20.1 Introduction

Cervical radiculopathy and myelopathy usually occur due to degenerative disc disease and spondylosis. ¹ The anterior approach to the cervical spine is a commonly used procedure to gain access to the vertebral bodies and interposed vertebral discs. The anterior cervical discectomy and fusion have become the most commonly performed cervical spine procedures and remain the gold standard for surgical intervention for symptomatic disc disease. ² Robinson and Smith introduced the approach and procedure that are now known as the ACDF in 1955. ³

20.2 Preop

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  Surgical table. Radiolucent flat table

  
  
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  Following induction of general anesthesia, the patient is positioned supine on the radiolucent table such that fluoroscopic AP and lateral views can be obtained. All bony prominences must be well padded to avoid postoperative palsies. The neck is placed in slight extension, according to the surgeon preference, and the shoulders are generally taped to the bed to maintain the position during surgery. Gardner-Wells tongs or other forms of cranial traction are applied based on the surgeon preference.

  
  
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  Preoperative images should be made easily accessible.

  
  
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  Somatosensory/motor evoked potential monitoring probes should also be situated by trained neuromonitoring personnel.

  
  
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  Surgical prepping and draping per institutional and surgeon guidelines.

20.3 Approach

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  Palpation of surgical landmarks. Hyoid (C3), thyroid cartilage (C4–5 interspace), cricoid cartilage (C6), carotid tubercle (C6); mark anterior edge of sternocleidomastoid muscle (SCM).

  
  
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  A transverse incision is made respecting the natural skin creases beginning from midline to the anterior medial border of the SCM. A longitudinal incision is also an option depending on the number of intended operative levels.

  
  
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  Following the skin and superficial fascia incision, the platysma muscle is encountered and cauterized transversely in line with the skin incision.

  
  
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  The investing layer of the deep cervical fascia is encountered next and divided. Blunt dissection through this areolar layer is used to retract the SCM laterally until the carotid sheath is identified. Dissection is carried medially to the carotid sheath (middle layer of the deep cervical fascia); the carotid sheath is then mobilized laterally, whereas the pharynx and strap muscles are gently mobilized medially with a retractor.

  
  
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  Blunt dissection is used to further develop a plane until the prevertebral fascia and longus colli/capitus musculature are encountered. At this point, a spinal needle is generally utilized to confirm desired operative level using lateral fluoroscopy (▶Fig. 20.1).

  
  
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  Once appropriately localized, the prevertebral fascia, anterior longitudinal ligament, and longus colli muscles are dissected off in a subperiosteal fashion to visualize the anterior vertebral body and intervertebral disc. Attention to midline is vital during longus colli muscle dissection and guided by the contour of the vertebral body. Dissection beneath the longus colli muscles will facilitate cervical self-retaining retractor placement.

  
  
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  Self-retainers are then placed underneath the longus colli muscles, according to the surgeon preference, to maintain visualization. Direct vertical line of sight the midline must be firmly established to avoid an asymmetrical approach and a potential for vertebral artery injury. Caspar distraction pin placement on the cephalad and caudal verterbral bodies is also an option that many surgeons utilize to gain further access to the disc space.

  
  
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  A high-powered surgical microscope may be used after cervical retractors are placed (▶Fig. 20.2).