779

Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
P AUL T ORNETTA III
EDITOR, VOL. 61

C OMMITTEE
P AUL T ORNETTA III
CHAIR
K ENNETH A. E GOL
M ARY I. O’C ONNOR
M ARK P AGNANO
R OBERT A. H ART

E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
in February 2012 in Instructional Course Lectures, Volume 61.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
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Advanced Techniques in
Cervical Spine Surgery
By Wellington K. Hsu, MD

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Disorders of the cervical spine can lead
to compression of neural elements and
cause myelopathy, radiculopathy, or a
combination of these conditions. Spinal
cord or nerve root compression can
be caused by a soft herniated nucleus
pulposus, osteophyte formation, facet
joint hypertrophy, and/or congenital
abnormalities of the cervical spine. If
nonoperative treatment fails, surgical
treatment can often lead to excellent
long-term clinical outcomes. The sur-
gical treatment of these disorders de-
pends on patient preference, clinical
findings, and the evidence-based litera-
ture. In the properly selected patient,
posterior cervical decompression for the
treatment of radiculopathy provides
potential advantages, including preser-
vation of neck motion, avoidance of
complications from anterior surgery,
and fewer postoperative restrictions.
A posterior fusion is indicated for
conditions involving an unstable, ky-
photic, or severely spondylotic cervical
spine. Advances in the understanding
of cervical spine anatomy have greatly
enhanced the surgeon’s options for
osseous fixation to achieve fusion.
Cadaveric and imaging studies have
demonstrated a high rate of anatomic
variability and the importance of pre-
operative imaging and planning before
surgery1-3. These studies have also es-
tablished reliable guidelines for screw
placement to avoid critical vascular,
neurologic, and visceral structures
during cervical spine instrumentation.
Awareness of these principles is essen-
tial to avoid complications and provide
excellent outcomes.
Posterior Cervical Decompression
Foraminotomy
The foramina are bordered superiorly
and inferiorly by the respective pedicles,
anteriorly by the disc and uncovertebral
joint, and posteriorly by the superior
articular facet. The average dimensions
of a cervical foramen are 9 to 12 mm
in height and 4 to 6 mm in width4. These
foramina are oriented at an angle of
45 from the midsagittal plane. Conse-
quently, patients are more susceptible
to foraminal narrowing in the anterior-
posterior plane.
Patients with radiculopathy from
nerve root compression in the foramina
(Fig. 1) can benefit from a foraminot-
omy, which decompresses the nerve root
by removing a portion of the superior
articular facet. This procedure allows the
nerve root to be mobilized, increasing
the space between it and the disc. In
many patients with foraminal disc her-
niation, a partial pediculectomy and
gentle retraction of the nerve root can
aid in the discectomy, particularly when
there is soft disc pathology rather than a
disc-osteophyte complex, which is dif-
ficult to remove posteriorly. A preoper-
ative computed tomography (CT) scan
is helpful in determining the etiology of
the foraminal compression. Posterior
foraminotomies are contraindicated for
centrally located disc herniations, cen-
tral spinal canal stenosis, and ossifica-
tion of the posterior longitudinal
ligament.
A posterior foraminotomy can be
performed with the patient in either a
sitting or a prone position. The sitting
position decreases the incidence of
intraoperative bleeding. It carries a the-
oretical risk of air embolism, but this
position has been used in hundreds of
cases without that complication5. When
the prone position is utilized, Mayfield
or Gardner-Wells tongs are used to
stabilize the head. Both arthroscopic and

Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of
his immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits
from commercial entities (Stryker, Inc., and Pioneer Surgical, Inc.)

J Bone Joint Surg Am. 2011;93:780-8

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approaches for radiculopathy may be

Fig. 1
Axial cross-sectional view of a cadaveric upper cervical spine with facet joint arthrosis (F) and
uncovertebral hypertrophy (VB), causing encroachment on the exiting nerve root (N). VA = vertebral
artery. (Reprinted, with permission, from: Papadopoulos SM, editor. Manual of cervical spine
internal fixation. 1st ed. Philadelphia: Lippincott Williams & Wilkins; 2004.)
microscopic techniques have been
described to aid visualization during
this procedure. After a preoperative
localization radiograph identifies the
cervical spine location, an incision is
made 1.5 cm off of the midline at the
appropriate level. Sharp dissection is
then performed through the fascia,
with either a self-retaining McCullough
retractor or a tube retractor docked
onto the lateral mass and the facet joint.
A localizing lateral radiograph is ob-
tained to confirm the cervical spine
level.
The medial third of the facet joint
is identified, and the overlying inferior
articular facet is then removed (at the C5
level for a C6 foraminotomy) with a
high-speed oscillating burr (Fig. 2). The
superior articular facet is well visualized
and is removed to unroof the foramen
and expose the traversing nerve root. An
oscillating burr, micro-Kerrison ron-
geurs, and angled curets are used to
remove up to the medial 50% of the
facet joint. To ensure adequate decom-
pression once the nerve root is exposed,
a nerve hook can be utilized to carefully
palpate the caudad pedicle (at the C6
level for a C6 foraminotomy) (Fig. 2, D).
The procedure must be carried out
lateral to the pedicle to ensure a com-
plete decompression.
When a soft disc herniation is
present, a partial pediculectomy is done
to minimize nerve root retraction. Once
the medial third of the pedicle is re-
moved with an oscillating burr, the
traversing nerve root can be gently
mobilized with a nerve hook to expose
the disc fragment. Since this space is
quite limited, an arthroscopic grabber or
micro-pituitary rongeur from a tympa-
noplasty set can facilitate free disc frag-
ment removal.
Posterior foraminotomies provide
excellent clinical outcomes when used
for the treatment of cervical radicu-
lopathy5,6. Of 736 patients with a
‘‘posterior-lateral foraminotomy,’’ 91.5%
were reported to have a good or excellent
result at an average of 2.8 years postop-
eratively 5, a finding that has been sup-
ported by other reports7,8. Factors that
contribute to worsening sagittal align-
ment after posterior foraminotomy
include an age over sixty years and
preoperative cervical lordosis of <107.
A posterior cervical foraminot-
omy provides a number of advantages
over anterior approaches in properly
selected patients. Anterior surgical
associated with complications, includ-
ing recurrent laryngeal nerve palsy,
dysphagia, dysphonia, and adjacent-
segment degeneration. The incidence of
symptomatic adjacent-segment degen-
eration after anterior cervical discec-
tomy and fusion is 2.9% per year (26%
in a group of patients seen at ten years
postoperatively)9. Posterior foraminot-
omy avoids the complications of ante-
rior surgery and may also reduce the risk
of adjacent-segment degeneration post-
operatively. In a study of 303 patients
followed for an average of 7.2 years after
a single-level posterior foraminotomy,
4.9% developed symptomatic adjacent-
segment degeneration10. The ten-year
rate of adjacent-segment degeneration
was calculated to be 6.7%. Furthermore,
unlike anterior fusion, posterior de-
compression maintains cervical spine
motion. In patients with multilevel
pathological involvement, a posterior
approach can lead to outcomes that
are comparable with those of the ante-
rior approach without limiting neck
motion6.
Some authors have suggested that
a C5 foraminotomy with a decompres-
sive procedure, such as a laminoplasty,
would lead to a decreased incidence of
C5 nerve root palsy. Patients with this
complication can have severe deltoid
weakness, preventing them from per-
forming some activities of daily living.
Although the exact cause of C5 nerve
root palsy is unclear, many authors have
suggested an ischemic etiology from
nerve root stretch after decompression.
No treatment modalities have been
successful in improving the outcome if
iatrogenic C5 nerve root palsy occurs,
but most patients regain functional
deltoid strength within six to nine
months after surgery11. Even though a
posterior foraminotomy would theo-
retically decrease nerve root tension
after posterior drift of the spinal cord, it
is unclear whether this would decrease
the incidence of this difficult postoper-
ative complication.
Laminectomy
Posterior cervical laminectomy has pri-
marily been used to treat central cervical
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Fig. 2
Posterior foraminotomy procedure. After the medial third of the corresponding facet joint is identified, the
inferior articular facet is removed with either micro-Kerrison rongeurs (A) or an oscillating burr (B) to expose the
overlying superior facet. Decompression of the facet is continued to the level of the nerve root (C). A nerve hook
can be used to palpate the pedicle inferiorly and ensure adequate lateral decompression (D). (Reprinted, with
permission, from: An HS, Xu R. Posterior cervical spine procedure. In: An HS, Riley LH 3rd, editors. An atlas of
surgery of the spine. 1st ed. London: Martin Dunitz; 1998.)

spine stenosis caused by spondylosis,
neoplastic conditions, or ossification
of the posterior longitudinal ligament.
Preoperative positioning is similar to
that for a foraminotomy, but a more
extensive soft-tissue dissection is re-
quired to expose the posterior cervical
spine.
Bilateral exposure of the lamina-
lateral mass junction is required for a
full laminectomy. One of several tech-
niques that have been described is use of
a high-speed oscillating burr to remove
this osseous bridge bilaterally (Fig. 3,
A). After removal of the outer osseous
cortex, the burr tip can be switched to an
extra-rough diamond-tip drill bit to
avoid catching soft tissue and dural
tears. Excision of the ligamentum fla-
vum is performed both cephalad and
caudad to the laminectomy sites. Lam-
ina removal is done with symmetric
upward traction with use of a towel
clamp at both ends of the decompres-
sion (Fig. 3, B). Care must be taken to
avoid rotation of the fragments and
subsequent impingement on the cervical
cord. Remaining ligamentum flavum
attachments to the lamina during this
part of the procedure can be removed
with a Kerrison rongeur.
Posterior Cervical Fusion
Posterior fusion is indicated for cervical
spine instability resulting from trau-
matic, iatrogenic, or degenerative causes;
pseudarthrosis after a prior arthrodesis;
or multilevel anterior procedures re-
quiring enhanced fixation. Surgeons can
choose between wiring and screw fixa-
tion techniques. Recent studies have
shown screw constructs to have greater
rigidity and result in higher fusion rates
than spinous process wiring12.
Subaxial Cervical Spine
A number of techniques for subaxial
screw fixation of the lateral mass have
been described. First described in
197913, the Roy-Camille technique uti-
lizes a starting point at the midpoint of
the lateral mass. With use of the neutral
alignment of the cervical spine (plumb
line), the screw trajectory is perpen-
dicular in the superior-inferior plane
with a 10 lateral orientation (Fig. 4).
The primary risk with this technique is
a breach of the facet joint in the area of
both the vertebral artery and the nerve
root (Fig. 5). The Magerl (transarticular
screw) technique14 utilizes a starting
point just medial and superior to that
used with the Roy-Camille procedure

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Fig. 3
and orients the screw in a cephalad
angle of 30 and a laterally directed
angle of 25 (Fig. 4). A broad or
prominent spinous process can inter-
fere with the screw trajectory with the
Magerl technique, which may increase
the risk of lateral screw cutout. There is
a risk of nerve root injury with both
783
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A D VA N C E D T E C H N I Q U E S
Standard open posterior cervical laminectomy.
After adequate soft-tissue exposure of the
lamina-lateral mass junction bilaterally, a high-
speed oscillating burr can be used to separate
this junction (A). Once the inner cortical bone is
adequately separated on each side, symmetric
traction is necessary to safely remove the bone
from the underlying cervical cord (B). Final in-
spection of the laminectomy site should dem-
onstrate retention of the facet joint capsules
and wide exposure of the cervical dura (C).
(Reprinted, with permission, from: Cooper PR,
Ratliff JK. Cervical laminectomy. In: Herkowitz
HN, editor. The cervical spine surgery atlas. 2nd
ed. Philadelphia: Lippincott Williams & Wilkins;
2003.)
techniques if they are not performed
properly.
Anderson et al. modified the
lateral-mass screw technique by using a
starting point slightly medial to the mid-
point of the lateral mass and a 35 to 40
superior and 10 lateral orientation15. I
prefer this method, in which a variable-
IN CE RV IC A L SP IN E SU RG E RY
length drill guide is used to optimize screw
lengths at each cervical level. Advance-
ment of drilling in 2-mm increments
ensures the strongest bone purchase
without violation of the traversing nerve
root. This screw trajectory appears to be
the most reliable for avoiding critical
neurovascular structures.
Stemper et al. demonstrated the
variations in the anatomy of the subaxial
cervical lateral mass in an in vivo CT
study of the cervical spine16. Bicortical
screw paths created with use of the
Roy-Camille and Magerl techniques
were drawn on sagittal CT images of
ninety-eight asymptomatic volunteers.
Although there was a moderate amount
of variation in screw lengths, no corre-
lation was found between screw length
and stature, body weight, or neck length.
At C3-C6, Magerl screw trajectories were,
on average, at least 2 mm longer than
Roy-Camille screw trajectories. The
screw lengths were the shortest (aver-
age, 9.8 mm in males and 8.5 mm in
females) at the C7 lateral mass.
Atlantoaxial Junction
Atlantoaxial fusions are indicated for
patients showing >5 mm of instability
on flexion-extension views; those with
severe cervical cord compression; and
those with traumatic injuries, such as
a Jefferson or unstable hangman frac-
ture. Historically, the use of sublaminar
wiring alone to stabilize this junction
with the modified Gallie17 or Brooks18
technique has led to acceptable clinical
outcomes, but the development of safe
and efficient protocols with lateral mass
and pedicle screw fixation in the upper
cervical spine has increased fusion rates
and often obviates the need for halo
vest immobilization postoperatively.
Patients with concomitant subaxial
cervical fracture or osteoporotic bone
leading to poor bone purchase may
require a halo postoperatively, but the
potential for complications with halo
use must be carefully considered, es-
pecially in elderly patients12.
The Magerl technique utilizes a
cancellous screw that crosses the C1-
C2 facet joint (Fig. 6). Percutaneous
starting points are made as caudad
as T1 to obtain the proper angle for
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Fig. 4
Cervical lateral mass fixation with use of either a Magerl or a Roy-Camille technique. While both techniques utilize a starting
point at the midpoint of the lateral mass in both the cephalad-caudad and the medial-lateral plane, the Magerl screw is
inserted in a 30 superior and 25 lateral orientation. The Roy-Camille screw takes a more perpendicular trajectory (0) and
10 lateral approach. (Reprinted, with permission, from: Stemper BD, Marawar SV, Yoganandan N, Shender BS, Rao RD.
Quantitative anatomy of subaxial cervical lateral mass: an analysis of safe screw lengths for Roy-Camille and Magerl
techniques. Spine [Phila Pa 1976]. 2008;33(8):893-7.)

adequate fixation. Biplanar fluoroscopy
is often required to identify the correct
trajectory of 0 in the medial-lateral
plane and 45 in the cephalad-caudad
plane. With a starting point in the
inferomedial quadrant of the C2 lateral
mass, the trajectory is aimed toward the
anterior tubercle of C1 on a lateral
fluoroscopy view. Either cannulated or
noncannulated screws can be used, but
the placement and control of the initial
Kirschner wire can be challenging. One
advantage of this technique is that a
standard set of fracture repair screws is
sufficient for adequate fixation. A pre-
operative CT scan of the cervical spine
is required to track the course of the
vascular structures at this level. The
presence of an anomalous vertebral
artery precludes the use of this screw.
The Harms technique utilizes
axial pedicle or pars interarticularis
and atlas lateral mass screws19. Pedicle
screws have been found to have a
greater insertional torque and pullout
strength than either laminar or pars
interarticularis screws in cadaveric
spines20. The C2 pedicle screw is in-
serted with a starting point that is just
superior and medial to the center of the
lateral mass (Fig. 7). A small laminot-
omy and palpation with a nerve hook
can often assist with the medial-lateral
orientation (10), while lateral fluo-
roscopy can guide the cephalad-caudad
direction (15). The C1 entry point is
identified at the junction of the lateral
mass and the inferior aspect of the
posterior arch (Fig. 7). Often, the
overhang of the C1 arch should be
removed with an oscillating burr at the
level of the lateral mass in order to
identify the landmarks and provide
room for the screw head. A Penfield
retractor can be used to palpate the
medial aspect of C1 to guide a 10
medial and 20 cephalad trajectory.
The most commonly used titanium
screw size is 3.5 · 28 mm. With this
procedure, the surgeon should try not
to violate the C2-C3 interspinous
space, and to leave as many muscle
attachments as possible to reduce
postoperative pain and increase sta-
bility. Any bleeding from the venous
plexus between C1 and C2 should be
controlled with FloSeal Hemostatic
Matrix (Baxter Healthcare, Fremont,
California); cottonoids; or a combina-
tion of Avitene (microfibrillar collagen)
(Devol, Warwick, Rhode Island), Gel-
foam (Upjohn, Kalamazoo, Michigan),
and thrombin.
Although the C1 lateral mass
screw is ideally placed with bicortical
purchase, anterior structures such as
the internal carotid artery must be
avoided. In a study of 149 CT recon-
struction images of the cervical spine,
Murakami et al. defined the variation of
the anatomy of the internal carotid
artery anterior to the C1 anterior arch21.
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with the proper entry point can avoid

injury to the internal carotid artery. This
ideal trajectory was confirmed with an
anatomic study of atlas specimens that
demonstrated less variability in C1 lat-
eral mass measurements compared with
those of other levels22.
When it is not possible to use C2
pedicle or pars interarticularis screws
because of anatomic variations, lami-
nar fixation can be considered. With an
entry point 5 mm lateral to the mid-
line of the spinous process and 6 mm
caudad to the cranial border of the
lamina, a 3.5 · 26-mm screw can often
be inserted2 (Fig. 8). In a biomechanical
analysis of C1 lateral mass-C2 pedicle
screw fixation, C1 lateral mass-C2
intralaminar screw fixation, and C1-C2
Fig. 5
sublaminar wire fixation techniques,
Sagittal cross section of a cadaveric specimen of a lateral mass (LM) in a man operated on with Elgafy et al. demonstrated that all three
3.5-mm cancellous screws when he was seventy-two years old. The lateral mass screw (S) is seen instrumentation systems were equally
violating the inferior articular process of C5 with its tip just short of the vertebral artery (VA) in
stable in flexion-extension and lateral
between the C5 nerve root and C6 ganglion. F = facet joint. (Reprinted, with permission, from:
bending23. While both screw constructs
were superior to the wiring technique in
Papadopoulos SM, editor. Manual of cervical spine internal fixation. 1st ed. Philadelphia:
axial rotation, there were no significant
Lippincott Williams & Wilkins; 2004.)
differences between the lateral mass-
In 64% of patients, the internal carotid cases, it was over the lateral third. The intralaminar and lateral mass-pedicle
artery was directly anterior to the mid- authors concluded that a 10 medial constructs in flexion-extension. In an
dle of the C1 lateral mass, and in 55% of orientation of the C1 lateral mass screw anatomic study of the axis in an Asian

Fig. 6
Transarticular screw fixation at C1-C2. The entry point for the transarticular screw is located in the inferomedial quadrant
of the lateral mass (B) with a neutral trajectory in the medial-lateral plane (A). Identification of the vertebral artery and the
C2 nerve root can aid in the drilling of this screw (B). (Reprinted, with permission of Elsevier, from: Feiz-Erfan I,
Klopfenstein JD, Vougioukas VI, Dickman CA. Surgical therapy for fractures and dislocations of the craniocervical
junction and upper cervical spine. In: Kim DH, Henn JS, Vaccaro AR, Dickman CA, editors. Surgical anatomy &
techniques to the spine. New York: Elsevier; 2006.)
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Fig. 7
C1-C2 fixation with use of the Harms technique. The entry point for the C2 pedicle screw is the superomedial quadrant of
the lateral mass (A) directed in a 15 cephalad and 10 medial trajectory. The C1 lateral mass screw is started in the
midpoint of the lateral mass just below the arch and oriented in a 10 medial direction for bicortical purchase (B).
(Reprinted, with permission, from: Harms J, Melcher RP. Posterior C1-C2 fusion with polyaxial screw and rod fixation.
Spine [Phila Pa 1976]. 2001;26(22):2467-71.)

population, Ma et al. demonstrated that
83% of patients had anatomic parame-
ters that allowed for a 3.5-mm screw,
while only a unilateral screw was suit-
able in 12% of cases2. In 5% of the cases
examined, the laminae were too thin
to accommodate screws on either side.
This and other studies highlight the
importance of preoperative CT planning
when either C2 pedicle or C2 laminar
screws are considered.
Fig. 8
Entry points for C2 laminar screws. (Reprinted, with permission, from: Ma
XY, Yin QS, Wu ZH, Xia H, Riew KD, Liu JF. C2 anatomy and dimensions
relative to translaminar screw placement in an Asian population. Spine
[Phila Pa 1976]. 2010;35(6):704-8.)
Occipital-Cervical Junction
Posterior fixation for occipital-cervical
fusion is required for clinical conditions
such as atlanto-occipital dissociation/
instability or basilar invagination. Depend-
ing on the associated condition, a decom-
pression of the opisthion (the hindmost
point on the posterior margin of the
foramen magnum) may be needed as well.
It is important to identify a
number of landmarks prior to formal
instrumentation. The external occipi-
tal protuberance is a palpable uprising
that marks the thickest portion of the
bone (Fig. 9, A). The superior and
inferior nuchal lines are ridges that
extend in the medial-lateral direction
from the external occipital protuber-
ance. The path from the external
occipital protuberance to the foramen
magnum marks a sharp anterior trajec-
tory that can make plate contouring a
substantial challenge. All screw fixation
should be caudad to the external occip-
ital protuberance to ensure good bone
quality and adequate soft-tissue cover-
age. At the external occipital protu-
berance, 12 to 18-mm-thick bone is
expected. However, the identification of
this point is important since a starting
point just 1 cm lateral and inferior to
it provides only 5 to 7 mm of bone
thickness. Although some authors have
advocated bicortical screw purchase,
unicortical screws at the external oc-
cipital protuberance provide adequate
pullout strength as the inner table has
only 10% of the overall thickness. A
wide array of occipital-cervical plate-
screw constructs that allow contouring
and flexibility in this articulation are
available. Regardless of the instrumen-
tation system, the construct should
allow adequate soft-tissue coverage,
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Fig. 9
Occipital-cervical fixation. The identification of anatomic landmarks (A) is essential to providing the optimum screw fixation in the occiput. Instru-
mentation systems should provide for screws in the midline of the occiput and a plate-rod interface that is secure and can be contoured to fit the skull (B
and C). (Fig. 9, A, reprinted, with permission, from: Herkowitz HN, editor. The cervical spine surgery atlas. 2nd ed. Philadelphia: Lippincott Williams &
Wilkins; 2003.)

avoid hardware prominence, and pro-
vide a stable plate-to-screw interface
to avoid postoperative complications
(Fig. 9).
Bone Graft
The choice of bone graft to be used in
conjunction with posterior cervical
fusion depends on a number of factors,
including fusion rates, the volume
required, complications, comorbid-
ities, and cost. Historically, structural
and cancellous autologous iliac crest
bone-grafting has been successfully
utilized in Brooks and Gallie as well
as subaxial fusion constructs. Because
the posterior cervical spine is a more
favorable biologic milieu for bone-
healing than is the posterior lumbar
spine, iliac crest bone-grafting can
often be avoided. Just as important as
the bone graft choice is the preparation
of the fusion surfaces, which should
include a subtotal facetectomy in the
subaxial spine and thorough prepara-
tion of the lamina, facet joint, and
occiput surfaces in the upper cervical
spine. Local bone graft from a laminec-
tomy site can provide an osteoinductive
stimulus necessary for bone-healing
in this environment24. Bone graft ex-
tenders such as ceramic scaffolds, used
in conjunction with local bone graft,
also can increase osseous healing, and
this is the method that I prefer. The
use of bone morphogenetic protein
(BMP) has led to high fusion rates in
the posterior cervical spine, but its use
may lead to wound complications and
local seroma formation25. At the pres-
ent time, use of BMP in this surgical
setting has not been approved by the
Food and Drug Administration in the
United States. The complications ap-
pear to be linked to the dose of growth
factor utilized.
Overview
In properly selected patients, posterior
cervical decompression and fusion can
successfully treat cervical myelopathy
and radiculopathy. The choice of a
posterior approach versus an anterior
approach depends on a number of
factors, including sagittal alignment, the
type and extent of the pathological
involvement, and patient preference.
Recent advances in spine surgeons’ un-
derstanding of anatomy and technique
have increased their level of comfort
with using instrumentation in the upper
and subaxial cervical spine. Further-
more, the use of concomitant minimally
invasive techniques with these proce-
dures leads to faster recovery times with
equivalent outcomes. Awareness of the
strengths and limitations of posterior
cervical techniques can greatly enhance
the surgeon’s ability to achieve excellent
clinical outcomes.
Wellington K. Hsu, MD
Departments of Orthopaedic Surgery and
Neurological Surgery, Feinberg School
of Medicine, Northwestern University,
676 North St. Clair Street, Suite 1350,
Chicago, IL 60611.
E-mail address: whsu@nmff.org
Printed with permission of the American
Academy of Orthopaedic Surgeons. This
article, as well as other lectures presented at

TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG
V O LU M E 93-A N U M B E R 8 A P R I L 20, 2 011
d d
the Academy’s Annual Meeting, will be
available in February 2012 in Instructional
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Course Lectures, Volume 61. The complete
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