Difficult Problems in Cervical Spine Surgery

This issue of Seminars in Neurosurgery presents eight manuscripts, each discussing a difficult problem in cervical spine surgery. Note that this is not a static discussion. Many of the problems once considered difficult are now routine. The volume of cervical spine operations performed per year in the United States attests to this, as does the general level of satisfaction with the surgical treatment of the more common cervical spine disorders, particularly cervical disc disease.

The last several decades have seen a tremendous increase in the general level of skill and knowledge possessed by spinal surgeons. This has been the result of several factors, including advances in research, increased emphasis on spinal surgery during training, and organized efforts on the part of specialty societies to disseminate skills and knowledge throughout the surgical community. As surgeons become more highly skilled and trained in the treatment of cervical spine disorders, however, certain consequences are inevitable.

First, controversy will arise about the treatment of the most common cervical spine disorders. Nowhere is this controversy more prevalent than in the surgical treatment of cervical spondylotic myelopathy. There is, however, nothing wrong or sinister about this controversy. It is merely a reflection of the intense desire among spinal surgeons to do what is best for their patients. Because, in most instances, the best treatment has not been rigorously defined, there is room for healthy and informed debate.

In this issue of Seminars in Neurosurgery, three manuscripts are offered regarding the surgical treatment of cervical spondylotic myelopathy. Dr. Scott Shapiro presents a thoughtful review of multilevel cervical corpectomy in the treatment of this common condition. Drs. Wienecke and Loftus discuss the role of multilevel anterior cervical discectomy and fusion, while Drs. Samartzis, Ratliff, and Perez-Cruet argue for the posterior approach.

Second, as surgeons become more comfortable with the treatment of degenerative spinal disorders, their skills will be applied to the treatment of other conditions. While the treatment principles which apply to degenerative spinal disorders do apply to some of these other conditions, there are still others where they do not. In these instances, it is very important for the surgeon to recognize this disparity and to implement an appropriate treatment plan.

Cervical spine injuries in athletes and ossification of the posterior longitudinal ligament are two such conditions. Drs. Purvines, Groff, and Feuer draw upon their extensive experience in the area of cervical spine injuries in athletes to synthesize a prevention, diagnosis, and treatment plan that recognizes not only the health of the patient but the desire to return to play. Drs. Surdell and White, in their discussion of ossification of the posterior ligament, identify the important differences between this condition and degenerative disease in developing a rational approach for treatment.

Finally, there will be complications. When unfavorable outcomes do occur, surgeons who perform spinal operations are obligated to investigate the cause, recognize the complication, and initiate treatment. While the treatment of some complications may be outside the expertise of an individual spinal surgeon, this is increasingly infrequent. What is needed, in these difficult situations, is thoughtful consideration of all treatment options, including the relative risks, benefits, and alternatives of each.

This issue presents three manuscripts addressing three common but difficult postoperative complications. Drs. Cheng, Maiman, and Chambers discuss the treatment of adjacent segment disease, including the perhaps controversial argument for pre-emptive treatment. Drs. Matz, Wolff, and Hadley describe their experience in the treatment of cervical kyphotic deformity. Finally, Dr. Timothy Puckett, an orthopedic surgeon, gives a detailed review of the treatment options for pseudarthrosis after cervical fusion.

The authors sincerely hope that this material will be of use to all spinal surgeons and their patients who suffer from diseases of the cervical spine. It is not the goal of the authors to eliminate all areas of uncertainty regarding the treatment of cervical spine disease. Rather, their goal is to identify and explore topics that are controversial, uncommon, or increasingly in need of further consideration. In addition, through careful review of what is known, it is hoped that strategies will be developed to resolve, in a scientific manner, some of these ongoing uncertainties.