====== Anterior cervical discectomy technique ======

[[Anterior cervical discectomy]] is usually straightforward but has multiple pitfalls and nuances 
((Golfinos JG, Dickman CA, Zabramski JM, Sonntag VKH, Spetzler RF: Repair of vertebral artery injury during anterior cervical decompression. Spine 19:2552–2556, 1994.))

see PDF article of Sonntag VK, Han PP, Vishteh AG. Anterior cervical discectomy. Neurosurgery.
2001 Oct;49(4):909-12. PubMed PMID: 11564253.

see also [[Anterior cervical discectomy and fusion technique]].

===== Position =====

In the operating room, the patient must not be hyperextended during intubation. 

The patient is placed supine with the neck slightly hyperextended. The head is not turned. 

Some use halter traction with this.

===== Equipment =====

a) microscope (not used by all surgeons)

b) C-arm


===== Incision =====

see [[Anterior cervical discectomy incision]].

Dissect in tissue plane medial to [[sternocleidomastoid muscle]] (SCM). For the C5–6 interspace, angle slightly cranially during dissection. For the C6–7 disc, proceed almost straight down to spine. Sweep [[omohyoid muscle]] medially (to stay out of it and to protect the [[recurrent laryngeal nerve]] (RLN). The [[trachea]] + [[esophagus]] are retracted medially. The [[carotid sheath]] + SCM are retracted laterally.
After verification of level with lateral [[Cervical spine x ray]] with [[spinal needle]] in the interspace, [[bipolar]] the [[prevertebral fascia]] and medial edges of the [[Longus colli muscle]]s longitudinally in the midline. [[Self-retaining retractor]] [[blade]]s are inserted underneath the [[fascia]] to retract the [[longus colli muscle]]s laterally. The anesthesiologist is asked to deflate the cuff on the [[endotracheal tube]] and then to re-inflate it using minimal leak technique to reduce the risk of compression injury from the retractor. The [[disc space]] is incised with a 15 [[scalpel blade]]. The [[discectomy]] is performed with [[curette]]s and pituitary [[rongeur]]s; a [[vertebral body spreader]] aids the exposure. The posterior longitudinal ligament is incised,one technique is to elevate it with a sharp nerve hook and then incise it with a #11 scalpel. The subligamentous space is probed with a blunt nerve hook. The posterior lip of the VB above and below are removed with a Kerrison rongeur with a small foot-plate. Decompression of the roots is verified with the blunt nerve hook. Fusion is performed at this time if desired by placing the graft in the interspace.
For redo operations (same or di erent levels): approach is usually from the same side as previous operation(s) since many patients have swallowing issues post-op, and some may be due to partial recurrent laryngeal nerve injury (which can be subclinical) and which could result in a permanent need for a feeding tube if a contralateral injury occurs. If for some reason it is desired to go to the opposite side, an evaluation by an ENT physician is recommended, and should include scoping the patient to rule-out subclinical problems that could turn into major di   culties if bilateral.
===== Intraoperative neurophysiological monitoring =====

see [[Intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion]]

===== Closure =====

After copious irrigation, the wound is closed. It is inspected once more by placing two self-retaining [[Cloward]] retractors in the wound, keeping one self-retaining retractor deep in the wound. The walls of the wound are checked for any bleeding, which is then controlled, and the opposite retractor is removed
slowly. The same maneuver is performed on the other side. The platysma layer is closed with interrupted 3-0 Vicryl suture (Ethicon, Inc., Somerville, NJ), and the skin is closed with a running subcuticular 4-0 Vicryl suture. The suture line is reinforced with Steri-Strips (3M Healthcare, St. Paul, MN)
or Dermabond (Closure Medical Corp., Raleigh, NC).

===== References =====