Risk evaluation of neck extension in patients with degenerative or ossified cervical spine undergoing extension-dependent surgical procedures

This study aimed to establish a structured clinical flow for evaluating the risk of iatrogenic spinal cord injury in patients with cervical spine pathology undergoing surgeries requiring neck extension. We retrospectively reviewed 152 patients who underwent anterior neck surgeries requiring cervical extension between March 2022 and February 2024. All patients received preoperative cervical computed tomography (CT) to assess for ossification of the posterior longitudinal ligament, degenerative stenosis, and other compressive pathologies. Patients with radiologic risk underwent symptom evaluation and were recommended cervical magnetic resonance imaging (MRI). Based on CT, MRI, and clinical findings, patients were stratified into risk groups, and cleared for extension, underwent intraoperative neck position modulation, or received preventive surgery. Radiologic pathology was identified in 27 patients (17.8%). MRI was performed in 10 patients; 3 showed T2 signal changes. Five patients met high-risk criteria, of whom 1 underwent preventive decompression and 4 received intraoperative position modulation. Neck extension was permitted without restriction in 134 patients (88.2%). No postoperative neurological deterioration occurred in any patient. Our proposed evaluation flow, integrating CT, MRI, and symptom-based assessment, enables safe and selective surgical planning for neck extension. Intraoperative neck position modulation may serve as a practical alternative to preventive decompression in patients with moderate risk, thereby avoiding unnecessary surgery without compromising neurological safety.