Anterior approaches to the cervical spine.

Excellent exposure of the cervical spine from C4 to T1 can be attained with the standard anterior approach which utilizes a longitudinal or transverse incision to gain access to the anterior border of the sternocleidomastoid which, along with the trachea, esophagus, and carotid sheath, is retracted. Blunt dissection anterior to the sheath exposes the prevertebral fascia and the anterior aspect of the spine from C4 to T1. Occasionally surgery in the lower cervical spine necessitates detachment of the sternal head of the sternocleidomastoid. Anterolateral approaches to the upper cervical spine and base of the skull often require partial release of the sternocleidomastoid from the mastoid process and retraction of the carotid sheath and hypoglossal and spinal accessory nerves. If these retropharyngeal approaches do not provide sufficient access to the base of the skull and C1 and C2, a transoral approach, possibly with mandible and tongue splitting, can be useful. Infection is a consideration in transoral surgery, however, and this approach is indicated only in special circumstances.