Cervical Spine – Posterior Approach

Modern Study Review (AI-Generated)

High-Yield Summary

The posterior cervical spine approach remains the gold standard for direct access to the dorsal cervical vertebrae, primarily indicated for decompression procedures (laminectomy, foraminotomy), posterior instrumentation, and tumor resection. It offers excellent visualization of posterior neural elements with minimal risk to anterior structures. Despite advances in minimally invasive and anterior approaches, the posterior approach is indispensable for multi-level decompression and stabilization.

Applied Anatomy & Intervals

Internervous Interval

Midline plane between the bilateral paracervical muscles innervated by the posterior rami of cervical spinal nerves.

Anatomic Landmarks

• Spinous processes of cervical vertebrae (palpable midline bony prominences).
• Laminae and facet joints visible after soft tissue dissection.
• Ligamentum flavum located between adjacent laminae.

Patient Positioning & Setup

Table Type

Radiolucent operating table to facilitate intraoperative imaging.

Patient Position

Prone position with the head secured in a Mayfield head clamp or equivalent fixation device. Neck is slightly flexed to optimize exposure and reduce venous congestion.

Specialized Equipment

• Intraoperative C-arm or fluoroscopy for level localization.
• Bipolar cautery for precise hemostasis.
• Gelatin-based hemostatic agents (e.g., Gelfoam) for controlling venous plexus bleeding.

Surgical Technique (The “Vital Steps”)

Incision & Superficial Dissection

• Midline longitudinal skin incision centered over the target cervical levels.
• Dissect through subcutaneous tissue and fascia to expose the nuchal ligament and paraspinal muscles.

Deep Dissection & Exposure

• Incise the nuchal ligament in the midline.
• Subperiosteal elevation of paraspinal muscles bilaterally off the spinous processes and laminae.
• Identify and preserve the ligamentum flavum between adjacent laminae.
• Remove ligamentum flavum starting at the inferior edge of the superior lamina.
• Perform laminectomy or laminotomy as indicated.
• Retract the spinal cord medially with extreme caution to avoid neural injury.
• Identify posterior vertebral body margins if anterior decompression is required.

The “Danger Zone”

Post-Operative Pearl

Early mobilization is encouraged; however, avoid excessive neck extension or rotation for 4-6 weeks to protect the posterior elements and any instrumentation placed.

Classic Clinical Notes

Cervical spine – posterior approach

• Position: Prone

• Incision: Midline of neck

• Internervous plane: Midline between left and right paracervical muscles (posterior rami of cervical nerves)

• Dissection:
• Continue incision down to spinous processes
• Expose posterior aspect of vertebrae subperiosteally
• Identify ligamentum flavum running between adjacent lamina
• Remove from leading edge of lamina of inferior vertebra
• Remove remaining ligamentum flavum and lamina
• Retract spinal cord medially
• Identify posterior portion of vertebral body

• Dangers:
• Spinal cord and nerve roots — avoid vigorous retraction
• Venous plexus in canal — use Gelfoam or bipolar cautery
• Segmental blood supply
• May be cut or stretched as muscles stripped past facet joints
• Usually causes no problems
• Vertebral artery — protected by bone because within transverse foramen

Last Updated on January 25, 2026 by orthonet