With increasing elderly patients, improvements in anesthesia, surgical techniques, and perioperative care have also increased the pool of elderly surgical candidates. This increase in both the population of, and improved perioperative care for geriatric patients, resulted in a 28-fold increase in cervical spine fusion procedures in the elderly from 1990 to 2004 1).
The basic principles of cervical spine surgery include adequate decompression, provision of a structurally competent, biologically functional bone graft, and creation of a stable construct to allow for solid fusion.
The options to achieve these goals have expanded significantly. Bone banking and bone graft substitutes yield increasingly viable alternatives to autogenous bone graft. New prosthetic implants and cages are under investigation. The science of bone growth factors seems to be promising and is expected to revolutionize the approach to spine arthrodesis. Various plating systems are available to provide internal stability to cervical spine constructs. It is important to understand the biomechanics of plating systems so that the optimal system may be used in a given situation. Long constructs place significant loads on SGs and anterior plates. It is important to consider the use of additional fixation, such as posterior segmental fixation in long constructs, which may be prone to failure using only anterior plate fixation. Anterior cervical plates for single-level ACDF remains controversial, whereas plating has been shown to improve the results of multilevel ACDF. Plating may provide a useful salvage option for a cervical nonunion, especially if deformity or neurologic compression dictates an anterior approach. Hardware failures may occur with anterior cervical plating, but most remain asymptomatic and do not require operative intervention 2).
Cervical spine surgery is broadly divided into fusion and nonfusion procedures.
The first evidence for surgical treatment of spinal disorders dates back to approximately 1500 BC. Conservative approaches to treatment have been the hallmark for thousands of years, but over the past 50 years progress has been rapid.
Transferral of knowledge occurred from Babylon (Bagdad) to Old Egypt, to the Greek and Roman empires and finally via the Middle East (Bagdad and Damascus) back to Europe. Recent advances in the field of anesthesia, imaging and spinal instrumentation have changed long-standing nihilism in the treatment of cervical spine pathologies to the current practice of advanced reconstructive surgery of the cervical spine. A critical approach to the evaluation of benefits and complications of these advanced surgical techniques for treatment of cervical spine disorders is required.
Advances in surgery now permit full mechanical reconstruction of the cervical spine. However, despite substantial experimental progress, spinal cord repair and restoration of lost functions remain a challenge. Modern surgeons are still looking for the best way to manage spine disorders 3).
Innovative surgical approaches allowed direct access to symptomatic areas of the cervical spine. Over the years, we observed a trend from posterior to anterior surgical techniques. Management of the degenerative spine has evolved from decompressive surgery alone to the direct removal of the cause of neural impingement. Internal fixation of actual or potential spinal instability and the associated instrumentation have continuously evolved to allow more reliable fusion. More recently, surgeons have developed the basis for nonfusion surgical techniques and implants.
The most important advances appear to be (1) recognition of the need to directly address the causes of symptoms, (2) proper decompression of neural structures, and (3) more reliable fusion of unstable symptomatic segments 4).