Spine Surgery for Upper Cervical Disorders

If the spinal cord is compressed, surgery will be part of the treatment discussion.

Head and upper neck disorders, which are also known as upper cervical disorders, craniovertebral junction (CVJ) abnormalities, and craniocervical disorders, occur at the base of your skull and top of your spine. These disorders potentially can pose a threat to your brain and spinal cord, but surgery can help protect these vital structures.
Surgeon at work in the operating room, with neck x-rays shownThe basic goals of craniocervical surgery are to decompress any cramped nerve structures (namely your spinal cord and/or brainstem) and stabilize the affected area.As with most spinal conditions, the typical approach is to try non-surgical methods (such as physical therapy, bracing, or pain medications) before considering surgery. However, some CVJ abnormalities may warrant surgery without trying conservative treatment first. Chiari malformations are an example of conditions that often require initial surgical treatment.

When Is Surgery Warranted for Upper Cervical Disorders?
The decision to undergo spine surgery for an upper cervical disorder is a personal one, and you and your doctor will discuss the specific risks and benefits that apply to you.

Generally, surgery enters the conversation for several reasons. These include:

  • If your spinal cord or brainstem is compressed.
  • If key structures in your craniocervical region are unstable, including bones and/or joints.
  • If you are experiencing neurological symptoms, such as weakness, numbness, or tingling.
  • If your symptoms haven’t responded to non-surgical treatment.

Common Surgical Approaches for CVJ Abnormalities
The basic goals of craniocervical surgery are to decompress any cramped nerve structures (namely your spinal cord and/or brainstem) and stabilize the affected area.

Decompression surgery creates space around nerves to reduce nerve-related pain and restore healthy nerve function.

While decompression surgery has clear benefits for your nerves, the process of freeing up space can cause instability in your spine. To establish stability, your surgeon may perform a spinal fusion immediately after the decompression surgery to prevent any excess movement that could cause future problems.

The goal of spinal fusion is to fuse at least 2 bones in your spine into 1 solid bone. To stimulate bone growth, your surgeon uses a bone graft (usually using bone from your own body called autograft) or a biological substance. To keep everything in place, your spine surgeon may use different types of spinal instrumentation, such as metal plates or screws, to immediately stabilize your spine until your bones fuse and become stable.

With many types of CVJ abnormalities—some congenital (present at birth) and some acquired (developing later in life)—many surgical approaches are available. Below are some of the most common techniques used to treat an upper cervical disorder.

C1-C2 posterior fusion
A posterior fusion of C1 and C2 is a common surgical approach for atlantoaxial instability—or excessive movement between the first 2 bones of the cervical spine, which are called the atlas (or C1) and the axis (C2).  Other conditions benefitting from this approach include platybasia and os odontoideum.

To decompress nerves and establish stability in your upper neck, your doctor may recommend a decompression surgery followed by a posterior spinal fusion. Posterior means “from the back,” so your surgeon will perform the surgery from the back of your neck.

Transoral decompression
A transoral decompression is an anterior surgery—that is, it is performed through the front. This approach is commonly used for people with basilar invagination. In the transoral approach, the surgeon enters through the mouth. Entering this way provides access to the front of the clivus (a bony part of the cranium at the bottom of the skull), C1, and C2. As with any decompression surgery, the goal of a transoral decompression is to create space around impinged nerves.

Occipital cervical fusion
An occipital cervical fusion stabilizes the critical juncture between the occiput bone and the cervical spine (you can read more about the meeting place of the skull and spine here). Your surgeon may use this approach to stabilize the joint between the top of the cervical spine and the base of the skull.

Posterior fossa decompression
Posterior fossa decompression is a procedure commonly used for chiari malformations. In this approach, the surgeon removes part of the skull to make more room for the brain and may also do laminectomies at C1 and C2.

Also in this surgery, the surgeon may increase the size of the dura, the sac around the brain. He or she does that by putting in a patch—made from either animal-derived or synthetic tissues—that will grow into the dura. The patch will make the dura bigger, giving more room for the brain. Not every surgery to treat a Chiari malformation will involve this step.

Anterior odontoid screw fixation
This procedure focuses on the peg-like bone in your axis (C2) called the dens, or odontoid process. The dens fits within the ring of the atlas (C1) and enables rotation in your head. If the dens is fractured by a traumatic injury, you may need surgery to stabilize it. In an anterior odontoid screw fixation, the spine surgeon accesses the dens from the front of your neck. Using imaging scans during surgery to ensure proper placement, the surgeon places a screw through the fractured dens. The screw holds the dens in place, preventing it from injuring your spinal cord.

Dens fracture, axis, Types 1, 2, 3

Ensuring Success After Upper Cervical Surgery
Surgery for craniocervical disorders can help you live a long and full life, but a great deal of success depends on how closely you follow your surgeon’s post-operative instructions. Make sure you ask your surgeon questions about how to safely navigate the recovery period, including the red flags that warrant emergency attention. Clear communication with your medical team will help ensure your health—from recovery and beyond.

Updated on: 08/21/18
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