Anterior Cervical Discectomy and Fusion
ACDF
The patient is positioned supine, A
roll is placed under the neck to
restore cervical lordosis.
Typical incision for a single- or
two-level discectomy, The
thyroid cartilage can be palpated
at C5; the cricoid cartilage can
be palpated at C6, The most
reliable anatomic landmark is the
carotid tubercle, which can be
palpated at C6.
• After induction of general anesthesia, a bag of intravenous fluid
wrapped in a surgical towel is placed under the neck to restore
lordosis
• The head may be placed on a doughnut
• Esophageal stethoscopes and nasogastric tubes are avoided, since
they can aggravate esophageal injury by retracting against rigid
objects
• Various anatomic landmarks may be palpated to estimate the level of
the disc space
o the hyoid bone is generally at C3
o the thyroid cartilage is at C5
o the cricoid cartilage is at C6
o The carotid tubercle, the most reliable landmark, can be
palpated at C6
• preoperative lateral cervical radiograph may be used to determine
location of the incision
• the ventral neck region is prepped and draped
• The incision for a single- or two-level discectomy generally follows
one of the neck creases
• The incision should extend from midline to the medial border of the
sternocleidomastoid muscle (SCM)
• Oblique incisions along the medial border of the SCM may be used if
access to three or more levels is desired
• The right side is generally preferred for a right-handed surgeon
• There is not an increased incidence of recurrent laryngeal nerve
palsies with a right-sided approach compared with a left-sided
approach.
• the incision is made with a no 10 blade
• Bovie electrocautery or Metzenbaum scissors can be used to traverse
the subcutaneous tissues to access the platysma muscle
• Divide platysma muscle, Undermine it to aid in retraction
• the medial border of the SCM is identified
• A plane is gently developed along the medial border of the SCM
using superficial and sharp dissection
• The carotid sheath is identified, and its contents are retracted
laterally
• the spine is bluntly palpated
• The omohyoid muscle at C5-6 may be divided if necessary to
improve exposure
• The prevertebral fascia is divided in the middle of the vertebral body
and swept off the spine by using a Kittner (Shaver)
• a localizing radiograph is obtained to confirm the level
• Once the level has been determined, optimal exposure is obtained by
cauterizing the edges of the longus colli muscle to gain access to the
uncovertebral joints
Cauterizing the edges of the
longus colli muscle to gain
access to uncovertebral joints
• This also aids in the identification of midline.
• Bovie electrocautery should be used judiciously below C6 to avoid
thermal injury to the recurrent laryngeal nerve
• Don’t attempt to expose to visualize the recurrent laryngeal nerve.
Position of retractor blades
under longus colli muscles,
Longus colli muscles are
undermined and released to
allow adequate retractor
purchase
• Self-retaining retractors are placed, with small teeth under the
medial longus colli muscle
• Larger-toothed retractors can be used, but care should be taken to
ensure that the teeth insert well under the longus colli
• Once the self-retaining retractors have been placed beneath the
longus colli, the surgeon may request the cuff of the endotracheal
tube to be deflated completely and reinflated only to prevent an air
leak
• A Cushing rongeur and a quarter-inch key elevator can be used to
remove ventral osteophytes and to “garden” the vertebral bodies . it
allows further exposes the ventral disc and prepares the vertebrae for
plating
• Caspar pins are placed into the vertebral body, which will allow the
graft to be placed under distraction
• These posts may be angled to reduce a kyphosis
• If radiographs are taken, the length of the distraction pins can be
used as a guide to select the appropriate screw length
"Gardening" with quarter-inch
key elevator to expose bone,
Note that the edges of the
longus colli muscle were
cauterized to allow access to
uncovertebral joints and lateral
disc, staying away from adjacent
disc joints
Placement of distraction pins,
Pins are placed in midline of the
vertebral bodies and may be
angled to reduce a kyphosis,
Distracting the pins allows
access to interspace and allows
graft to be placed under the
distraction, In addition if a
radiographic or fluoroscopy
image is obtained, the pin length
can be used as guide for the
depth of vertebral body to
choose anterior screw length
A no 15 blade is used to incise the
annulus and anterior disc
• using curettes, the disc is removed to the level of the posterior
longitudinal ligament (PLL)
• applying distraction across the disc space
• As the inferior aspect of the vertebral bodies are naturally scalloped,
the ventral lip of the superior vertebral body may be drilled to
improve visualization of the disc space and prepare for graft insertion
• Dorsal osteophytes and end plates may be drilled to access the PLL
• further drilling of the dorsal edge of the caudal vertebra and
undercutting with 3-mm thin-lipped cervical Kerrison rongeurs may
be performed to remove osteophytes
• Lorward- and back-angled curettes may be used to cut the PLL from
bone
• The PLL is thinner laterally and may be easier to open laterally
• The PLL is carefully removed to avoid cerebrospinal fluid leak
• A small burr may be used to drill the lateral inferior uncovertebral
joint
Drilling the ventral lip of the rostral vertebral body, The ventral lip of
the rostral vertebral body is drilled to gain access to the disc space,
This helps to create parallel end plates, improves visualization, and
prepares for graft insertion, It is important to go wide and expose
the uncovertebral joints
• This permits identification of the pedicle and the nerve root, which
is rostral to the pedicle
• Foraminotomies are performed, using a 2-mm Kerrison rongeur
• It is important to stay on bone to avoid epidural veins
• Decompression should extend laterally until direct visualization of
the medial aspect of the nerve root is achieved
• It is important to remove the cartilaginous end plate of both
vertebral bodies and visualize punctate bleeding from the bone to
ensure an optimal environment for arthrodesis
• The goal of graft site preparation in using the allograft is to create a
combination of cancellous and cortical bone by drilling the ventral
caudal edge of the rostral vertebra and dorsal rostral edge of the
caudal vertebral body
• Cortical bone prevents graft subsidence, while the of cancellous bone
enhances fusion
• If bone morphogenetic protein is to be used, on the other hand, it is
vital to preserve the cortical end plate
• Cancellous bone in contact with bone morphogenetic protein (BMP)
may result in osteolysis.
• Struts are typically countersunk 2 to 3 mm below vertebral body
surface
• To check the stability of the graft, an angled curette can be used to
attempt to pull the graft out of the interspace, The angled curette
also may be used to palpate the posterior aspect of the graft to ensure
that the graft does not compress the spinal cord
Anterior Cervical Plating
• The ideal cervical plate allows for an increased loading force to be
applied to the graft, decreased incidence of graft dislodgement, and
effective stabilization of the spine to create an arthrodesis
• Currently, all plating systems have a locking mechanism of some sort
for the screws to prevent backout
• In constrained constructs, fixed-angle screws prevent any motion of
the construct, while semiconstrained devices with a combination of
fixed-angle and variable-angle screws allow for an element of
subsidence of the construct
• Semiconstrained plates may also have a rotational or translational
component, with translation or rotation occurring again at the plate-
screw interface
• Soft tissue and ventral osteophytes should have been adequately
removed to allow the plate to sit evenly on the spine
• Using the Atlantis plate, we typically place fixed screws caudally and
use variable screws rostrally
Plate placement, The shortest plate
is selected, This allows for
placement of either fixed-angle
screws or variable- angle screws
adjacent to strong subchondral
bone
• An appropriately sized plate is
selected
• A plate-holding pin or plate holder
may be placed in any of the rostral
or caudal screw holes to permit
temporary fixation while drilling
and placing screws
• This allows screws to be inserted at a predetermined angle of 12
degrees caudal and 6 degrees medial convergent angles.
• Once the drill guide is seated, the screw hole is drilled by using
either a 13-mm drill bit
• we place uni-cortical screws
• The drilled hole is tapped at the same angle
• In most cases, only the outer cortex requires tapping
• If the screw length is not known at this point, a depth gauge may be
used to verify or select appropriate screw length
• A second screw is placed diagonally from the first screw on the
opposite side of the plate.
• After placement of the first two screws, the plate-holding pin is
removed, and the remaining bone screws are placed after drilling
and tapping
• Final tightening is performed sequentially until the plate evenly and
firmly abuts the surface of the spine
• A drain may be placed, and the platysmal layer is approximated with
resorbable sutures
• Skin closure can be performed by using a subcuticular resorbable
suture