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Cervical Anterior Approach

Indications
• Excision of herniated discs (R.B.Cloward, personalcommunication,
1969)
• Interbody fusion
• Removal of osteophytes from the uncinate processes and from either
the anterior or the posterior lip of the vertebralbodies
• Excision of tumors and associated bone grafting
• Treatment of osteomyelitis
• Biopsy of vertebral bodies and disc spaces
• Drainage of abscesses
Position of Patient
• Place the patient supine on the operating table with a small sandbag
or roll between the shoulder blades to ensure extension of the neck.
• Turn the patient's head away from the planned incision to provide
good access to the side of the neck.
• Some cases may require application of halter traction so that it can be
used later if distraction is required.
• Elevate the table 30° to reduce venous bleeding and make the neck
more accessible.
• Place the patient's arm at his or her side after careful padding.
Landmarks
• Hard palate–arch of the atlas
• Lower border of the mandible–
C2-3
• Hyoid bone–C3
• Thyroid cartilage–C4-5
• Cricoid cartilage–C6
• Carotid tubercle–C6
Superficial Surgical Dissection
• Incise the fascial sheath over the
platysma in line with the skin
wound (Fig. 6-72).
• Then, split the platysma
longitudinally using the tips of
the index fingers, dissecting
parallel to the long fibers.
Superficial Surgical Dissection
• Identify the anterior border of
the sternocleidomastoid muscle
and incise the fascia
immediately anterior to it.
Superficial Surgical Dissection
• Using the fingers, gently retract the
sternocleidomastoid muscle laterally.
Retract the Sternohyoid and sternothyroid
strap muscles (with the associated
trachea and underlying esophagus)
medially.
• The carotid sheath enclosing the common
carotid artery, vein, and vagus nerve now
can be exposed, if necessary.
Superficial Surgical Dissection
• Retract the sternocleidomastoid
and the carotid sheath laterally,
and the strap muscles, trachea, and
esophagus medially to expose the
longus colli muscle and pretracheal
fascia.
• Retract the sternocleidomastoid
muscle and carotid sheath laterally,
and the strap muscles and thyroid
structures medially, then split the
longus colli muscle longitudinally in
the midline (cross-section).
Superficial Surgical Dissection
• Retract the sternocleidomastoid
muscle and carotid sheath
laterally, and the strap muscles
and thyroid structures medially,
then split the longus colli muscle
longitudinally in the midline
(cross-section).
Superficial Surgical Dissection

• Dissect the longus colli muscle


subperiosteally from the
anterior portion of the vertebral
body and retract each portion
laterally to expose the anterior
surface of the vertebral body.
• The longus colli muscles are
retracted to the left and right of
the midline to expose the
anterior surface of the vertebral
body (cross-section).
Deep Surgical Dissection
• Using cautery, split the longus colli muscle longitudinally over the
midline of the vertebral bodies that need to be exposed.
• Then, dissect the muscle subperiosteally with the anterior
longitudinal ligament and retract each portion laterally (i.e., to the left
and right of the midline) to expose the anterior surface of the
vertebral body.
• Obtain a lateral radiograph after placing a needle marker in the
appropriate vertebral body to identify the level correctly.
• Make sure that the retractors are placed underneath each of the
longus colli muscles, widening the exposure while protecting the
recurrent laryngeal nerve, trachea, and esophagus.
Dangers
• Nerves
• Recurrent laryngeal nerve
• Sympathetic nerves and stellate ganglion – Horner’s Syndrome
• Vessels
• carotid sheath and its contents are protected by the anterior border of the
sternocleidomastoid muscle. Do not place self-retaining retractors in this area, or the
sheath will be endangered. If additional retraction is necessary, use handheld
retractors with rounded ends.
• The vertebral artery, which lies in the costotransverse foramen on the lateral portion
of the transverse processes, should not be visible during the approach unless the
plane of operation strays well away from the midline.
• The inferior thyroid artery may cross the operative field in lower cervical approaches.
If it is divided accidentally, it may retract behind the carotid sheath, where it is
difficult to retrieve and tie off