Introduction to Spinal Decompression and Access

Spinal decompression and access procedures are essential to understand before

discussing stabilization techniques. These procedures, including laminotomy,
laminectomy, discectomy, and corpectomy, involve removing various spinal structures to
relieve pressure on nerves or access damaged areas. The type and extent of the procedure
depend on the patient's specific condition and the structures involved.

After completing this course, you will be able to:

• Understand the importance of decompression and access procedures in spinal

surgery

• Define laminotomy and its purpose

• Define laminectomy and its variations

• Define discectomy and its purpose

• Define corpectomy and its purpose

A laminotomy is a surgical procedure where an incision is made into the lamina, the bony
structure in the posterior part of the spine. This is done to decompress nerves or access
the discs or nerves.
 laminectomy is a surgical procedure that involves removing part or all of the lamina, a
bony structure in the spine. The amount of bone removed can vary, ranging from a partial
laminectomy, where only a small portion is taken out, to a more extensive removal.

A complete or total laminectomy is the removal of the entire lamina.

These procedures can be done to decompress nerves or they can be done to get access to
other parts of the anatomy like the disc.
Procedure When to Use

• To decompress nerves

Laminotomy • To access discs or nerves

• May not involve fusion

• To decompress nerves

Laminectomy • To access discs or other anatomy

• Amount of bone removal varies (partial to total)

• To remove herniated nucleus pulposus

• Total discectomy: usually during corpectomy

Discectomy
• Typically only removes nucleus pulposus and inner
disc, not annulus

• For vertebral body tumors

Corpectomy • For severe trauma like burst fractures

• Removes vertebral body and adjacent discs

Introduction to cervical procedure

Understanding cervical spine procedures like ACDF, arthroplasty, and
posterior cervical surgeries is crucial for both patient care and effective
communication with healthcare teams for several reasons.
Grasping the basics of these procedures ensures consistency in patient care,
minimizes errors, and promotes a cohesive treatment plan. You'll better
understand the treatment options, the potential benefits and risks, and what
to expect during recovery. This informed decision making leads to greater
patient satisfaction and engagement in their healthcare journey.
Anterior cervical disectomy and fusion (ACDF)
This is a common surgical procedure for treating cervical spine conditions. It
involves making an incision in the front of the neck to access the damaged
disc. The disc is removed (discectomy) and the vertebrae are stabilized with
an interbody spacer and an anterior plate to provide stabilization until fusion
occurs. The goal is to decompress nerves, restore disc height, and provide
stability.

Anterior cervical arthroplasty

This procedure is similar to an ACDF but with a key difference: instead of
fusing the vertebrae, an artificial cervical disc is inserted to preserve natural
motion. This allows for continued flexibility and range of motion at the treated
level.

Posterior cervical procedure

These are less common than anterior approaches but are used in certain
cases. They involve making an incision in the back of the neck. Posterior
cervical procedures may include laminoplasty (surgically repairing the lamina
to decompress the spinal cord) or fusion/stabilization using specialized
systems.

Anterior Cervical Discectomy and Fusion (ACDF)

An Anterior Cervical Discectomy and Fusion (ACDF) is a surgical procedure
used to treat various conditions affecting the cervical spine. The goal of an
ACDF is to relieve pressure on the spinal cord or nerve roots in the neck, while
also stabilizing the spine. This is achieved by removing a damaged or
herniated disc through an incision in the front of the neck, followed by fusing
the adjacent vertebrae together using a bone graft or interbody spacer, and
securing them with a metal plate. This procedure can help alleviate symptoms
such as neck pain, numbness or weakness in the arm, and difficulty with
coordination or balance. Let's take a closer look at the steps involved in an
ACDF.

ACDF Steps
1. Incision and exposure
The surgeon makes a small incision in the front of the
neck. Retractor blades are then used to gently move the
soft tissues (such as the trachea and esophagus) aside,
providing access to the anterior cervical spine.

2. Annulotomy
A small incision is made in the annulus fibrosus (the
tough outer layer of the disc) to allow for removal of the
disc material. This is necessary because the annular
fibers are too thick to remove the disc intact
3. Disectomy
Specialized instruments, such as a pituitary, are used to
remove the nucleus pulposus and any remaining disc
fragments from within the disc space.

4. Endplate preparation
A curette is used to remove the cartilage from the
vertebral endplates, promoting bleeding and facilitating
fusion.
 5. Decompression
The surgeon ensures that the spinal cord and nerve roots
are adequately decompressed by removing any remaining
disc or bone fragments.
6. Spacer placement
A piece of bone or an interbody spacer with bone graft is
placed in the disc space for fusion and to restore disc
height.

7. Fusion and stabilization

An anterior cervical plate and screws are used to hold the
vertebrae in place until a solid fusion occurs.

Cervical interbody options

There are many cervical interbody options to maintain disc height
and support the spine's natural alignment, a specialized device is
placed in the disc space, along with bone graft to encourage fusion.
The bone graft is packed within the interbody device to aid in fusion.
There are several types of spacers used in neck surgery. Some
surgeons use donor bone, shaped for the purpose. Others use
medical-grade plastic (PEEK) devices. Examples of PEEK devices
include Anatomic PEEK and Cornerstone™ PSR systems. The
Divergence™ system is a type of PEEK device that doesn't require an
extra plate. Titanium is also used. The Endoskeleton™ TC system
needs a plate, but the Endoskeleton™ TCS system does not when
used with its integrated screws
Anatomic PEEK Cervical Fusion System
The Anatomic PEEK Cervical Fusion System is indicated for cervical
interbody fusion pro- cedures in skeletally mature patients with
cervical disc disease at one level from the C2-C3 disc to the C7-T1
disc. Cervical disc disease is defined as intractable radiculopathy
and/or myelopathy with herniated disc and/or osteophyte formation
on posterior vertebral endplates producing symptomatic nerve root
and/or spinal cord compression confirmed by radiographic studies.
This device is to be used in patients who have had six weeks of non-
operative treat- ment. The Anatomic PEEK device is to be used with
supplemental fixation. The Anatomic PEEK Cervical Fusion System
is also required to be used with autogenous bone and/or allograft
bone graft comprised of cancellous and/or corticocancellous bone
graft, and/or demineralized allograft bone with bone marrow
aspirate, and is to be implanted via an open anterior approach.
Anatomic PEEK™ Cervical Fusion System with Nanotechnology
Anatomic PEEK™ cervical fusion system with nanotechnology
devices including those with macro-, micro-, and nano-roughened
surface textured features are indicated for use for anterior cervical
interbody fusion in skeletally mature patients with cervical disc
degeneration and/or cervical spinal instability, as confirmed by
imaging studies (radiographs, CT, MRI), that results in radiculopathy,
myelopathy, and/or pain at multiple contiguous levels from C2 to T1.
These patients should have had at least six weeks of non-operative
treatment. The Anatomic PEEK™ device is to be used with
supplemental fixation; the hyperlordotic implants (≥ 10°) are
required to be used with an anterior cervical plate. The Anatomic
PEEK™ cervical fusion system with nanotechnology is also required
to be used with autogenous bone and/or allograft bone graft
comprised of cancellous and/or corticocancellous bone graft,
and/or demineralized allograft bone with bone marrow aspirate, and
is to be implanted via an open anterior approach.
Endoskeleton™ TC Interbody System
Endoskeleton™ TC Interbody System devices including those with
macro-, micro-, and nano-roughened surface textured features are
indicated for use for anterior cervical interbody fusion in skeletally
mature patients with cervical disc degeneration and/or cervical
spinal instability, as confirmed by imaging studies (radiographs, CT,
MRI), that results in radiculopathy, myelopathy, and/or pain at
multiple contiguous levels from C2 to T1. The Endoskeleton™ TC
Interbody System is indicated to be used with supplemental fixation
cleared by the FDA for use in the cervical spine and autograft bone,
allograft bone comprised of cancellous and/or corticocancellous
bone, demineralized allograft with bone marrow aspirate, or a
combination thereof.
Endoskeleton™ TCS Interbody System
Endoskeleton™ TCS Interbody System devices including those with
macro-, micro-, and nano-roughened surface textured features are
intended for use for anterior cervical interbody fusion in skeletally
mature patients with cervical disc degeneration and/or instability, as
confirmed by imaging studies (radiographs, CT, MRI) that results in
radiculopathy, myelopathy, and/or pain at multiple contiguous levels
from C2 to T1. The device is indicated to be used with autograft
bone, allograft bone comprised of cancellous and/or
corticocancellous bone, demineralized allograft with bone marrow
aspirate, or a combination thereof. The device is a stand-alone
system when used with Endoskeleton™ TCS Interbody System
integrated screws. When used without the integrated screws, the
Endoskeleton™ TCS Interbody System requires additional
supplemental fixation cleared by the FDA for the cervical spine.
Cornerstone™ PSR Cervical Interbody Fusion Device
The Cornerstone™ PSR Cervical Interbody Fusion Device is indicated
for cervical interbody fusion procedures in skeletally mature
patients with cervical disc disease at one level from the C2-C3 disc
to the C7-T1 disc. Cervical disc disease is defined as intractable
radiculopathy and/or myelopathy with herniated disc and/or
osteophyte formation on posterior vertebral endplates producing
symptomatic nerve root and/or spinal cord compression confirmed
by radiographic studies. This device is to be used in patients who
have had six weeks of non-operative treatment. The Cornerstone™
PSR Cervical Interbody Fusion Device is to be used with
supplemental fixation. The Cornerstone™ PSR Cervical Interbody
Fusion Device is also required to be used with autogenous bone
and/or allograft bone graft comprised of cancellous and/or
corticocancellousbone graft, and/or demineralized allograft bone
with bone marrow aspirate and is to be implanted via an open,
anterior approach.
Divergence™ Anterior Cervical Fusion System
Stand-alone interbody
The Divergence™ Anterior Cervical Fusion System consists of a
stand-alone interbody device indicated for use in anterior cervical
interbody fusion procedures in skeletally mature patients with
cervical disc disease at one level from C2-C3 to C7-T1. Cervical disc
disease is defined as intractable radiculopathy and/or myelopathy
with herniated disc and/or osteophyte formation on posterior
vertebral endplates producing symptomatic nerve root and/or spinal
cord compression confirmed by radiographic studies. The
Divergence™ Anterior Cervical Fusion System must be used with
internal screw fixation. The Divergence™ Anterior Cervical Fusion
System is also required to be used with with autogenous bone
and/or allograft bone graft comprised of cancellous and/or
corticocancellous bone graft, and/or demineralized allograft bone
with bone marrow aspirate and is to be implanted via an open,
anterior approach. This cervical device is to be This cervical device
is to be used in patients who have had 6 weeks of non-operative
treatment. Patients with previous non-fusion spinal surgery at
involved level may be treated with the device.

Anterior Cervical Plate options

When it comes to Anterior Cervical Discectomy and Fusion (ACDF)
procedures, the right stabilization system makes all the difference.
Let's dive into three leading options: the Zevo™, Atlantis Vision™
Elite, and Atlantis Translational™ plate systems.
Indications
ZEVO™ Anterior Cervical Plate System
The ZEVO™ Anterior Cervical Plate System is intended for anterior
interbody screw fixation from C2 to T1. The system is indicated for
use in the temporary stabilization of the anterior spine during the
development of cervical spinal fusions in patients with: 1)
degenerative disc disease (as defined by neck pain of discogenic
origin with degeneration of the disc confirmed by patient history and
radiographic studies), 2) trauma (including fractures), 3) tumors, 4)
deformity (defined as kyphosis, lordosis, or scoliosis), 5)
pseudarthrosis, and/or 6) failed previous fusions. NOTA BENE: This
device system is intended for anterior cervical intervertebral body
fusions only. WARNING: This device is not approved for screw
attachment to the posterior elements (pedicles) of the cervical,
thoracic, or lumbar spine.
ATLANTIS® Anterior Cervical Plate System
Atlantis™ Anterior Cervical Plate System: Properly used, this system
is intended for anterior interbody screw fixation from C2 to T1. The
indications and contraindications of spinal instrumentation systems
should be well understood by the surgeon. The system is indicated
for use in the temporary stabilization of the anterior spine during the
development of cervical spinal fusions in patients with:
1)degenerative disc disease (DDD - as defined by neck pain of
discogenic origin with degeneration of the disc confirmed by patient
history and radiographic studies), 2) trauma (including fractures), 3)
tumors, 4) deformity (defined as kyphosis, lordosis, or scoliosis), 5)
pseudarthrosis, and/or 6) failed previous fusions. Nota bene: this
device system is intended for anterior cervical intervertebral body
fusions only. Warning: this device is not approved for screw
attachment to posterior elements (pedicles) of the cervical,
thoracic, or lumbar spine.
Arthroplasty
The word "arthroplasty" comes from the root words "arthro,"
meaning joint, and "plasty," meaning repair, so an arthroplasty is the
repair of a joint. In a cervical arthroplasty, the surgeon is repairing or
replacing the disc with an artificial cervical disc.
This procedure is similar to an ACDF, but instead of an interbody
device with bone graft, an artificial cervical disc is placed within the
disc space. Unlike an ACDF, the goal is not to fuse but to retain the
normal motion in the spine. Our cervical arthroplasty product option
is the Prestige LP™ Cervical Disc System. Depending on the
patient's pathology and if they're indicated for the Prestige LP™
cervical disc, this could be an option for patients to retain their
motion instead of a fusion procedure.

PRESTIGE LP™ Cervical Disc System

The Prestige LP™ Cervical Disc is inserted into the disc space after
an anterior cervical discectomy. It is made of titanium ceramic
composite and consists of two components which are designed to
allow for motion after implantation by articulating via a ball and
trough mechanism. The Prestige LP™ Cervical Disc is designed to
preserve physiologic motion of the cervical spine by allowing for
flexion/extension with A/P translation, right and left lateral bending,
and right and left axial rotation..
Two-level cervical arthroplasty example
Below is an example of an x-ray showing a two level cervical
arthroplasty using the Prestige LP™ cervical disc system, specifically
showing the patient flexing their head forward and extending their
head back. This illustrates how a cervical arthroplasty procedure
allows for that motion to be retained without a fusion.
Prestige LP™ Brief Summary
BRIEF SUMMARY OF INDICATIONS, CONTRAINDICATIONS, AND
WARNINGS FOR THE PRESTIGE LP™ CERVICAL DISC:
The PRESTIGE LP™ Cervical Disc is indicated in skeletally mature
patients for reconstruction of the disc from C3-C7 following
discectomy at one level or two contiguous levels for intractable
radiculopathy (arm pain and/or a neurological deficit) with or
without neck pain, or myelopathy due to abnormality localized to
the level of the disc space and at least one of the following
conditions confirmed by imaging (CT, MRI, X-rays): herniated
nucleus pulposus, spondylosis (defined by the presence of
osteophytes), and/or visible loss of disc height as compared to
adjacent levels. The PRESTIGE LP™ Cervical Disc is implanted using
an anterior approach. Patients should have failed at least 6 weeks of
non-operative treatment or have had the presence of progressive
symptoms or signs of nerve root/spinal cord compression in the
face of continued non-operative management prior to implantation
of the PRESTIGE LP™ Cervical Disc.
The PRESTIGE LP™ Cervical Disc should not be implanted in patients
with active systemic infection or localized infection at the surgical
site; osteoporosis or osteopenia defined as a DEXA bone mineral
density T-score ≤ -1.0; allergy or sensitivity to titanium, aluminum or
vanadium; marked cervical instability on neutral resting lateral or
flexion/extension radiographs; translation >3.5mm and/or >11°
rotational difference from that of either level adjacent to the treated
levels; severe spondylosis at the level to be treated, characterized
by bridging osteophytes, loss of disc height >50%, an absence of
motion (<2°) as this may lead to a limited range of motion and may
encourage bone formation (e.g. heterotopic ossification, fusion);
severe facet joint arthropathy; significant cervical anatomical
deformity or clinically compromised vertebral bodies at the affected
level(s) due to current or past trauma (e.g., by radiographic
appearance of fracture callus, malunion or nonunion) or disease
(e.g., ankylosing spondylitis, rheumatoid arthritis); or significant
kyphotic deformity or significant reversal of lordosis.
The PRESTIGE LP™ Cervical Disc should only be used by surgeons
who are experienced with anterior cervical spinal procedures and
have undergone adequate hands-on training in the use of this
specific device. Only surgeons who are familiar with the implant
components, instruments, procedure, clinical applications,
biomechanics, adverse events, and risks associated with the
PRESTIGE LP™ Cervical Disc should use this device. Medtronic will
offer hands-on training to physicians prior to their first use of the
device. A lack of adequate experience and/or training may lead to a
higher incidence of adverse events, including neurological
complications.
The safety and effectiveness of this device has not been established
in patients with the following conditions: axial neck pain as the
solitary symptom; skeletally immature patients, pediatric or
adolescent children (<21 years old), or those over the age of 78;
prior cervical spine surgery, including prior surgery at the index level
or adjacent levels; more than two cervical discs or two non-adjacent
cervical discs that require surgical treatment; facet joint pathology
of involved vertebral bodies; spinal metastases; an endocrine or
metabolic disease that affects bones such as Paget’s
disease, osteomalacia, renal osteodystrophy, Ehlers-
Danlos Syndrome, or osteogenesis imperfecta; chronic or acute
renal failure or history of renal disease; taking medications known to
potentially interfere with bone/soft tissue healing (e.g., steroids);
diabetes mellitus requiring daily insulin management; serious
mental illness; being treated for alcohol and/or drug abuse; and
pregnant.
Devices with metal-on-metal articulating surfaces (such as the
Prestige LP Cervical Disc) may release wear debris, metallic
particles or metal ions locally near the device and/or systemically.
The short and long term effects of the wear debris, metallic particles
and metal ions on the body are not known, but certain groups of
patients may be at a higher risk including patients who are pregnant,
patients who are planning to get pregnant, and patients who have
renal disease.
Patients in the clinical study of the PRESTIGE LP™ Cervical Disc
were instructed to use non-steroidal anti-inflammatory drugs
(NSAIDs) for two weeks postoperatively. It has been reported in the
literature that short-term postoperative use of NSAIDs may reduce
the instance of heterotopic ossification (HO). To reduce the instance
of HO, it is recommended that the PRESTIGE LP™ device be
implanted in subjects able to tolerate the use of NSAIDs for two
weeks post-operatively.
Caution: Federal law (USA) restricts this device to sale by or on the
order of a physician.
Please see the package insert for the complete list of indications,
warnings, precautions, adverse events, clinical results, and other
important medical information.

Our posterior cervical options are the Infinity™ Occipitocervical-

Upper Thoracic System and the Centerpiece™ 2.0 Plate Fixation
System.
The lateral offset connectors and MAS extension connectors are
intended to be used with 3.5mm and larger diameter multi axial
screws. The lateral offset connectors and MAS extension
connectors are not intended to be used with 3.0mm screws.
The Infinity™ Occipitocervical-Upper Thoracic System is used for
posterior fixation of the cervical spine from the occiput down to
T3. The image shown here is an example of the various implant
options included within the Infinity system from an occipital plate all
the way down to connectors and tapered rods to connect into the
upper thoracic region. The majority of posterior cervical procedures
are not this complex and are performed from C3-C7.

The Centerpiece™ 2.0 Plate Fixation System is intended for use in

the lower cervical and upper thoracic spine (C3 to T3) in
laminoplasty procedures. The system incorporates a variety of pre-
cut, pre-contoured plate designs and offers a complete and
versatile solution.

The Centerpiece™ fixation system is used in a decompression

procedure called a laminoplasty, or a surgical repair of the lamina.
There is no fusion in a laminoplasty procedure. It is performed for
decompression by opening up the lamina over the spinal cord to
allow the spinal cord to have more space to move around.
Indication
Infinity™ OCT System
The Infinity™ OCT System is intended to provide immobilization and
stabilization of spinal segments as an adjunct to fusion for the
following acute and chronic instabilities of the craniocervical
junction, the cervical spine (C1 to C7), and the thoracic spine from
T1-T3:
• Traumatic spinal fractures and/or traumatic dislocations.
• Instability or deformity.
• Failed previous fusions (e.g. pseudarthrosis).
• Tumors involving the cervical spine.
• Degenerative disease, including intractable radiculopathy
and/or myelopathy, neck and/or arm pain of discogenic origin
as confirmed by radiographic studies, and degenerative
disease of the facets with instability.
The Infinity™ OCT System is also intended to restore the integrity of
the spinal column even in the absence of fusion for a limited time in
patients with advanced stage tumors involving the cervical spine in
whom life expectancy is of insufficient duration to permit
achievement of fusion.
The Infinity™ OCT System may be used with PASS OCT Patient
Specific UNiD OCT rods. In order to achieve additional levels of
fixation, the Infinity™ OCT System may be connected to the CD
Horizon™ Spinal System and Vertex™ Reconstruction System rods
with the Infinity™ OCT System rod connectors. Transition rods with
differing diameters may also be used to connect the Infinity™ OCT
System to the CD Horizon™ Spinal System. Refer to the CD Horizon™
Spinal System package insert, Vertex™ Reconstruction System and
PASS OCT Spinal System package insert for a list of the indications
of use.
Centerpiece™ Plate Fixation System
The Centerpiece™ Plate Fixation System is intended for use in the
lower cervical and upper thoracic spine (C3 to T3) in laminoplasty
procedures. The Centerpiece™ Plate Fixation System is used to hold
the graft material in place in order to prevent the graft material from
expulsion or impinging the spinal cord.