The side of the incision, left or right mainly depends on the surgeons’ preference.
By using a left sided approach the recurrent laryngeal nerve can be avoided.
By using a right sided approach the same nerve can be visualized and protected.
For patients undergoing revision metastatic spine tumor surgery and/or with history of radiation, a head and neck surgeon can help reduce the risk of approach related complications.
The transverse incision is made at the level required. A transverse incision will give a better cosmetic outcome, however, only limited exposure.
If a multilevel fixation is considered, a more longitudinal incision is required.
Injuries of the esophagus can occur as a complication of the approach.
In addition to the tracheotube a nasogastric tube should be inserted to better identify and thus help prevent accidental injury to the esophagus.
These are serious and potentially lethal complications. Consultation with thoracic or ENT surgeons should be obtained.
Platysma muscle is transected in line with the skin incision.
The deep cervical fascia is identified and divided along the anteromedial border of the sternocleidomastoid muscle.
The carotid pulse is palpated and the dissection is directed medial to the carotid sheath.
A finger is then used for blunt dissection between the carotid sheath laterally and trachea and esophagus medially down to the prevertebral fascia.
Note: In case of carotid artery injury direct pressure should be applied and vascular surgery consultation requested urgently.
The recurrent laryngeal nerve is identified and protected.
The prevertebral fascia is cut longitudinally allowing direct visualization of the vertebra and the longus colli muscle.
The level is verified with fluoroscopy. The longus coli muscle is mobilized and retractors are placed.
The platysma muscle is sutured followed by a subcutaneous and skin closure.
A wound drain is inserted through a separate stab incision.