Surgical approaches

Cervical spine: anterolateral approach (Smith–Robinson)

Background information

• One of the most common approaches to the neck

• Extensile – allows access to all levels

• Uses – anterior discectomy and fusion, anterior corpectomy and fusion or cage insertion for burst fracture, tumour or infection, kyphosis correction and vertebral artery exposure

Technique

• Patient placed in supine position with their head slightly extended and fixed, i.e. in Mayfield clamp

• Skin incision is made along the transverse skin crease or longitudinally

• Risk of recurrent laryngeal palsy is lower with approaches from left

• Platysma incised in line of incision

• Fascia incised anterior to sternocleidomastoid

• Blunt dissection between omohyoid/sternothyroid and midline structures

• Dissect between carotid sheath (laterally) and thyroid (medially) to expose deep fascia

• Can ligate thyroid artery for access

• The prevertebral plane is behind the fascia deep to the posterior pharynx

• Anterior longitudinal ligament divided in midline, retracted laterally with periosteum ±longus colli to improve exposure

Complications

• Injury to recurrent laryngeal nerve, hypoglossal nerve, vascular or visceral injury

• Neck swelling with airway compromise requiring urgent decompression; early dysphagia due to swelling

Cervical spine: posterior approach

Background information

• Access to occiput and posterior elements of cervical spine

• Can access the lateral masses

• Carried out for posterior cervical fusion, decompression of the canal, reduction and fixation for trauma and removal of lateral discs by foraminotomy

Technique

• Skull traction recommended

• Patient prone, head supported (no pressure on eyes)

• The shoulders are taped down, tilt head up

• Midline skin incision at occipitocervical junction; incision from below occipital protuberance to C3

• Fascia divided – access occiput and spinous process of C2

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