17 Anterior Cervical Diskectomy and Fusion A 38-year-old man presents to the office with long-standing neck pain radiating into the bilateral upper extremities. He notes numbness and tingling in the forearms bilaterally. He also has weakness along with decreased grip strength and upper extremity dexterity bilaterally. He denies any recent trauma or infections. Conservative therapy with home exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), and oral steroids have only provided temporary relief. • Symptomatic cervical disk herniation with radiculopathy or myelopathy (Fig. 17.1). • Cervical spondylosis with radiculopathy or myelopathy. • Ossification of the posterior longitudinal ligament present with myelopathy. • Unstable cervical fractures. Fig. 17.1 (a,b) Sagittal and axial T2-weighted MRI demonstrating a herniated nucleus pulposus at C4–C5 with spinal cord compression. • Supine. • Superficial landmarks include the following: – Lower border of mandible (C2–C3.) – Hyoid bone (C3). – Thyroid cartilage (C4–C5). – Cricoid cartilage (C6). • Superficial dissection: – Skin incision at the level of pathology: oblique from midline to the posterior border of the sternocleidomastoid (SCM): ∘ Incise the fascial sheath over the platysma; split the platysma longitudinally ∘ No internervous plane is present as the platysma, which is innervated by the facial nerve, is divided beneath the fascial sheath. – Identify the anterior border of the SCM and incise the fascia immediately anterior to it; gently retract the SCM laterally. – Retract the strap muscles and tracheoesophageal structures medially. An internervous plane is present between the SCM (CN XI) and the strap muscles (C1–C3). • Deep dissection: – The carotid sheath is now exposed; develop a plane between the carotid sheath and midline structures. – Retract the carotid sheath and SCM laterally. – After development of a plane deep to the pretracheal fascia, the cervical vertebrae should be visible. – Split the longus colli muscles longitudinally (Fig. 17.2): ∘ The recurrent laryngeal nerve is at risk during this approach; protect it with placement of retractors under the medial edge of the longus colli. • Structural bone grafts are placed after the diskectomy is performed: – Bone grafts can be auto- or allograft. – Grafts can also be alternative materials such as polyetheretherketone (PEEK) or carbon fiber filled with local bone obtained from the osteophyte resection or from bone graft substitutes. • Anterior cervical plate and screws are used to stabilize the vertebral levels directly adjacent to the resected disk space.
17.1 Case Presentation: Presentation and Preoperative Imaging
17.2 Indications
17.3 Positioning
17.4 Approach
17.5 Implants and Hardware
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