Background. The transverse skin incision for anterior cervical spine surgery is not extensile, thus it must be made at the accurate level. The use of palpable bony landmarks is unreliable due to anatomical variations and pre-operative fluoroscopy to identify the level takes up operating room time, increases the radiation dose to the patient and increases the overall cost of the operation. Objective. To describe a simple, fast and inexpensive method of accurate transverse skin incision placement for anterior cervical spine surgery and to report on its use in 54 consecutive adult patients. Patients and Methods. In each case a ratio was recorded on the lateral cervical spine radiograph based on the distance between the clavicle and mandible and the operative level; this was then applied to measurements on the patient's neck. Results. Procedures performed consisted of a mix of discectomy and fusion, disc replacement and combinations of both. The operative level ranged from C2-C3 to C7-T1, the most common being C5-C6. Twenty-three patients had a single-level, 26 a two level and 5 a three level procedure; all cases were performed through one single transverse incision. Conclusion. We describe the highly successful use of a straightforward method for accurate level transverse skin incision placement for cervical spine surgery In no case was it necessary to radically extend or to make a separate incision. There were no cases where the wrong level was operated on

Introduction: Anterior cervical spine surgeries are associated with high incidence (up to 60%) of early postoperative dysphagia and hoarseness of voice. These symptoms have been attributed to retraction injury on the larynx, trachea and oesophagus. Pressure from retractors producing ischaemia might explain the soft tissues complications following anterior cervical approach. Conventional retractor systems rely on the soft tissues for stability and create a vertical surgical channel but a novel system (Seex retractor) is fixed directly to the spine and rotates to allow an oblique approach. This may reduce retraction pressure by the Seex retractor on tissues This is the first investigation of retraction pressures using any two different retractor systems for anterior cervical spine surgery. The aims of this study were to measure the retraction pressure on the larynx, trachea and oesophagus during the anterior surgical approach to the cervical spine, in cadavers using conventional (Cloward) retractor and Seex retractor and to investigate the effect of flat or curved blades on retraction pressure. Methods: In a cadaveric model, through a standard anteriomedial approach simulated anterior cervical discectomy procedure was performed in cadavers at C3/4, C4/5, C5/6 and C6/7 levels using Cloward retractor with curved blade (Cervical Large Retractor Set. No. C50-1380: Cloward Instrument Corporation), Seex retractor with flat blade and Seex retractor with curved blade (Patent holder Dr. K. Seex, No PCT/AU05/001205). An online pressure transducer (Tekscan pressure measurement system) was applied between the retractor blade and medial tissues. Retraction pressures were recorded for all the retractors at each level on two separate occasions. Average retraction pressure (ARP), average peak retraction pressure (APRP), pressure distribution along the area of retraction, pressure difference at the edge and surface of the retractor blades, pressure variation with flat and curved blades were determined and compared. Results: A total of 40 sets of pressure recordings were made from 5 cadavers. Cloward retractor system generated an ARP of 33 mmHg (range 16 – 66 mmHg). ARP of Seex retractor with curved blade was 20 mmHg (range 9 – 50 mmHg) and that of Seex retractor with flat blade was 25 mmHg (range 10 – 74 mmHg). At one level ARP was same for all the three retractors. At another level ARP was same for Cloward retractor and Seex retractor with flat blade but higher than that of Seex retractor with curved blade. At two other levels Seex retractor with flat blade showed higher ARP than others. At 36 levels Cloward retractor showed highest ARP. This was statistically significant with Pearson’s Chi-square test (X2=10.023, degree of freedom=1, p = 0.0015) and Fisher exact test, p = 0.0005. Cloward retractor system showed an APRP of 124 mmHg (37 – 255 mmHg). While that of the Seex retractor with curved blade was 69 mmHg (14 – 254 mmHg) and that of Seex retractor with flat blade was 94 mmHg (18 – 255 mmHg). Of the 40 sets of the recordings at 32 levels Cloward retractor system generated highest APRP. With the Seex retractor itself flat blade generated more APRP than curved blade in 31 sets of measurements; it was reverse in 3 sets and in 6 sets APRP was same. Only at one level curved blade generated higher ARP than flat blade, at 11 levels it was same. At 28 levels ARP was higher with flat blade. Discussion: Cloward retractor generated significantly high retraction pressure (peak and average contact pressure) than Seex retractor in majority of the cases. Curved blades generate less retraction pressure than the flat ones. Based on these findings a prospective randomised study is underway in live patients

Background:. Cervical spine injured patients often require prolonged ventilatory support due to intercostal paralysis and recurrent chest infections. This may necessitate tracheotomy. Concern exists around increased complications when anterior cervical spine surgery and tracheotomies are performed. Objective:. The primary aim of this study was to evaluate the effect of tracheostomy in anterior cervical surgery patients in term of complications. In addition, the aetiology of trauma and incidence of anterior surgery and ventilation in this patient group was assessed. Methods:. Patients undergoing anterior cervical surgery and requiring ventilation were identified from the unit's prospectively maintained database. These patients were further sub-divided into whether they had a tracheotomy or not. The aetiology of injury and incidence of complications were noted both from the database and a case note review. Results:. Of the 1829 admissions over an 8.5 year period, 444 underwent anterior cervical surgery. Of these 112 required ventilation, and 72 underwent tracheotomy. Motor vehicle accidents, followed by falls, were the most frequent cause of injury. There was a bimodal incidence of tracheostomy insertion; on the day of spine surgery and 6–8 days later. There was no difference in the general complication rate between the two groups. With regards to specific complications attributable to the surgical approach / tracheotomy, there was again no statistically significant difference. The timing of the tracheotomy equally had no effect on complication rate. Although the complications occurred mostly in the formal insertion group as opposed to percutaneous insertion technique, this was most likely due to selection bias. Conclusion:. Anterior cervical surgery and subsequent tracheostomy are safe despite the intuitive concerns. Timing does not affect the incidence of complications and there is no reason to delay the insertion of the tracheotomy. Ventilation in general is associated with increased complications rather the tracheotomy tube