17.1 Case Presentation: Presentation and Preoperative Imaging

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.

17.2 Indications

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  Symptomatic cervical disk herniation with radiculopathy or myelopathy ( Fig. 17.1 ).

  
  
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  Cervical spondylosis with radiculopathy or myelopathy.

  
  
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  Ossification of the posterior longitudinal ligament present with myelopathy.

  
  
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  Unstable cervical fractures.

17.3 Positioning

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  Supine.

  
  
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  Superficial landmarks include the following:

  
  
  
  
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    Lower border of mandible (C2–C3.)

    
    
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    Hyoid bone (C3).

    
    
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    Thyroid cartilage (C4–C5).

    
    
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    Cricoid cartilage (C6).

17.4 Approach

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  Superficial dissection:

  
  
  
  
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    Skin incision at the level of pathology: oblique from midline to the posterior border of the sternocleidomastoid (SCM):

    
    
    
    
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      Incise the fascial sheath over the platysma; split the platysma longitudinally

      
      
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      No internervous plane is present as the platysma, which is innervated by the facial nerve, is divided beneath the fascial sheath.

    
    
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    Identify the anterior border of the SCM and incise the fascia immediately anterior to it; gently retract the SCM laterally.

    
    
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    Retract the strap muscles and tracheoesophageal structures medially. An internervous plane is present between the SCM (CN XI) and the strap muscles (C1–C3).

  
  
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  Deep dissection:

  
  
  
  
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    The carotid sheath is now exposed; develop a plane between the carotid sheath and midline structures.

    
    
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    Retract the carotid sheath and SCM laterally.

    
    
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    After development of a plane deep to the pretracheal fascia, the cervical vertebrae should be visible.

    
    
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    Split the longus colli muscles longitudinally ( Fig. 17.2 ):

    
    
    
    
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      The recurrent laryngeal nerve is at risk during this approach; protect it with placement of retractors under the medial edge of the longus colli.