Abstract
Background Surgery on the posterior cervical spine involves bilateral exposure and removal of midline structures, which may lead to chronic neck pain, dropped head syndrome, and an ugly scar. We present our experience of an innovative technique of posterior cervical approach using spinous process osteotomy with preservation of midline structures.
Methods A total of 25 consecutive myelopathic patients underwent 1- to 4-level posterior cervical decompression with or without fusion and were followed up prospectively for 6 to 24 months. Left-sided exposure was done through a midline skin incision, and bilateral exposure of the spine was achieved through spinous process osteotomy. Laminectomy with or without instrumented fusion was performed, and the wound was closed over a drain. All patients were mobilized without orthoses.
Results There were 15 men and 10 women with a mean age of 68 years; mean blood loss was 150 mL; mean operating time was 150 minutes; mean follow-up was 12 months. The mean improvement in Neck Disability Index at final follow-up was 26% with a 2-point improvement in visual analog scale. Japanese Orthopaedic Association score improved from a mean of 12 to 16, and using Odom’s criteria, the final outcome was good in 19 patients and excellent in 6. Nurick grade improved from 3 to 1, and all patients reported significant relief of myelopathic symptoms without chronic neck pain. Two patients had postoperative superficial wound infections, and 1 patient underwent reoperation for hematoma.
Conclusion In this cohort study, the spinous process osteotomy technique was easy to perform, was safe with a low complication rate, and had positive outcomes. However, more studies are required to compare its efficacy with other techniques.
Introduction
Posterior cervical surgeries like laminectomy and laminoplasty are common procedures.1,2 The standard posterior surgical approach to the cervical spine involves a midline skin incision and bilateral muscle dissection with subperiosteal exposure of the lamina and lateral masses at the relevant levels.3 If required, some surgeons insert lateral mass screws at this stage using the caudal spinous process as a guide. Decompression of the spinal canal is then performed, which invariably involves removal of the relevant spinous processes along with their posterior ligamentous attachments.3 However, this causes inadvertent damage to the posterior ligamentous complex (PLC), including the nuchal ligament (NL), which runs from the occipital protuberance to the spinous process of C7 and is continuous with the supraspinous and interspinous ligaments.4,5 The PLC has been reported to play a big role in maintaining the stability of the middle and lower cervical spine.6 It has been shown that resection of the NL increases the range of flexion and reduces stiffness of the spine in flexion, and any injury to it could predispose a patient to cervical instability and malalignment.4 Damage to the PLC during posterior cervical surgery has been shown to result in the development of axial neck pain, kyphosis, dropped head syndrome, and an ugly puckered scar.6–10 While the effects of surgical dissection of the muscular attachments of the C2 and C7 spinous processes have been well reported,10–16 there are only a few reports on the clinical effects of iatrogenic damage to the PLC in the subaxial cervical spine.4,17 All these studies have shown that damage to the muscular attachments of the C2 and C7 spinous processes, paraspinal muscles, and the NL is an important contributory factor in postoperative pain, loss of lordosis, and loss of function.4–17 Aoyama et al18 reported that preservation of paraspinal muscles and spinous processes is important for maintaining lordosis in the caudal disc and in the cephalad part of the cervical spine. Thus, new techniques (like skip laminectomy, minimally invasive surgery, or endoscopic surgery) have been developed to preserve anatomy and minimize some of these deleterious effects.18–22 A similar technique is spinous process osteotomy (SPO), which has been well described for posterior exposure of the lumbar spine.23,24
However, to our knowledge, its use in the surgical exposure of the posterior cervical spine has not been reported in the literature. Cervical SPO allows the PLC to remain in continuity and retain its function. The senior author (H.V.D.) has regularly used SPO in the lumbar spine and applied the same technique in the cervical spine with some modifications. The aim of this study was to assess the preliminary outcomes of SPO in the cervical spine and evaluate its potential for reducing some of the postoperative complications associated with standard surgical exposure.
Methods
The local hospital Research and Ethics Committee confirmed that formal ethics approval was not required for this study. We interrogated the logbook of a single surgeon performing this technique to retrospectively identify all consecutive patients who underwent posterior cervical surgery in a single institution between October 2020 and October 2024. Before surgery, all cases had been discussed in the local spinal multidisciplinary team meeting, and informed consent had been obtained from all patients. Paper and electronic medical records were used to obtain patient demographics, preoperative patient-reported outcome measures, and operative notes. Pre- and postoperative outcomes were recorded at clinic follow-up. Outcome measures included pre- and postoperative 10-point visual analog scale for pain, Neck Disability Index (0–100), Nurick grade (0–VI), and modified Japanese Orthopaedic Association Score (0–18 points). Postoperative Odom grade (poor- excellent) was collected. Clinical letters from follow-up and readmission records were reviewed for evidence of postoperative complications. Pre- and postoperative radiographs were also assessed for evidence of complications, for example, loss of cervical lordosis. We included patients who both did and did not undergo simultaneous instrumented fusion of the cervical spine following decompression.
Surgical Technique
After induction of general anesthesia (GA) with endotracheal intubation, the patient was positioned prone on a radiolucent spinal table. As per the hospital protocol, a single dose of intravenous flucloxacillin, 2 g, was given at induction of anesthesia, and Teicoplanin or a suitable alternative was used if the patient was allergic to penicillin. If required, the head was stabilized with a Mayfield head holder or a sculpted sponge face cushion (CS Prone Plus Head Support System, Care Surgical UK). Hair was trimmed as required. Both arms were kept straight and supported on padded armrests. If required, broad adhesive tapes were used on both sides to bring the shoulder blades down and flatten the skin fold, which was also aided by injecting 20 mL of 0.5% bupivacaine with adrenaline subcutaneously in the midline.
Following skin preparation and draping, a level check was performed with image intensification using a 22G spinal needle docked onto the facet joint. A midline posterior skin incision was made to expose the appropriate levels, with a left-sided exposure up to the base of the spinous processes that was done using monopolar diathermy. Care was taken to stay within the avascular but irregular plane of the NL while dissecting over the interlaminar space. A further level check was performed by attaching a hemostat to the chosen spinous process. A McCulloch self-retaining retractor was used to facilitate exposure with a retractor blade on the left side and a spike medially at the interspinous level. Alternatively, a Cobb elevator or Langenbeck retractor was used to retract the soft tissues and improve visualization. At each level, a 3 m burr was used to mark the bone at the junction of the lamina and base of the spinous process. SPO was performed using a small and curved McCulloch osteotome, where the bone had been marked previously, with care being taken to ensure that the blade of the osteotome was parallel to the floor to avoid inadvertent entry into the spinal canal (Figure 1). Bony bleeding from the base of the spinous process was controlled with bone wax. A combination of Langenbeck retractors and Cobb elevators was used to complete subperiosteal muscle dissection on the contralateral side under direct vision, using monopolar diathermy, to expose the lamina and lateral masses, as required. Care was taken while exposing the interlaminar interval to prevent entry into the spinal canal. Self-retaining retractors were used to obtain bilateral exposure of the spine at each level (Figure 2). If required, SPO was extended to the level above or below to facilitate exposure. Subsequent surgery was performed in the standard fashion. Figure 3 shows the serial steps of the procedure. When required, instrumented fusion was done with lateral mass screws.
Before wound closure, the spinous processes were carefully examined for any sharp spikes, which were trimmed with bone nibblers. The wound was irrigated with 100 mL of betadine–saline solution mixed in a 50% proportion. A deep drain was inserted, and closure was done using No. 1 Vicryl absorbable sutures, ensuring deep “bites” into the PLC. 2-0 Vicryl was used to close the subcutaneous layer. 3-0 Subcuticular Monocryl was used for skin closure, and the wound was sealed with surgical glue (Figure 4). A small dressing was used over the drain site, and no postoperative antibiotics were used. No cervical collar was routinely used, but a soft collar was prescribed for some patients for pain control. All patients were mobilized as soon as possible, and the suction drain was removed after 24 hours.
Axial drawing showing the posterior ligamentous complex and nuchal ligament (in blue) attached to the spinous process, with spinous process osteotomy being done using a curved osteotome placed at the junction of the lamina and base of the spinous process. A retractor is used on the left side to improve visualization.
Axial drawing showing intact posterior ligamentous complex and nuchal ligament (in blue) still attached to the spinous process. A self-retaining retractor is being used for bilateral exposure of the spine.
(a) Intraoperative photograph showing McCulloch osteotome being used to perform a spinous process osteotomy (note: left side of photo is the cranial direction). (b) Intraoperative photograph showing contralateral exposure being done by retracting midline structures with a Langenbeck retractor. (c) Intraoperative photograph showing good bilateral exposure of the cervical spine achieved through spinous process osteotomy. (d) Intraoperative photograph showing good decompression of the spinal cord achieved through spinous process osteotomy approach.
Axial drawing showing that the posterior ligamentous complex and nuchal ligament (in blue) are still intact and attached to the spinous process after wound closure.
Results
A total of 25 patients with degenerative cervical myelopathy had decompressive laminectomy with SPO between 2020 and 2024 (Table 1). There were 15 men and 10 women, with a mean age of 68 years (range 52–81 years). A total of 16 patients underwent a 2-level laminectomy, 4 patients underwent a 3-level laminectomy, and 5 patients underwent a 4-level laminectomy. Six patients underwent simultaneous instrumented fusion using lateral mass screws and rods. Mean follow-up was 12 months (range 6–24 months). Mean operative time for the procedures was 150 minutes (range 60–300 minutes), with a mean estimated blood loss of 190 mL (range 100–300 mL). Mean postoperative length of stay was 3.5 days (range 2–43 days), with 1 patient staying for 42 days because of social circumstances. After exclusion of that patient, the mean length of stay was 2 days. One patient required a return to the operating room for washout of a postoperative hematoma, and 2 patients needed oral antibiotics for treatment of superficial wound infection.
Patient demographics.
All patients recorded improvements in all patient-reported outcome measures (Table 2). Mean Neck Disability Index improved by 26 (range 20–84), from 40 to 14. Visual analog scale improved from a mean score of 3 preoperatively (range 0–4) to 1 postoperatively (range 0–3). Nurick’s grade (improved in all patients, from a mean score of 2.5 preoperatively (range 0–4) to 1 postoperatively (range 0–2). All patients recorded improvements in the Japanese Orthopaedic Association score, from mean of 12 to 16. Finally, Odom’s criteria postoperatively were “good” in 19 patients and “excellent” in 6 patients.
Clinical improvement in NDI, JOA, VAS, Nurick grade, and Odom’s criteria.
Discussion
Posterior cervical spine surgery is routinely undertaken for myelopathy, radiculopathy, fractures or dislocations, tumor removal, and other pathologies. 1–3 Usually, the surgical approach involves a midline skin incision with bilateral muscle dissection and removal of the spinous processes along with the attached PLC.3 In humans, the PLC has been reported to have an important function of supporting the weight of the head and maintaining normal cervical lordosis.4–6,17,18 While the effects of surgical dissection of the muscular attachments of C2 and C7 spinous processes have been well reported,11–17,25 the clinical results of iatrogenic damage to the PLC in the subaxial cervical spine have not been as well reported.17,18 However, it is logical to infer that any iatrogenic damage to the PLC could contribute to postoperative kyphosis, dropped head syndrome, chronic pain, and an ugly scar. Sakaura et al5,25 reported that damage to the NL attached to the C6 and C7 spinous processes played an important role in preventing undesirable radiologic changes after laminoplasty. In a systematic review of literature,16 it was reported that postoperative axial neck pain can be reduced by less invasive surgery, reconstruction of the extensor musculature, avoiding detachment of the semispinalis cervicis muscle, and early removal of external immobilization. Various techniques have been developed to decrease iatrogenic damage to the tissues, including minimally invasive procedures like skip laminectomy and endoscopic or minimally invasive surgery done through metal tubes.19–22,25 However, many patients have multilevel pathology,1–3 which may be difficult to address with such techniques and may need a more standard type of procedure. Also, these conditions affect elderly and frail patients; in such situations, the senior author (H.V.D.) felt that SPO may be suitable, as its use in bilateral exposure of the lumbar spine has been well described.23,24 A similar technique was developed for use in the cervical spine to enable quick exposure of the posterior cervical spine while maintaining the integrity of the PLC and the NL.
Our series confirms that the cervical SPO technique achieves good bilateral exposure of the posterior cervical spine and is an easy, safe technique with a low complication rate and positive postoperative outcomes. Its technical advantages include only unilateral muscle dissection, preservation of the PLC and NL, preservation of blood supply and nerve innervation of the PLC and paraspinal muscles in the contralateral side, and significant reduction of dead space. Its clinical value is decreased postoperative pain, early mobilization, lack of need to use a cervical collar, and a neat scar without chronic neck pain or kyphosis.
Although the ability to use the spinous process as a landmark (to rest the drill), while inserting lateral mass screws is lost with SPO, the senior author (H.V.D.) has not noted that to be a major drawback. Sometimes, especially while inserting lateral mass screws, it may be difficult to expose the most cranial or caudal level on the contralateral side. In those situations, the senior author has improved exposure by subperiosteal muscle dissection on that side to get adequate access. SPO can also be done without special equipment, and no extra time is spent in doing the exposure. We acknowledge that some iatrogenic soft tissue damage does occur during a 1-sided exposure, but the blood and nerve supply of the PLC and paraspinal muscles on the contralateral side was preserved. SPO also avoids the creation of dead space, which invariably occurs when the midline structures are removed as part of the exposure. In this case series, there were 2 patients who developed superficial wound infections requiring oral antibiotic treatment. Another patient developed a postoperative hematoma that needed a return to the operating room. However, the latter patient had a previous history of venous thromboembolism and developed a hematoma when anticoagulant treatment was restarted 24 hours after surgery. Apart from that case, SPO did not cause increased perioperative bleeding or other approach-related problems. Concerns surrounding the potential for sharp bony spikes to cause damage to the thecal sac and/or the spinal cord were not encountered in this study and have not been reported to be a significant problem when SPO has been used in the lumbar spine. Furthermore, the performance of SPO should already be familiar to surgeons who use it during posterior lumbar decompressions and thus can easily transfer that skill to the cervical spine without the need for additional training in a “new technique.”
We acknowledge that this is a small and retrospective study involving only patients operated on by a single surgeon. However, all patients had been discussed in the local spinal multidisciplinary team meeting. Although most patients had a laminectomy and only 6 patients had instrumented fusion, we believe that this did not have any impact on the outcome of the surgical approach. Another potential drawback of this study was that no comparative cohort was used; however, we intended to only present preliminary results of this innovative surgical approach. We are also aware that this technique may have been routinely used by some surgeons for a long time, but as far as we know, results have not been reported. Although our results are very encouraging, more research is needed, including a larger series and a control group to allow direct comparison of the efficacy of this procedure.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Ethics Approval The local hospital Research and Ethics Committee confirmed that formal ethics approval was not required for this study.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2026 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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