ACDF (Anterior Cervical Discectomy + Fusion)
Patient phenotype
Cervical radiculopathy or myelopathy from disc herniation, spondylosis. 40s-70s. Often otherwise well; some with significant comorbidities. Myelopathy patients = fall risk, careful positioning.
Procedure
Right or left transverse anterior neck incision. Carotid + jugular retracted laterally, esophagus + trachea medially. Disc removed, interbody graft + plate. ~1-2 hours per level. Supine, head neutral.
Anesthetic plan
GETA with reinforced ETT (avoid kinking with retraction) or standard with confirmation of position post-positioning. Avoid neuromuscular blockade if MEPs/SSEPs needed. Smooth emergence (cervical hematoma risk).
Setup
- ·Standard monitors + temp
- ·1-2 PIVs
- ·A-line if myelopathy + tight cord, or comorbidities
- ·Reinforced ETT or careful taping with extension considered
- ·Neuromonitoring: SSEP, MEP if myelopathy or cord at risk
- ·Forced air warmer
Biggest concerns by phase
Myelopathy → cord at risk during positioning
Severe central canal stenosis + neck extension → cord compression. Awake fiberoptic intubation often used; positioning done with patient awake/cooperative; SSEP baseline before/after positioning. Document neuro pre.
Difficult airway in cervical myelopathy
Reduced neck mobility, sometimes preexisting cord injury. AFOI considered if myelopathic. Otherwise, video laryngoscope + minimal neck movement.
Recurrent laryngeal nerve injury
Retraction or direct injury to RLN → vocal cord paralysis, voice change, aspiration. Right-sided approach has higher RLN risk (more variable course). ETT cuff pressure ≤ 25 cmH₂O (some advocate routine release after retractor placement).
Esophageal injury
Retraction or screw misplacement → esophageal perforation. Rare but devastating (mediastinitis). Watch for postop fever, dysphagia, chest pain.
Neuromonitoring — TIVA or balanced
MEPs need TIVA (propofol + remi) or low-dose volatile (≤ 0.5 MAC). NMB blocks MEP — can use minimal/none after intubation. Sugammadex if rocuronium used.
Smooth emergence + neuro check
Avoid bucking/coughing (hardware stress, hematoma risk). Confirm neuro intact (move all 4) before leaving OR.
Cervical hematoma — airway emergency
Expanding hematoma → tracheal deviation/compression → airway compromise. Recognize early: increasing neck swelling, stridor, dyspnea. Open wound at bedside if airway loss imminent. Reintubation may need fiberoptic + decompression.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
58-yo M with severe cervical myelopathy (Nurick 4), gait imbalance, MRI showing severe C5-6 cord compression. ACDF planned. Plan for airway + intraop?
What an examiner probes for
- ▹Awake fiberoptic intubation + awake positioning
- ▹SSEP/MEP monitoring + TIVA
- ▹Avoidance of NMB after induction
- ▹MAP target for cord perfusion (MAP > 80)
- ▹Postop neuro check + hematoma surveillance
Sources
- Cottrell Neuroanesthesia 6e
- AANS Spine Guidelines
Anatomy reference
Sourced reference images. 4 matches for "cervical vertebra spine neck".
