Fusion vs motion preservation Solid fusion stops pain related o the motion segment Adjacent motion segment degenerates faster- 25% symptomatic at 20 years

PRESTIGE Formerly Bristol disc (Cummins) 2-nd generation modified as 2-piece all metal prosthesis (ball-and-socket) Secured vertebral bodies anterior screws 100 implantations

Prestige titanium

BRYAN DISC Two anatomically shaped metal plates Low friction, low wear rates 4000 implantations RCT with fusion 2002 20 centres >500 pt

Prodisc C

MATERIALS Cobalt - Chrome Alloy (CoCr)

Titanium Plasma Spray surface FIXATION Primary: Central Keel Secondary: Titanium Plasma Spray surface

MIDLINE MARKING

RETAINER SCREW INSERTION

VERTEBRAL BODY RETAINER

DISTRACTION

DISCECTOMY AND DECOMPRESSION

KEEL CUTTING

BOX CUTTING

ADJUSTMENT DEPTH TRIAL

TRIAL IMPLANT INSERTION

IMPLANT INSERTION

Final result

Surgical approaches C1/2 anterior: trans oral C1/2 posterior: midline sub-occipital Sub-axial anterior: anterior cervical decompression Sub-axial posterior: cervical laminectomy, laminoplasty, foramenotomy

Posterior Approaches Occiput C1 C2 Subaxial C2-7

Posterior cervical fixation C1/2 with or without occipital fixation C3-7 cervicothoracic

Atlantoaxial instability

C1 articular mass screw

C1/C2 articular mass screws

Incision

First steps

Exposure of the spines and laminae 2

Exposure of lateral masses

Exposure of the laminae and lateral masses

Removal of the laminae

Spectrum of pathology Prolapsed discs, osteophytic compression: ‘wear and repair’ Inflammatory: rheumatoid, ankylosing spondylitis Trauma: odontoid, rotatory subluxation Neoplastic: meningiomas, schwannomas, metastatic cord compression Congenital Klippel Feil, fused, Down’s, enterogenous cysts Infection: discitis, osteomyelitis, epidural abscess

Spectrum of pathology Prolapsed discs and osteophytic compression; ‘wear and repair’ Inflammatory: rheumatoid, ankylosing spondylitis Trauma: odontoid, rotatory subluxation Neoplastic: meningiomas, schwannomas, metastatic cord compression Congenital Klippel Feil, fused, Down’s, enterogenous cysts