Anterior Approach to the Cervical Spine: Elegance Lies in Its Simplicity

Abstract

Introduction: Since the landmark publication by Smith and Robinson, approaches to the cervical spine anteriorly have undergone many modifications and even additions. Nevertheless, at its core, the anterior approach remains an elegant and efficient approach to deal with majority of cervical spine pathologies including the degenerative cervical spine.

Methodology: For this review, we searched for all major cases series and randomized control trials of anterior cervical approaches using the PubMed databases. Articles having the details of clinical variables and outcomes were tabulated and analyzed.

Results: A total of 9 case series for transoral, 7 case series for transmanubrial, 19 case series for anterior cervical discectomy and fusion (ACDF), 6 studies for ACDF versus posterior cervical foraminotomy, 37 case series for ACDF versus arthroplasty, and 7 studies for ACDF versus anterior cervical corpectomy and fusion have been included. The majority of the case series suggested that the anterior cervical procedures have good clinical outcomes. The upper cervical spine approached by the transoral route had good outcomes in ventral compressive pathologies, with morbidity of cerebrospinal fluid leak in 7% of patients. The midcervical spine approached by ACDF had better clinical outcomes equivalent to the majority of modifications even in multiple-level pathologies. The transsternal approach had provided greater access and stability to the cervicothoracic junction with minimal morbidity.

Conclusion: The anterior cervical approach can address the majority of cervical pathologies. They provide adequate corridor from craniovertebral junction to T4 with minimal morbidity, thus providing a good clinical outcome.

Keywords: Anterior cervical approach; cervical spine; cervical spondylotic myelopathy; corpectomy.

Figure 1

PRISMA chart depicting transoral surgeries

Figure 2

PRISMA chart for the case series of anterior cervical discectomy and fusion

Figure 3

PRISMA chart depicting the case series comparing anterior AQ12 cervical discectomy and fusion and anterior cervical corpectomy and fusion

Figure 4

PRISMA chart depicting anterior cervical discectomy and fusion versus anterior cervical disc arthroplasty

Figure 5

PRISMA chart comparing anterior cervical discectomy and fusion versus posterior cervical foraminotomy

Figure 6

PRISMA chart comparing transternal approaches

Figure 7

(a) Magnetic resonance imaging T2-weighted sagittal images showing atlantoaxial dislocation with retroflexed odontoid, causing compression of the cervical cord along with cord signal changes. (b and c) Postoperative sagittal computed tomography and magnetic resonance imaging T2-weighted images showing decompression of the cervical cord with transoral decompression of the odontoid

Figure 8

(a) Magnetic resonance imaging T2-weighted sagittal images showing subluxation of the C5–C6 vertebrae causing compression of the cervical cord along with cord signal changes. (b-d) Postoperative sagittal X-ray, computed tomography, and magnetic resonance imaging T2-weighted images showing decompression and realignment of the cervical cord with fixation using cervical plates and screws

Figure 9

(a) Magnetic resonance imaging T2-weighted sagittal images showing C5–C6 level OPLL with kyphosis causing compression of the cervical cord pronounced at the C6 level. (b) Postoperative sagittal computed tomography images showing decompression and restoration of the cervical lordosis after C6 corpectomy and fixation using cervical plates and screws