Anterior Cervical Discectomy

Volker K.H. Sonntag, M.D., Patrick P. Han, M.D.,

A. Giancarlo Vishteh, M.D.
Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital
and Medical Center, Phoenix, Arizona

A
nterior cervical discectomy is performed for a variety
of reasons. The most common is a degenerative disease
that induces an osteophyte or a herniated nucleus pul-
posus that then causes radiculopathy or myelopathy (1, 3).
The operation is usually straightforward but has multiple
pitfalls and nuances (2). This article presents the senior au-
thor’s (VKHS’s) surgical technique for anterior cervical disc-
ectomy. Once conservative treatment for cervical radiculopa-
thy, myelopathy, or both, has failed, surgical intervention is
indicated. Depending on the location of the compression, the
amount of axial pain, and the lordosis of the cervical spine, an
anterior or posterior approach is used. The anterior approach
for a single-level discectomy is described below.
In the operating room, the patient must not be hyperex-
tended during intubation. Somatosensory evoked potentials
are routinely monitored. The patient is placed supine with the
neck slightly hyperextended. The head is not turned. The
Caspar operating table attachment is used to help visualize
the lower cervical spine on either plain radiographs or fluo-
FIGURE 1. Patient positioning with the Caspar headholder.
roscopy. The Caspar table attachment also allows slight hy-
The patient’s head is maintained in a neutral position with an
perextension of the neck. The neck bar is placed under the
elastic chin strap. The cervical spine is maintained in either a
lower cervical and upper thoracic areas to avoid undue pres-
neutral or a minimally extended posture to recreate the cer-
sure on the cervical spine (Fig. 1).
vical lordosis. Adhesive tape is run along the lateral margin
of the shoulder joint and arm and is affixed to the foot of the
SURGICAL APPROACH (see video at web bed to assist with intraoperative fluoroscopic visualization of
site article) the distal cervical spine. To avoid a pressure injury to the
brachial plexus, the tape should not be run directly over the
Superficial landmarks serve as the reference points to de-
clavicle. An intrascapular roll is placed to facilitate operative
termine the level of the skin incision, but intraoperative ra-
access by allowing the shoulders to fall below the coronal
diographs or fluoroscopic studies are obtained to verify the
plane of the cervical spine. The neck bar is placed under the
level. The cervical spine is approached from the right side
upper thoracic spine. Both the scalp leads for evoked poten-
unless the patient has undergone a prior approach from the
tial monitoring and the endotracheal tube (not shown) would
left side. If so, the original incision line is used. If a patient has
be rostral in the operative field. (Courtesy, Barrow Neurolog-
subclinical vocal cord paralysis on the side of the incision,
ical Institute.)
proceeding with an incision on the opposite side is risky. The
potential for recurrent laryngeal nerve palsy is highest on the
right side, although the risk has not been documented in anterior to the sternocleidomastoid muscle, is made if three or
recent reports. The thoracic duct, however, can be injured more interspaces are involved. The angle of the mandible
when the approach is from the left side. tends to correspond to the level of C2, the hyoid bone corre-
A transverse incision is made for a one- or two-level ante- sponds to the level of C2–C3, and the inferior border of the
rior cervical discectomy. A carotid incision, parallel and just thyroid cartilage is estimated to be at C4–C5 (Fig. 2). The skin

Neurosurgery, Vol. 49, No. 4, October 2001 909

910 Sonntag et al.
FIGURE 2. Orientation to the vertebral column may be esti-
mated by palpating superficial anatomic structures. The
hyoid bone sits approximately at the level of the C2–C3 disc
space. The top of the thyroid cartilage can be estimated as
the C3–C4 disc space. The inferior border of the thyroid car-
tilage (dotted line) can be estimated as the C4–C5 level. The
C7–T1 disc space sits approximately one finger’s breadth
above the clavicle. The carotid-type incision (solid line) is
made if three or more interspaces are involved. (Courtesy,
Barrow Neurological Institute © 1993.)
is incised sharply to the level of the platysma, which also is
divided sharply. When more than one level is exposed, rostral
and caudal subplatysmal dissection is mandatory.
The plane between the carotid sheath laterally and the
esophagus and trachea medially is dissected sharply and
bluntly (Fig. 3). The omohyoid muscle can be divided if ex-
tensive exposure is required or if it is directly in the route of
the approach. The prevertebral tissues are dissected, initially
with a “peanut” and then with low-power monopolar cauter-
ization. The longus colli muscles are visible overlying the
anterior longitudinal ligaments and vertebral bodies. With the
monopolar cautery device set on low and its tip slightly bent,
the longus colli muscle is dissected gently from the vertebral
body approximately 2 to 3 mm laterally. The teeth of the
self-retaining retractor blades, which are placed beneath the
dissected longus colli muscles, often get caught on an osteo-
phyte. It is best to remove such osteophytes, usually with
Neurosurgery, Vol. 49, No. 4, October 2001
FIGURE 3. Axial view of the plane of dissection and expo-
sure of the prevertebral space. The carotid sheath and the
jugular vein are retracted laterally, and the trachea and
esophagus are retracted medially. (Courtesy, Barrow Neuro-
logical Institute.)
large pituitary rongeurs, so that the blades can be hooked
under the longus colli muscles (Fig. 4).
A Caspar post is placed in what is thought to be one of the
appropriate vertebrae, and a lateral radiograph or fluoro-
scopic study is obtained. A post is preferred to a needle
because it provides a more fixed landmark. If the post is in an
incorrect vertebral body, it easily can be moved and placed in
the correct vertebral body. After the correct level is identified,
a second vertebral post is placed. The post spreaders are
positioned over the post, and no distraction is performed until
the anterior anulus is incised (Fig. 5). Then vertical traction is
placed on the vertebral bodies using the post spreaders.
Removal of the disc begins after the anulus has been cut
(Fig. 6A). The anterior two-thirds of the disc is removed with
angled curettes and pituitary rongeurs of various sizes (Fig.
6B). An osseous lip, which is usually present on the superior
vertebral body, is removed with a No. 2 Kerrison rongeur
(Codman/Johnson & Johnson, Raynham, MA) or with a Mi-
das Rex AM-8 drill (Midas Rex Institute, Fort Worth, TX). The
superoanterior lip of the inferior vertebral body is drilled until
it is flush with the endplate. The microscope is brought into
the surgical field, and the rest of the disc is removed.
The posterior ligament becomes visible. It is wise to coag-
ulate the posterior ligament to help identify its fibers and to
FIGURE 4. Once the tips of
the self-retaining retractors
are positioned beneath the
dissected longus colli mus-
cles, the cervical vertebral
bodies are exposed anteri-
orly. (Courtesy, Barrow Neu-
rological Institute.)

FIGURE 5. Interbody posts and spreader in position. Two-
headed arrow, direction of movement of the posts. (Courte-
sy, Barrow Neurological Institute.)
FIGURE 6. A, the discec-
tomy is initiated by incising
the anulus with a No. 11
blade. B, after the anulus
fibrosus has been opened
initially, a small amount of
distraction is applied across
the vertebral bodies by using
the post spreaders. A curette
is used to “scrape” the carti-
laginous endplate to remove
additional disc material.
(Courtesy, Barrow Neurolog-
ical Institute.)
coagulate the veins running through it. Coagulation also
seems to make entering the ligament easier with the micro-
curette. The posterior ligament is incised with the curette or
with the No. 1 Kerrison rongeur.
The symptomatic site is decompressed first. That is, if the
patient has a left radiculopathy, the patient is turned 10 to 20
degrees away from the surgeon, who is on the right side so
that the left foramen is easily seen. With microcurettes and a
micro-Kerrison rongeur, the foraminotomy is performed by
removing the osteophytes and disc material. Often the herni-
ated disc is posterior to the ligament and is identified at this
time. It is often difficult to determine how far lateral to carry
the dissection. Helpful landmarks are the origin of the nerve
root, fat in the axilla, the curvature of the uncovertebral joint,
or extensive venous bleeding from the laterally positioned
veins. Bipolar coagulation and Avitene (Davol, Inc., Cranston,
RI) are used to control these epidural veins. The uncovertebral
joint is best identified at the beginning of the curvature of the
endplate. When the osteophyte is removed, the surgeon al-
ways must bite bone with the Kerrison rongeur, an angled
curette, or both. The surgeon should never bite into “air” for
fear of injuring the vertebral artery.
Neurosurgery, Vol. 49, No. 4, October 2001
Anterior Cervical Discectomy 911
Once decompression of the symptomatic side is completed,
if no fusion is contemplated, the nonsymptomatic side is
treated just as diligently to prevent postoperative radiculop-
athy related to settling (Fig. 7). If fusion is planned, the Smith-
Robinson fusion technique is preferred. Endplates are rough-
ened with the drill, and bone chips and shavings from the
drilling are saved to place into the middle of the fibula au-
tograft. A posterior shelf of bone (1–1.5 mm) is formed by
drilling the inferior vertebral bodies where the shelf is almost
preformed by the curvature of the vertebral body (Fig. 8). If
plating is not planned, a 1-mm anterior shelf is drilled as well
(Fig. 9). Again, the cortical endplate must not be denuded
completely. At this time, a graft is fashioned to fit the in-
terspace. Distraction of the interspace spreader is increased,
and the fibula graft filled with cancellous bone shavings is
tapped gently into the interspace (Fig. 10).
Alternatively, an autograft can be obtained from the iliac
crest. An incision is made 2 cm posterior to the anterior iliac
spine. Soft tissue is dissected down to the iliac crest, and the
periosteum is dissected sharply with a knife or a monopolar
cauterization device. An appropriate-sized tricortical piece of
iliac crest is obtained to fit the interspace. In a patient with a
large iliac crest, a bicortical autograft can be obtained. After
the autograft or allograft is placed, the distracting posts are
removed. If no plating is pursued, the graft should be placed
just below the formed anterior lip. If plating is considered, the
anterior lip is unnecessary, and the graft is tapped flush with
the vertebral bodies. The microscope is then removed from
the surgical field.
When an anterior plate is placed, an appropriate-sized plate
is chosen. The vertebral bodies must be void of osteophytes
and soft tissue before the plate is applied. The two superior
screws should be placed just above the interspace 6 degrees
medially and 12 degrees rostrally, and the inferior screws are
placed 12 degrees caudally and 6 degrees medially. The
screws are fastened to the plate with the appropriate locking
mechanisms.
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 re-
moved 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
FIGURE 7. Axial view of the
operative site after discec-
tomy. The disc space has a
keystone configuration after
the disc and the posterior
longitudinal ligaments have
been resected and the
foramina have been decom-
pressed. (Courtesy, Barrow
Neurological Institute.)
912 Sonntag et al.

FIGURE 10. Sagittal view of

the operative site after disc-
FIGURE 8. A shelf drilled
ectomy or osteophytectomy
along the superior aspect of
and spinal canal decompres-
the inferior vertebral body
sion with fusion. (Courtesy,
prevents retromigration of
the Barrow Neurological
the bone graft. (Courtesy,
Institute.)
Barrow Neurological
Institute.)

days of discharge, patients are seen in the office for a “wound

FIGURE 9. Sagittal view of
the anterior and posterior
vertebral body shelves. Dot-
ted line defines posterior
vertebral body shelf. (Cour-
tesy, Barrow Neurological
Institute.)
is reinforced with Steri-Strips (3M Healthcare, St. Paul, MN)
or Dermabond (Closure Medical Corp., Raleigh, NC).
For patients who undergo a fusion procedure, anterior and
lateral radiographs are obtained in the recovery room to ver-
ify the position of the graft, the plate, and the screws. Patients
without an internal fixation device wear a rigid collar for 4 to
6 weeks. In patients who receive internal fixation and in those
who undergo no fusion, external orthosis is not applied rou-
tinely, except to control pain. Patients are discharged the day
after surgery. A problem with swallowing is the usual reason
why patients are kept longer in the hospital. Within 7 to 10
check.” Flexion-extension radiographs are obtained 6 weeks
after the operation in patients with a fusion construct. If
evidence of fusion is present and there are no signs of
pseudarthrosis, patients are started on exercise therapy at that
time. Patients who do not undergo a fusion procedure can
start exercise 2 to 3 weeks after surgery.
Received, January 24, 2001.
Accepted, April 20, 2001.
Reprint requests: Volker K.H. Sonntag, M.D., c/o Neuroscience Pub-
lications, Barrow Neurological Institute, 350 W. Thomas Road, Phoe-
nix, AZ 85013-4496. Email: neuropub@chw.edu
REFERENCES
1. Cloward RB: The anterior approach for removal of ruptured cer-
vical disks. J Neurosurg 15:602–617, 1958.
2. Golfinos JG, Dickman CA, Zabramski JM, Sonntag VKH, Spetzler
RF: Repair of vertebral artery injury during anterior cervical de-
compression. Spine 19:2552–2556, 1994.
3. Robinson RA, Smith GW: Anterolateral cervical disc removal and
interbody fusion for cervical disc syndrome. Bull John Hopkins
Hosp 96:223–224, 1955.

Instructions for Contributors:

Email Address Needed for All Submissions
In preparation for moving to an online submission and review process and electronic
proofs, we emphasize the following, found in the Instructions for Contributors:

Author Contact Information Page—Include a separate page with the

name, address, telephone and fax numbers, and email address of the
author responsible for correspondence and galley proofs. Clearly indi-
cate if changes of address are anticipated, and include forwarding ad-
dresses. It is the corresponding author’s responsibility to notify the Edi-
torial Office of changes of address.

Thank you for your cooperation in providing us with all of your contact infor-
mation, including your email address.

Neurosurgery, Vol. 49, No. 4, October 2001