Updated: 1/24/2023

Anterior Approach to Cervical Spine

Review Topic
  • 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
  • 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
  • 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
  • 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

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Questions (7)

(SBQ18SP.13) A 60-year-old male undergoes a C6-7 ACDF for intractable C7 radiculopathy via a left-sided approach. He previously had the same procedure performed at a more cephalad level through a left-sided approach that left him with hoarseness that resolved with time. Video V labels the anatomic landmark then shows a technique step that is part of the routine dissection for this procedure. Excessive electrocautery during this technical step in the lateral muscles that are being retracted would put the patient at risk for which of the following symptoms:

QID: 211245

Change in the pitch of the voice, vocal fatigue, and difficulty with explosive sounds



Deviation of the tounge to the ipsilateral side



Ipsilateral pupillary miosis, enophthalmos, and loss of ciliospinal reflex



Paresis of the ipsilateral strap musculature



Dural perforation and CSF leak



L 4 A

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(OBQ06.221) A myelopathic patient undergoes anterior cervical diskectomy and fusion through a left sided approach. Facial asymmetry is noticed postoperatively in the recovery room. A clinical photo is shown in Figure A. What additional finding would likely be found on physical exam?

QID: 232

Pupillary dilation and hyperhidrosis on the patient's right side



Pupillary dilation and hyperhidrosis on the patient's left side



Pupillary constriction and hyperhidrosis on the patient's right side



Pupillary constriction and anhidrosis on the patient's left side



Pupillary constriction and anhidrosis on the patient's right side



L 1 C

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(OBQ05.53) A 53-year-old female is 8 hours status post the procedure seen in Figure A. You are called to the room by the nurse who reports the patient is having difficulty breathing. On arrival, you note that the patient has stridor on inspiration and a firm mass under the incision. What is the most likely cause of her respiratory compromise?

QID: 939

Postoperative edema






Vocal cord paralysis



Allergic reaction






L 1 D

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Evidence (20)
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