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Manubrial autograft for anterior cervical fusion
Technical note
Manubrial autograft for anterior cervical fusion Emil A. Popovic MS BS FRACS Department of Neurosurgery, The Melbourne Neuroscience Centre, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
Summary Anterior cervical fusion is a commonly performed procedure and the most common graft material used is anterior iliac crest autograft. However, this donor site is a source of significant patient discomfort. The author describes the use of tricortical manubrial autograft which provides a surgically convenient donor site with less morbidity than with traditional iliac crest. © 1999 Harcourt Publishers Ltd Journal of Clinical Neuroscience (1999)6(6), 510 © 1999 HarcourtPublishesLtd
Keywords: spine, cervical, fusion, autograft, discectomy, manubrium Received 8 September 1998 Accepted 26 October 1998
neck scars for the discectomy, and n o w cosmesis is no longer a factor in determining donor site choice. The author still uses iliac crest graft for anything more that a single level discectomy, i.e. corpectomies o f one or more levels. For low cervical cases, e.g. C7/7, the transverse neck incision can be extended to a vertical c o m p o n e n t over the m a n u b r i u m as an inverted L shaped incision.
OPERATION The donor site is draped within the discectomy operative field. A 3 c m transverse incision is made d o w n to periosteum, the latter elevated and then, using a smooth periosteal elevator or curved end o f a M a c D o n a l d dissector, the superior and posterior surfaces o f the m a n u b r i u m are dissected free o f soft tissue. Care is taken behind the upper manubrium not to dissect too deeply as the left brachiocephalic vein lies in close proximity. A standard craniotome e.g. Midas Rex B 1 drill with the craniotomy foot plate, is used to cut a tricortical graft about 1-2 m m wider than the height o f the undistracted discectomy space. The donor site has been satisfactorily filled in and contoured with bone wax. The author has been quite satisfied with the manubrial autograft. The advantages have been threefold: 1. the discectomy and donor sites are draped within the one small operative field, 2. the donor site is less painful than with iliac crest and 3. the w o u n d heals with a very cosmetic scar.
Correspondence to: E. A. Popevic, Tel.: +61 03 9349 4865; Fax: +61 03
9349-4861
INTRODUCTION Anterior cervical discectomy is a c o m m o n l y performed procedure for the relief o f nerve root and/or spinal cord compression by disc prolapse or osteophyte. The debate over discectomy with or without the use o f a graft is still unresolved but, w h e n a graft is employed, the traditional material has been autologous tricortical anterior iliac crest. 1 Other graft materials have included bicortical iliac wing dowels, 2 autologous cervical vertebra, 3 allografts, 4 xenografts such as Kiel bone, titanium cages 5 and synthetics such as biocompatible osteoconductive p o l y m e r (BOP); 6"7 fibula and tibia have been used for longer grafts. 8,9 Autologous iliac crest grafts have been very satisfactory but are the source o f major discomfort to patients following cervical discectomy, w h i c h can last several weeks; they have been associated with donor site complications ranging from 1% to as high as 29% and allografts have had the problem o f a lesser fusion rate. 1°-:3 The author has used manubrial autograft with apparently equivalent rates o f fusion but with lesser donor site pain and a cosmetically satisfactory scar. Since September 1997 the author has used manubrial autograft for 18 single level anterior cervical discectomies; initially these procedures were reserved for patients, mainly men, w h o w e r e n ' t concerned about a scar over the manubrium. But it soon b e c a m e apparent that these transverse scars healed as well as the transverse
REFERENCES 1. Smith GW, Robinson RA. The treatment of certain cervical spine dosorders by anterior removal of the iutervertebral disc and interbody fusion. J Bone Joint Surg (Am) 1958; 40: 617~524. 2. ClowardRB. The anterior approach for removal of ruptured cervical discs. J Neurosurg 1958; 15: 602-617. 3. Williams RC. Anterior cervical fusion utilizing autogenous bone graft from the cervical vertebrae. Ace Medical 1986 Order #901986. 4. ClowardRB. Creation and operation of a bone bank. J Neurosurg 1970; 33: 682-688. 5. Zdeblick T. Cervical interbody fixation using tapered, rectangular and bone devices. 1998 Global Spine Meeting, June 5-7, Hawaii. 6. ShapiroSA. Cranioplasty,vertebral body replacement,and spinal fusion with tobramycin-impregnatedmethylmethacrylate.Neurosdrgery 1991; 28: 789-791. 7. SegalR, Alsawaf M, Tabatabai A et al. The use of visible light-curing resin for vertebral body replacement. J Neurosurg 1991; 75:91-96. 8. Fernyhough JC, White JL LaRocca H. Fusion rates in multilevel cervical spondylosiscomparing ailograft fibula with autograft fibula in 126 patients. Spine 1991; 10(suppl): $561-$564. 9. VerbiestH. Anterolateraloperations for fractures and dislocations in the middle and lower parts of the cervical spine. J Bone Joint Surg (Am) 1977; 59: 45-48. 10. Espersen O, Buhl M, Eriksen EF et al. Treatment of cervical disc disease using Cloward's technique. I. General results, effect of different operative methods and complicationsin 1106 patients. Aeta Neurochir t984; 70: 97-114. 11. Gore DR, Sepic SB, Gardner GM et al. Neck pain: a long-term follow-up of 205 patients. Spine 1987: 12: 1-5. 12. GrahamJJ. Complicationsof cervical spine surgery. A five year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine 1989; 14: 1046-1050. 13. YoungerEM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989; 3: 192-195.
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Manubrial autograft for anterior cervical fusion Emil A. Popovic MS BS FRACS Department of Neurosurgery, The Melbourne Neuroscience Centre, The Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
Summary Anterior cervical fusion is a commonly performed procedure and the most common graft material used is anterior iliac crest autograft. However, this donor site is a source of significant patient discomfort. The author describes the use of tricortical manubrial autograft which provides a surgically convenient donor site with less morbidity than with traditional iliac crest. © 1999 Harcourt Publishers Ltd Journal of Clinical Neuroscience (1999)6(6), 510 © 1999 HarcourtPublishesLtd
Keywords: spine, cervical, fusion, autograft, discectomy, manubrium Received 8 September 1998 Accepted 26 October 1998
neck scars for the discectomy, and n o w cosmesis is no longer a factor in determining donor site choice. The author still uses iliac crest graft for anything more that a single level discectomy, i.e. corpectomies o f one or more levels. For low cervical cases, e.g. C7/7, the transverse neck incision can be extended to a vertical c o m p o n e n t over the m a n u b r i u m as an inverted L shaped incision.
OPERATION The donor site is draped within the discectomy operative field. A 3 c m transverse incision is made d o w n to periosteum, the latter elevated and then, using a smooth periosteal elevator or curved end o f a M a c D o n a l d dissector, the superior and posterior surfaces o f the m a n u b r i u m are dissected free o f soft tissue. Care is taken behind the upper manubrium not to dissect too deeply as the left brachiocephalic vein lies in close proximity. A standard craniotome e.g. Midas Rex B 1 drill with the craniotomy foot plate, is used to cut a tricortical graft about 1-2 m m wider than the height o f the undistracted discectomy space. The donor site has been satisfactorily filled in and contoured with bone wax. The author has been quite satisfied with the manubrial autograft. The advantages have been threefold: 1. the discectomy and donor sites are draped within the one small operative field, 2. the donor site is less painful than with iliac crest and 3. the w o u n d heals with a very cosmetic scar.
Correspondence to: E. A. Popevic, Tel.: +61 03 9349 4865; Fax: +61 03
9349-4861
INTRODUCTION Anterior cervical discectomy is a c o m m o n l y performed procedure for the relief o f nerve root and/or spinal cord compression by disc prolapse or osteophyte. The debate over discectomy with or without the use o f a graft is still unresolved but, w h e n a graft is employed, the traditional material has been autologous tricortical anterior iliac crest. 1 Other graft materials have included bicortical iliac wing dowels, 2 autologous cervical vertebra, 3 allografts, 4 xenografts such as Kiel bone, titanium cages 5 and synthetics such as biocompatible osteoconductive p o l y m e r (BOP); 6"7 fibula and tibia have been used for longer grafts. 8,9 Autologous iliac crest grafts have been very satisfactory but are the source o f major discomfort to patients following cervical discectomy, w h i c h can last several weeks; they have been associated with donor site complications ranging from 1% to as high as 29% and allografts have had the problem o f a lesser fusion rate. 1°-:3 The author has used manubrial autograft with apparently equivalent rates o f fusion but with lesser donor site pain and a cosmetically satisfactory scar. Since September 1997 the author has used manubrial autograft for 18 single level anterior cervical discectomies; initially these procedures were reserved for patients, mainly men, w h o w e r e n ' t concerned about a scar over the manubrium. But it soon b e c a m e apparent that these transverse scars healed as well as the transverse
REFERENCES 1. Smith GW, Robinson RA. The treatment of certain cervical spine dosorders by anterior removal of the iutervertebral disc and interbody fusion. J Bone Joint Surg (Am) 1958; 40: 617~524. 2. ClowardRB. The anterior approach for removal of ruptured cervical discs. J Neurosurg 1958; 15: 602-617. 3. Williams RC. Anterior cervical fusion utilizing autogenous bone graft from the cervical vertebrae. Ace Medical 1986 Order #901986. 4. ClowardRB. Creation and operation of a bone bank. J Neurosurg 1970; 33: 682-688. 5. Zdeblick T. Cervical interbody fixation using tapered, rectangular and bone devices. 1998 Global Spine Meeting, June 5-7, Hawaii. 6. ShapiroSA. Cranioplasty,vertebral body replacement,and spinal fusion with tobramycin-impregnatedmethylmethacrylate.Neurosdrgery 1991; 28: 789-791. 7. SegalR, Alsawaf M, Tabatabai A et al. The use of visible light-curing resin for vertebral body replacement. J Neurosurg 1991; 75:91-96. 8. Fernyhough JC, White JL LaRocca H. Fusion rates in multilevel cervical spondylosiscomparing ailograft fibula with autograft fibula in 126 patients. Spine 1991; 10(suppl): $561-$564. 9. VerbiestH. Anterolateraloperations for fractures and dislocations in the middle and lower parts of the cervical spine. J Bone Joint Surg (Am) 1977; 59: 45-48. 10. Espersen O, Buhl M, Eriksen EF et al. Treatment of cervical disc disease using Cloward's technique. I. General results, effect of different operative methods and complicationsin 1106 patients. Aeta Neurochir t984; 70: 97-114. 11. Gore DR, Sepic SB, Gardner GM et al. Neck pain: a long-term follow-up of 205 patients. Spine 1987: 12: 1-5. 12. GrahamJJ. Complicationsof cervical spine surgery. A five year report on a survey of the membership of the Cervical Spine Research Society by the Morbidity and Mortality Committee. Spine 1989; 14: 1046-1050. 13. YoungerEM, Chapman MW. Morbidity at bone graft donor sites. J Orthop Trauma 1989; 3: 192-195.
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