Indications Overview widely used approach that exposes anterior vertebral bodies from C2 to T1 Indications cervical radiculopathy anterior cerical disctomy & fusion (ACDF) myelopathy anterior corpectomy and fusion tumor anterior corpectomy and fusion odontoid fracture C2 anterior screw osteosynthesis infection & epidural abscess anterior cervical discectomy & fusion (ACDF) Applied surgical anatomy It is important to understand the three fascial layers of the neck superficial fascia formed by the investing layer of deep cervical fascia platysma and external jugular vein are only structures superficial to it surround neck like a collar, but splits around the SCM and trapezius pretracheal fascia continous with carotid sheath at sheath's lateral margin superior and inferior thyroid vessels run from the carotid sheath through the pretracheal fascia to the midline prevertebral fascia thick and tough fascia that lines in front of the prevertebral muscles the cervical sympathetic trunk (runs over transverse processes) runs on its surface Landmarks angle of mandible correlates with the C2-3 disc space carotid tubercle is the anterior tubercle of the transverse process of C6 Planes Superificial divide platysma which is innervated high up in the neck by the facial (seventh) cranial nerve Middle sternocleidomastoid (spinal accessory nerve) strap muscles (segmental innervation from C1, C2, C3) Deep left longus colli muscles (segmental branches of cervical nerves) right longus colli muscles Preparation Anesthesia general as airway needs to be protected Position supine Imaging cross table lateral required to identify correct level shoulders/arms often pulled caudal to obtain better visualization of C7 Approach Incision make transverse skin crease incision at appropriate level extend obliquely from the midline to the posterior border of the SCN side surgeons preference Superficial Dissection incise fascia over platysma spit platysma with finger identify anterior border of SCM incise fascia and retract SCM lateral identify and retract strap muscles medially (sternohyoid and sternothyroid) identify the carotid pulse and retract carotid sheath lateral cut through pretrachial fascia localize superior and inferior thyroid arteries and tie off if necessary Deep dissection split longus colli muscles and anterior longitudinal ligament be aware of sympathetic chain that lies on longus colli lateral to vertebral body subperiostally disect to expose anterior surface of vertebral body retract longus colli muscles and ALL laterally identify level with needle in disc space and lateral xray Structures at Risk Recurrent laryngeal nerve injury rate 2.3% (same injury rate for left RLN and right RLN) left RLN ascends in neck in tracheoesophageal groove after branching off from parent nerve the vagus at the level of the arch of the aorta right RLN runs alongside the trachea in the neck after hooking around the right subclavian artery crosses from lateral to medial to reach midline more vulnerable than left during exposure because it has a more variable course lies more anterolateral protect by placing retractors under medial edge of longus colli muscle Sympathetic nerves and stellate ganglion damage or irritation causes Horner's syndrome characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face caused by injury to sympathetic chain, which sits on the lateral border of the longus colli muscle at C6 protect by subperiosteal dissection of longus colli muscles from midline Carotid sheath and contents protected by the anterior border of SCM be careful with lateral retractor placement Postoperative retropharyngeal hematoma presents with respiratory difficulties tense hematomas should be emergently decompressed if causing respiratory compromise physical exam will show a tense mass under the incision most common cause is postsurgical edema