Anterior Subaxial Cervical Approach

  • George N. Rymarczuk
  • Courtney Pendleton
  • James S. Harrop


There are a wide variety of disorders that can affect the subaxial cervical spine. Neoplasms are one such disorder: they may be either primary lesions or metastases and range from the histologically benign to the malignant. There has been significant increase of the knowledge and categorization/classification of these tumors and how they affect the spine. Several applicable treatment algorithms that can be tailored to each individual patient have been developed.

Treatment of neoplasms of the subaxial cervical spine often requires a multifaceted approach, incorporating the input of spinal surgeons, medical oncologists, and radiation oncologists, as well as other subspecialists such as plastic surgeons, neuro-interventionalists, and rehabilitation therapists. Ever-advancing image-guided radiotherapy techniques, as well as advances in chemotherapy treatments, are rapidly changing the manner in which these lesions are treated, limiting morbidity while maintaining the similar palliative effect of aggressive resection. Nonetheless, surgery still plays a significant role in the treatment of neoplastic disease of the subaxial cervical spine.


Subaxial cervical spine Anterior cervical approach Spine Oncology Study Group SINS Criteria NOMS Framework 


  1. 1.
    Smith GW, Robinson RA. The treatment of certain cervical-spine disorders by anterior removal of the intervertebral disc and interbody fusion. J Bone Joint Surg Am. 1958;40-A(3):607–24.CrossRefGoogle Scholar
  2. 2.
    Cloward RB. The anterior approach for removal of ruptured cervical disks. J Neurosurg. 1958;15(6):602–17.CrossRefGoogle Scholar
  3. 3.
    de Jonge T, Slullitel H, Dubousset J, Miladi L, Wicart P, Illés T. Late-onset spinal deformities in children treated by laminectomy and radiation therapy for malignant tumours. Eur Spine J. 2005;14(8):765–71.CrossRefGoogle Scholar
  4. 4.
    Lonstein JE. Post-laminectomy kyphosis. Clin Orthop Relat Res. 1977;128:93–100.Google Scholar
  5. 5.
    O'Shaughnessy BA, Liu JC, Hsieh PC, Koski TR, Ganju A, Ondra SL. Surgical treatment of fixed cervical kyphosis with myelopathy. Spine. 2008;33(7):771–8.CrossRefGoogle Scholar
  6. 6.
    Kriskovich MD, Apfelbaum RI, Haller JR. Vocal fold paralysis after anterior cervical spine surgery: incidence, mechanism, and prevention of injury. Laryngoscope. 2000;110(9):1467–73.CrossRefGoogle Scholar
  7. 7.
    Shriver MF, Lewis DJ, Kshettry VR, Rosenbaum BP, Benzel EC, Mroz TE. Dysphagia rates after anterior cervical Diskectomy and fusion: a systematic review and meta-analysis. Global Spine J. 2017;7(1):95–103.CrossRefGoogle Scholar
  8. 8.
    Pavlov H, Torg JS, Robie B, Jahre C. Cervical spinal stenosis: determination with vertebral body ratio method. Radiology. 1987;164(3):771–5.CrossRefGoogle Scholar
  9. 9.
    Lim J-K, Wong H-K. Variation of the cervical spinal Torg ratio with gender and ethnicity. Spine J. 2004;4(4):396–401.CrossRefGoogle Scholar
  10. 10.
    Cohen ZR, Fourney DR, Marco RA, Rhines LD, Gokaslan ZL. Total cervical spondylectomy for primary osteogenic sarcoma: case report and description of operative technique. JNS Spine. 2002;97:386–92.Google Scholar
  11. 11.
    Rades D, Fehlauer F, Stalpers LJA, Wildfang I, Zschenker O, Schild SE, et al. A prospective evaluation of two radiotherapy schedules with 10 versus 20 fractions for the treatment of metastatic spinal cord compression: final results of a multicenter study. Cancer. 2004;101(11):2687–92.CrossRefGoogle Scholar
  12. 12.
    Rades D, Fehlauer F, Schulte R, Veninga T, Stalpers LJA, Basic H, et al. Prognostic factors for local control and survival after radiotherapy of metastatic spinal cord compression. J Clin Oncol. 2006;24(21):3388–93.CrossRefGoogle Scholar
  13. 13.
    Rades D, Karstens JH, Alberti W. Role of radiotherapy in the treatment of motor dysfunction due to metastatic spinal cord compression: comparison of three different fractionation schedules. Int J Radiat Oncol Biol Phys. 2002;54(4):1160–4.CrossRefGoogle Scholar
  14. 14.
    Gilbert RW, Kim JH, Posner JB. Epidural spinal cord compression from metastatic tumor: diagnosis and treatment. Ann Neurol. 1978;3(1):40–51.CrossRefGoogle Scholar
  15. 15.
    Maranzano E, Latini P, Perrucci E, Beneventi S, Lupattelli M, Corgna E. Short-course radiotherapy (8 Gy x 2) in metastatic spinal cord compression: an effective and feasible treatment. Int J Radiat Oncol Biol Phys. 1997;38(5):1037–44.CrossRefGoogle Scholar
  16. 16.
    Maranzano E, Bellavita R, Rossi R, De Angelis V, Frattegiani A, Bagnoli R, et al. Short-course versus split-course radiotherapy in metastatic spinal cord compression: results of a phase III, randomized, multicenter trial. J Clin Oncol. 2005;23(15):3358–65.CrossRefGoogle Scholar
  17. 17.
    Katagiri H, Takahashi M, Inagaki J, Kobayashi H, Sugiura H, Yamamura S, et al. Clinical results of nonsurgical treatment for spinal metastases. Int J Radiat Oncol Biol Phys. 1998;42(5):1127–32.CrossRefGoogle Scholar
  18. 18.
    Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes? Spine. 2009;34(22 Suppl):S78–92.CrossRefGoogle Scholar
  19. 19.
    Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 2013;18(6):744–51.CrossRefGoogle Scholar
  20. 20.
    Laufer I, Iorgulescu JB, Chapman T, Lis E, Shi W, Zhang Z, et al. Local disease control for spinal metastases following “separation surgery” and adjuvant hypofractionated or high-dose single-fraction stereotactic radiosurgery: outcome analysis in 186 patients. J Neurosurg Spine. 2013;18(3):207–14.CrossRefGoogle Scholar
  21. 21.
    Lovelock DM, Zhang Z, Jackson A, Keam J, Bekelman J, Bilsky M, et al. Correlation of local failure with measures of dose insufficiency in the high-dose single-fraction treatment of bony metastases. Int J Radiat Oncol Biol Phys. 2010;77(4):1282–7.CrossRefGoogle Scholar
  22. 22.
    Bilsky MH, Laufer I, Burch S. Shifting paradigms in the treatment of metastatic spine disease. Spine. 2009;34(22 Suppl):S101–7.CrossRefGoogle Scholar
  23. 23.
    Fisher CG, DiPaola CP, Ryken TC, Bilsky MH, Shaffrey CI, Berven SH, et al. A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and expert consensus from the Spine Oncology Study Group. Spine. 2010;35(22):E1221–9.CrossRefGoogle Scholar
  24. 24.
    Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324–8.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • George N. Rymarczuk
    • 1
  • Courtney Pendleton
    • 1
  • James S. Harrop
    • 1
  1. 1.Department of Neurological Surgery, Thomas Jefferson University HospitalPhiladelphiaUSA

Personalised recommendations