This is a brief of ACCF

1. Anterior Cervical Approach

2. Definition
The anterior approach to the cervical spine
exposes the anterior vertebral bodies from C3
to T1. It also allows direct access to the disc
spaces and uncinate processes in the region.

3. Indication
1. Excision of herniated discs (R.B. Cloward, personal communication, 1969)21
2. Interbody fusion (see the section regarding the anterior approach to the iliac crest for bone graft)
3. Removal of osteophytes from the uncinate processes and from either theanterior or the posterior lip of the vertebral bodies
4. Excision of tumors and associated bone grafting
5. Treatment of osteomyelitis
6. Biopsy of vertebral bodies and disc spaces
7. Drainage of abscesses

4. Patient Position
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 degrees to reduce venous
bleeding and make the neck more accessible.

5. Landmark
Make an oblique incision in the skin crease of the neck at the
appropriate level of the vertebral pathology.
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

6. Incision
If the level of pathology is
localized, make a transverse skin
crease incision at the appropriate
level of the vertebral pathology.
The incision should extend
obliquely from the midline to the
posterior border of the
sternocleidomastoid muscle

7. Superficial Surgical Dissection
Retract the sternohyoid and sternothyroid strap muscles (with the associated trachea and
underlying esophagus) medially.
Using the fingers, gently retract the sternocleidomastoid muscle laterally.
Identify the anterior border of the sternocleidomastoid muscle and incise the fascia
immediately anterior to it.
Then, split the platysma longitudinally using the tips of the index fingers, dissecting
parallel to the long fibers. The platysma fibers can also be divided with a knife.
Incise the fascial sheath over the platysma in line with the skin wound.

8. Superficial Surgical Dissection
Palpate the artery. Develop a plane between the medial
edge of the carotid sheath and the midline structures
(thyroid gland, trachea, and esophagus), cutting through the
pretracheal fascia on the medial side of the carotid sheath.
The carotid sheath enclosing the common carotid artery,
vein, and vagus nerve now can be exposed, if necessary.

9. Superficial Surgical Dissection
Two arteries connect the carotid sheath with the midline
structures. These two vessels, the superior and inferior
thyroid arteries, may limit the extent to which this plane can
be opened up above C3-4. Occasionally, either or both of
them may have to be ligated and divided to open the plane.
Retract the sheath and its enclosed structures laterally with
the sternocleidomastoid muscle.

10. 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 prevertebral 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).

11. 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).
Superficial Surgical Dissection

12. The platysma muscle is split in line with its fibers : The muscle is
difficult to denervate, because most of its nerve supply comes
from the cervical branch of the facial nerve and begins in the
region of the mandible.
Carotid Sheath : The sheath contains the common carotid artery,
which divides at the upper border of the thyroid cartilage into
internal and external carotid arteries. It also contains the internal
jugular vein and the vagus nerve
Superficial Surgical Dissection and Its Danger

13. Deep Surgical Dissection
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.
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.

14. Deep Surgical Incision and Its Danger
The longus colli muscles lie on the anterior surface of the vertebral column,
between C1 and T3.
The muscles are pointed at their ends and broad in the middle. They must be
removed from the vertebral bodies to expose the vertebrae.
Removal does not denervate them, because they are innervated segmentally
and laterally from their posterior surfaces.
Running on the anterolateral surfaces of the longus colli muscles is the cervical
sympathetic trunk, with its numerous ganglia.

15. Anatomical Consideration
Nerve
• The recurrent laryngeal nerve may be traumatized during the
deepest layer of the approach. Protect it by placing the retractors
well under the medial edge of the longus colli muscle.
• The sympathetic nerves and stellate ganglion may be damaged or
irritated, causing Horner syndrome. Protect them by making sure
that dissection onto the bone is subperiosteal from the midline.
• Avoid dissecting out onto the transverse processes

16. Recurrent Laryngeal Nerve
The two recurrent laryngeal nerves
are branches of the vagus nerve.
The left recurrent laryngeal nerve
descends into the thorax within the
carotid sheath.
It curves around the aortic arch and
ascends back in the neck, running
between the trachea and esophagus
to supply the larynx.
The right recurrent laryngeal nerve
descends within the carotid sheath
and curves around the subclavian
artery before ascending into the
neck at a higher level than the left
recurrent laryngeal nerve.

17. Anatomical Consideration
The carotid sheath and its contents have
been resected.
The larynx and its related structures are
retracted medially.
The longus colli and scalenus muscles with
their overriding prevertebral fascia are seen.
The sympathetic chain lies on the lateral
border of the longus colli muscle.
Note the position of the recurrent laryngeal
nerve between the trachea and esophagus.

18. Vessel
• The 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 hand-held retractors with rounded ends
• The vertebral artery, which lies in the transverse 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
Anatomical Consideration

19. The longus colli, the longus capitis, and
the scalenus anticus muscles have
been resected to reveal the anterior
portion of the vertebral bodies and
transverse processes.
Note the course of the vertebral artery
through the transverse processes
anterior to the spinal nerve. Note the
course of the superior and inferior
thyroid vessels.
Anatomical Consideration