Anterior Cervical Approach 

Posted bythespinebookadminPosted inProcedures

Landmarks 

  • C1 – Hard palate 
  • C23 – Lower border mandible 
  • C 3 – hyoid 
  • C4 – top of thyroid 
  • C5 – bottom of thyroid cartilage  
  • C6 – cricoid, carotid ttubercle (on TP) 

Steps 

  • Transverse skin incision 
  • Platysma longitudinal 
  • Anterior border SCM, incise fascia 
  • SCM lateral, strap medial 
  • Pretracheal fascia 
    • Carotid lateral 
    • Trachea, esophagus medial 
    • Sup and inf thyroid arteries from carotid to midline (ligate PRN) 
  • Prevertebral fascia, longus colli, ALL in midline 
    • Sympathetic chain over TPs 
  • Subperiosteal elevation over VB and disc 

ACDF additional steps 

  • Confirm levels with fluro 
  • Decompress 
    • Back to PLL (rremove to remove PLL to visualize cord 
    • Uncinate to uncinate (Safe Zone), VA 
    • Prepare endplate 
  • Anterior foraminotomy 
    • Kerrison and burr 
    • Laterally open 
    • Open foramen 
  • Graft sizing 
  • Select and fix anterior plate 
    • Ideal size; screws immediately adjacent to endplates 
  • Smith-Robinson Approach 
    • Carotid sheath laterally 
    • Trachea/ esophagus medially 
    • *Rampersaud trick – deflate ETT cuff as RLN runs between esophagus and trachea so relieves pressure 
    • Laterally – Sympathetic chain  
      • Horner’s syndrome – transient, variable onset 
        • Ptosis, myosis, anhydrosis 
      • Lateral over longis colli 
    • ACDF corpectomy 
      • Myelopathy – minimal 15-18mm 
      • Be wary of vertebral arteries  
        • Review Axial MRI 
  • <5% permanent RLN problems 
    • Aspiration 
    • Hoarseness 
    • etc 

ACCF additional steps 

  • Corpectomy in line with discectomy borders 

Complications 

  • Pseudoarthrosis 
    • ACDF 10% single level, 30% multi 
    • RF 
      • Smoking 
      • DM 
      • Multi level 
      • revision 
  • RLN injury 
    • Traditionally thought R side more at risk because aberrant pathway 
    • ENT consult if no improvement in 6 weeks 
    • Drop the ETT when around the esophagus/ trachea (Dr. Ramp) 
  • Hypoglossal nerve 
    • Tongue deviat eto side of injury 
  • VA 
    • Don’t decompress beyond uncinates 
  • Dysphagia and hoarseness 
    • Caused by HW impingement 
    • Local steroid in retropharyngeal space decreases dysphagia 
    • Higher risk at higher levels 
    • Low profile plates better 
    • No profile anchored cage is best 
  • Esophageal injuy 
    • Early pef 
      • Repair right away intrarop 
      • Insert tthen withdraw NG tube 
        • Methylene blue test 
    • Late pef 
      • Difficult to repai 

  • Horner’s 
    • Sympathetic chain on lateral border of longus coli at C6 
    • Ptosis, anhydrosis, miosis, enophthalmos, loss of ciliospinal reflex 
  • ASD 
  • Aiwary complications 
    • O time >5h 
    • Exposue above C4 
    • 4 levels in construct 

Pearls 

  • 5 structures crossing anterioro approach 
    • Sup thy 
    • Inf thy 
    • Ansa cervicalis (cervical plexus) 
    • Hypoglossal nerve 
    • Omohyoid nerve 
  • How many levels with a single incision 
    • 2 level discectomy 
    • 1 level corpectomy 
  • Complications 
    • RLN R>L (hoarseness) 
    • Sympathetics chain (Horner’s) 
    • Carotid sheath contents 
      • Carotid A, internal jugular, vagus nerve 
    • Esophageal perf 
    • Trachea 
    • Postop retropharyngeal hematoma 
      • Intubate 
      • Emergent decompression 
  • Revision: 
    • No RLN palsy – use other side 
    • With RLN – use same side