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Chapter Summary
• Context: Anterior cervical fixation techniques constitute the cornerstone of subaxial cervical spine reconstruction for degenerative disc disease, compressive myelopathy, traumatic fracture-dislocations, tumors, and cervical deformity. Pioneered by Smith-Robinson and Cloward for discectomy and fusion, the field was revolutionized by the introduction of anterior cervical plating (Caspar, Morscher) and modern dynamic, constrained, and semi-constrained anterior locking plate systems. Furthermore, multi-level anterior cervical corpectomy and fusion (ACCF) expanded access to retrovertebral compressive pathologies, supported by expandable or static titanium mesh and PEEK cages. In recent years, zero-profile integrated stand-alone interbody cages with integrated anchoring screws or blades have emerged to minimize postoperative dysphagia by eliminating bulky anterior plate profiles. Achieving high fusion rates and lordosis restoration while avoiding devastating complications requires meticulous prevertebral dissection, respect for visceral and neurovascular borders, thorough endplate preparation, and appropriate plate construct selection.
• Chapter Objective: Detail the anatomical, biomechanical, and surgical foundations of anterior cervical fixation techniques (ACDF, ACCF, plating systems, and stand-alone integrated cages). The reader will master the Smith-Robinson retropharyngeal approach, endplate preparation, implant selection, lordosis restoration, and the prevention and management of complications including dysphagia, esophageal perforation, hardware loosening, and pseudarthrosis.
• Anatomical access: The Smith-Robinson approachThe anterior cervical approach utilizes the natural fascial cleavage plane between the sternocleidomastoid muscle and carotid sheath laterally, and the strap muscles, trachea, and esophagus medially (Figure 75.1). Longus colli muscle subperiosteal elevation establishes safe bilateral exposure while protecting the sympathetic trunk and vertebral arteries.
• Anterior Cervical Discectomy and Fusion (ACDF)ACDF directly decompresses disc herniations and osteophytes under microscopic visualization. The posterior longitudinal ligament (PLL) and uncocervical joints are resected when necessary to decompress the spinal cord and exiting nerve roots. Interbody cages (PEEK, 3D porous titanium) packed with autograft/allograft restore disc height, foraminal dimensions, and segmental lordosis.
• Anterior Cervical Corpectomy and Fusion (ACCF)Indicated for multi-level retrovertebral compressive pathology, severe trauma with burst fracture, and cervical tumors. A 1- or 2-level corpectomy is performed between the medial borders of both uncinate processes (15–18 mm width). Reconstruction utilizes structural strut grafts, static titanium mesh, or expandable corpectomy cages combined with long anterior cervical plate fixation.
• Anterior plating vs Zero-profile stand-alone devicesAnterior cervical plates (rigid, semi-constrained, dynamic) provide immediate mechanical stability, prevent graft extrusion, and accelerate fusion. Zero-profile stand-alone cages with integrated locking screws or blades fit entirely within the intervertebral disc space, reducing soft-tissue friction against the esophagus and significantly lowering the incidence of postoperative dysphagia.
• Complications and preventionComplications include dysphagia, esophageal or pharyngeal perforation, recurrent laryngeal nerve palsy, Horner syndrome (cervical sympathetic chain injury), vertebral artery laceration, graft subsidence, and pseudarthrosis. Gentle blunt retractor placement, endotracheal cuff pressure monitoring, and proper plate sizing minimize these risks.
• Clinical Application: In clinical practice, anterior cervical fixation is the primary choice for single- and multi-level ventral cord compression with lordotic or reducible alignment. Preoperative MRI and CT assess the location and extent of compressive pathology, disc height, and uncinate anatomy. During the Smith-Robinson approach, medial visceral retraction should be intermittent and gentle, and the endotracheal cuff deflated and reinflated to 20 cm H2O after retractor placement to reduce recurrent laryngeal nerve ischemia. During discectomy and corpectomy, drilling must never stray lateral to the uncinate process line to safeguard the vertebral arteries. When placing anterior plates, the plate must be contoured to the patient's physiological cervical lordosis and keep at least 5 mm distance from adjacent unfused disc spaces to prevent adjacent segment ossification (ALOD).
