Approaches

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Anterior (Smith-Robinson) approach (to subaxial spine)

  • Indication
    • Exposes C2-T1
    • Anterior cervical discectomy + fusion
    • Anterior cervical corpectomy + fusion
    • Infection, Odontoid fracture
  • Position
    • Supine, 30° head-up with sandbag in interscapular region to extend neck
    • Neck rotated slightly to contralateral side
  • Landmarks
    • See table
  • Incision
    • Right or left side (below C5, L-side safer in avoiding inadvertent injury to RLN
    • Transverse incision over ant. Sternocleidomastoid
    • Can use oblique incision
  • Internervous plane
    • No true INP
  • Superficial dissection
    • Platysma, in-line with fibres
  • Deep dissection
    • Incise deep cervical fascia at ant. Border of Sternocleidomastoid
    • Sternocleidomastoid muscles laterally, strap muscles medially (sternohyoid/sternothyroid)
    • Retract SCM laterally with carotid sheath laterally
    • Retract strap muscles with trachea & oesophagus medially
    • Expose prevertebral fascia + longus colli muscles- retract laterally with incised ALL
    • Be aware of sympathetic chain (lies on LC lateral to VB)
    • Divide prevertebral fascia longitudinally in the midline to expose disc + vertebral body
    • K-wire/clip & lateral x-ray to confirm level
  • Risks
    • Superior thyroid artery above C4, Inferior thyroid artery below C6, may need ligating
    • Recurrent Laryngeal Nerve (more so on the right)
    • Carotid sheath (encloses common carotid artery, internal jugular vein and vagus nerve)
    • Thoracic duct below C7 in Left-sided approach
    • Sympathetic nerves + stellate ganglion – damage causes Horners syndroome (ptosis, anhydriosis, miosis, enophthalamos)

Answer