speed-angled microdrill during discectomy and osteophysectomy. Later, the art of interbody grafting with tricortical iliac crest and different types of metallic cages needs to be mastered. Hence, as a responsible spinal surgeon, one should have great technique in handling tissues of different textures in a small place.
In the book, basic applied anatomy of the neck en route to the desired cervical disc is described. Many technical points are of my personal views experienced over a period of time by doing this procedure in a large number of patients and by observing many senior surgeons performing them.
While midcervical spine approach is the easiest, the upper and lower cervical regions need special care. For the upper cervical spine approach, a large incision and wider dissection is needed to reach C2/3, while a deep dissection and tunnel such as angulated narrow approach is required for C7/T1. Carotid sheath is an important landmark for all the approaches.
Recurrent laryngeal nerve courses between esophagus and trachea, and the loop on the right side is not a problem since no attempt is made to identify or dissect it to preserve and hence it's always done through right side.
The book gives details of microsurgical techniques step by step with high quality pictures, and in some places with illustrations from different cases for a single procedure. Since microsurgical techniques are shown and readers are advised to go through the pictures carefully to understand the minute points. The technique of harvesting iliac crest tricortical bone graft and counter sink method of interbody grafting is highlighted. To add on with ACDF, a chapter on Corpectomy is also added. The book ends with pictures of instruments that are essential for ACDF.