Operative Planning

• Imaging
  
  
  
  
  • Magnetic resonance imaging (MRI)
    
  • Computed tomography (CT) myelogram if MRI is inconclusive
    
  • Flexion/extension x-rays
    
  • CT scan may be helpful/necessary to assess presence/configuration of osteophyte and to better understand bone anatomy/quality
  
  
• Monitoring (e.g., motor evoked potentials, somatosensory evoked potentials, electromyography) may be considered depending on patient’s pathology, monitoring availability, and local/surgeon practice

Equipment

• Basic spine tray
  
• 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
  
• Interbody support (e.g., fibula or cage)

Operating Room Set-up

• Headlight
  
• Loupes or microscope
  
• Bipolar cautery and insulated-tip Bovie cautery
  
• Intraoperative x-ray and/or fluoroscopy

Anesthetic Issues

Positioning

• Head on soft padded “doughnut” in neutral position
  
• Gentle cranial extension with shoulder roll (as tolerated)
  
• Appropriate padding to prevent pressure neuropathies
  
• Arms tucked at sides.
  
• Intraoperative x-ray/fluoroscopic imaging used to confirm cervical alignment and guide incision

Planning of Sterile Scrub and Prep

• Use disposable clippers for minimal shave (if needed)
  
• Betadine detergent scrub
  
• Alcohol wipe

Mark Incision

• Localization using anatomic landmarks and intraoperative x-ray
  
• Transverse curvilinear incision in skin crease for most cases
  
• Consider longitudinal incision along medial sternocleidomastoid muscle for difficult anatomy or many levels
  
• Consider injection of subcutaneous lidocaine with epinephrine

Exposure

• Incision with no. 10 or no. 15 blade
  
• Elevate and divide platysma sharply
  
• Dissect along medial border of sternocleidomastoid
  
• For lower cervical approach, identify omohyoid and divide if necessary
  
• 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
  
• Verify levels with x-ray/fluoroscopy
  
• Insert self retaining anterior cervical retractor system
  
• Distraction posts may be helpful for exposure, decompression, and alignment