Anterior Cervical Approach

Operative Planning

Imaging options
- Magnetic resonance imaging (MRI) (best assessment of spinal canal/cord)
- Computer tomography (CT)
- Myelogram if MRI is inconclusive
- Flexion/extension x-rays
Patient counseling regarding surgical risks
- Swallowing dysfunction (common, usually very transient)
- Potential voice change (less common, also typically very transient)

Equipment

Basic spine tray
Additional helpful instruments:
- Small pediatric Weitlaner retractor (blunt ideal)
- Debaky forceps, vascular clips
- Kittner dissector sponges
High-speed drill (Midas Rex with AM-8 bit) (consider angled handpiece and diamond burr)
Anterior cervical retractor set (e.g., Shadow-Line [V Mueller Neuro], TrimLine [Medtronic], Thompson-Farley)
One- and 2-mm Kerrison punches with thin footplates

Operating Room Set-up

Anesthetic Issues

Prophylactic intravenous antibiotics (cefazolin 2 g for adults) 30 minutes prior to incision. Consider vancomycin if planning instrumentation
Foley catheter for prolonged surgery
Consider arterial line for patients who require enhanced monitoring of blood pressure
Special anesthetic regimens may be needed if spinal neurophysiological monitoring used
Bite block when using motor evoked potentials

Positioning

Head on soft padded “doughnut” in neutral position (especially if fusion to be performed)
Gentle cranial extension with shoulder roll (as tolerated)
Appropriate padding to prevent pressure neuropathies
Arms tucked at sides. Gentle shoulder traction may be helpful but use caution to avoid/limit brachial plexus stretch.
Intraoperative x-ray/fluoroscopic imaging used to confirm cervical alignment and guide incision

Sterile Scrub and Prep

Use disposable clippers for minimal shave (if needed)
Betadine detergent scrub
Alcohol wipe (avoid leaving residual as potentially flammable with intraoperative sparks from cautery)
Sterile towel to dry

Initial localization using anatomic landmarks
Confirmatory final localization with f luoroscopy
Transverse curvilinear incision in skin crease for most cases
Consider longitudinal incision along medial sternocleidomastoid muscle for difficult anatomy (e.g., obese patient or many levels)
Consider injection of subcutaneous lidocaine with epinephrine (may minimize skin bleeding and patient stress)

Exposure

Incision with no. 10 or no. 15 blade
Along incision line, elevate and divide platysma sharply with Metzenbaum scissors or Bovie cautery (with attention to underlying veins)
Dissect along medial border of sternocleidomastoid
For lower cervical approach, identify omohyoid (usually around C5–C6, may divide if needed but can usually work above it)
Identify, protect, and work medially to the carotid sheath structures
Kittner dissectors and handheld Cloward retractors helpful to identify/develop appropriate plane to expose longus coli muscles, prevertebral fasica, and underlying disc spaces and vertebral bodies