Review Question - QID 219603

In this patient who has undergone prior anterior spine surgery, a same-sided approach should be utilized to avoid injury to the contralateral recurrent laryngeal nerve (RLN) (Answer 4).

Anterior cervical discectomy and fusion (ACDF) is indicated for patients with progressive neurologic deficits secondary to cervical stenosis and/or radicular symptoms. ACDF can be performed through a left- or right-sided anterior approach based on surgeon preference. Injury to the RLN is a known risk, though only reported in about 1% of cases. There is a theoretically increased risk of nerve injury with a right-sided approach although many surgeons still prefer this side if they are right-handed. In the setting of revision ACDF, an approach through the same side as the initial surgery is recommended in case there was an injury to the RLN that was not appreciated. Damage to both the left and right RLN could lead to complete vocal paralysis which is a devastating complication.

Oh et al. reviewed recurrent laryngeal nerve injury following single and multiple-level ACDF. 3,514 patients were included in the meta-analysis and the rate of recurrent laryngeal nerve palsy was noted to be 1.2% overall. Also, there were no significant differences in the rate of palsy between single- and multiple-level fusions.

Yee et al. published a general review on the complications of anterior cervical spine surgery. Their published rates of complication included: dysphagia (5.3%), esophageal perforation (0.2%), recurrent laryngeal nerve palsy (1.3%), infection (1.2%), adjacent segment disease (8.1%), pseudoarthrosis (2%), graft/hardware failure (2.1%), CSF leak (0.5%), hematoma (1%), horner syndrome (0.4%), C5 palsy (3%), vertebral artery injury (0.4%), and new/worsening neurologic deficit (0.5%). They note that while overall rates of complication are low, the unique anatomy in the anterior neck requires extreme understanding and caution.

Incorrect Answers:
Answer 1: Posterior foraminotomy is contraindicated in the setting of a large central disc herniation.
Answer 2: Posterior cervical fusion is an option but has a higher rate of infection, especially in a smoker like this patient.
Answer 3: ACDF at C5-6 is appropriate but should be performed through an approach on the same side of the neck to avoid any complications related to vocal cord paralysis.
Answer 5: A four-level fusion construct is not indicated in this patient who has symptoms localized to one level where there is a large disc herniation and degenerative change.