Less exposure surgery for multilevel anterior cervical fusion using 2 transverse incisions

Technical note

Restricted access

Multilevel anterior cervical fusion often necessitates a large extensile incision for exposure and substantial retraction of the esophagus for placing long plates, potentially predisposing patients to complications such as dysphagia, dysphonia, and neurovascular injury. To the authors' knowledge, the use of 2 incisions as an option has not been published, and so it is not intuitive to young surgeons or widely practiced. In this report, the authors discuss the advantages and raise awareness of using 2 incisions for multilevel anterior cervical fusion, and they document a safe skin bridge length. They also describe the advantages of using 2 incisions for performing multilevel anterior cervical fusion either at contiguous or noncontiguous levels as in adjacent-segment disease. By using the 2-incision technique, the authors made the surgery technically easier and diminished the amount of esophageal retraction otherwise needed through 1 long transverse or longitudinal incision. A skin bridge of 3 cm was safe.

Abbreviation used in this paper:ACDF = anterior cervical discectomy and fusion.

Article Information

Current affiliation for Dr. Ricchetti: Cleveland Clinic, Cleveland, Ohio.

Address correspondence to: Kingsley R. Chin, M.D., 1100 West Oakland Park Boulevard, Suite 3, Fort Lauderdale, Florida 33480. email: kingsleychin@gmail.com.

Please include this information when citing this paper: published online July 6, 2012; DOI: 10.3171/2012.5.SPINE111112.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Case 1. Lateral plain radiograph of the cervical spine demonstrating a C4–6 fusion with adjacent-segment disease at C3–4 and C6–7.

  • View in gallery

    Case 1. Intraoperative photographs of the planned anterior incisions. The skin bridge measured 3 cm between the 2 incisions.

  • View in gallery

    Case 1. Six-week postoperative lateral plain radiograph of the cervical spine showing fusion from C-3 to C-7.

  • View in gallery

    Case 2. Sagittal reconstructed CT scans of the cervical spine demonstrating degenerative disc disease at C3–4, with severe degeneration and kyphosis at C6–7 in a patient after laminectomies at C3–6.

  • View in gallery

    Case 2. Postoperative lateral radiograph of the cervical spine showing fusion at C3–4 with anterior plating, and posterior instrumented fusion from C-3 to T-3 using C3–5 lateral mass screws and C7–T3 pedicle screws (not clearly visualized).

  • View in gallery

    Intraoperative image showing a 3-level ACDF performed with the 2-incision technique. Using this approach, both ends of the anterior cervical plate are well visualized simultaneously to ensure correct placement.


  • 1

    Albert TJMurrell SE: Surgical management of cervical radiculopathy. J Am Acad Orthop Surg 7:3683761999

  • 2

    Auerbach JDJones KJFras CIBalderston JRRushton SAChin KR: The prevalence of indications and contraindications to cervical total disc replacement. Spine J 8:7117162008

  • 3

    Berger RA: The technique of minimally invasive total hip arthroplasty using the two-incision approach. Instr Course Lect 53:1491552004

  • 4

    Berger RA: Total hip arthroplasty using the minimally invasive two-incision approach. Clin Orthop Relat Res 417:2322412003

  • 5

    Berger RADuwelius PJ: The two-incision minimally invasive total hip arthroplasty: technique and results. Orthop Clin North Am 35:1631722004

  • 6

    Bohlman HHEmery SEGoodfellow DBJones PK: Robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. Long-term follow-up of one hundred and twenty-two patients. J Bone Joint Surg Am 75:129813071993

  • 7

    Chin KRAhn J: Controlled cervical extension osteotomy for ankylosing spondylitis utilizing the Jackson operating table: technical note. Spine (Phila Pa 1976) 32:192619292007

  • 8

    Chin KRAuerbach JDAdams SB JrSodl JFRiew KD: Mastication causing segmental spinal motion in common cervical orthoses. Spine (Phila Pa 1976) 31:4304342006

  • 9

    Chin KREiszner JRAdams SB Jr: Role of plate thickness as a cause of dysphagia after anterior cervical fusion. Spine (Phila Pa 1976) 32:258525902007

  • 10

    Duwelius PJ: Two-incision minimally invasive total hip arthroplasty: techniques and results to date. Instr Course Lect 55:2152222006

  • 11

    Emery SE: Cervical spondylotic myelopathy: diagnosis and treatment. J Am Acad Orthop Surg 9:3763882001

  • 12

    Emery SEBohlman HHBolesta MJJones PK: Anterior cervical decompression and arthrodesis for the treatment of cervical spondylotic myelopathy. Two to seventeen-year follow-up. J Bone Joint Surg Am 80:9419511998

  • 13

    Holly LTMoftakhar PKhoo LTWang JCShamie N: Minimally invasive 2-level posterior cervical foraminotomy: preliminary clinical results. J Spinal Disord Tech 20:20242007

  • 14

    Riew KDCheng IPimenta LTaylor B: Posterior cervical spine surgery for radiculopathy. Neurosurgery 60:1 Suppl 1S57S632007

  • 15

    Santiago PFessler RG: Minimally invasive surgery for the management of cervical spondylosis. Neurosurgery 60:1 Suppl 1S160S1652007

  • 16

    Sehati NKhoo LT: Minimally invasive posterior cervical arthrodesis and fixation. Neurosurg Clin N Am 17:4294402006

  • 17

    Song JKChristie SD: Minimally invasive cervical stenosis decompression. Neurosurg Clin N Am 17:4234282006




All Time Past Year Past 30 Days
Abstract Views 120 120 13
Full Text Views 106 106 1
PDF Downloads 194 194 1
EPUB Downloads 0 0 0


Google Scholar