Application of the Cervical Subaxial Anterior Approach at C2 in Select Patients

The purpose of this study was to assess the feasibility and radiographic indications of using the subaxial anterior approach for decompression and fusion at C2. Anterior exposure at C2 was difficult and associated with increased morbidity. The subaxial anterior approach is easy and familiar to spine surgeons but did not provide satisfying exposure in all patients. This article describes a series of patients undergoing anterior surgery involving C2 through the subaxial anterior approach. Patients were selected based on lateral extension radiographs showing a mandibular angle higher than the C3 upper endplate. Forty-two patients (29 men and 13 women) with average age of 45 years and an average follow-up of 9.7 months were reviewed. Etiologies included Hangman's fracture (n=35), traumatic disk herniation at C2-C3 (n=1), C3 fracture (n=2), ossification of the posterior longitudinal ligament (n=2), and tumor (n=2). Single-level diskectomy (n=36) and corpectomy (n=6) were performed. Exposure was satisfactory, and operations went smoothly in all patients except in 1 man with a muscular neck. One (2.4%) postoperative complication of choking and trouble swallowing liquids was observed and diminished in 3 months with no treatment. Pre- and postoperative Japanese Orthopaedic Association scores were 13.86 +/- 2.25 and 16.50 +/- 0.76, respectively, with an improvement rate of 85% 624% in 14 patients who had preoperative neurological dysfunction. A fusion rate of 100% was achieved. The subaxial anterior approach may be simple and safe for exposure at C2 in select patients. Complicated exposure, such as the transoral or retropharyngeal approach, should be avoided in these patients.