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Generally, a combined anterior and posterior cervical approach is associated with significant morbidity since it requires an extended operative time, greater intraoperative blood loss, and both anterior- and posterior-related surgical complications. However, there are some instances where a circumferential cervical fusion can be advantageous. Our objective is to discuss the indications for circumferential cervical spine procedures. A narrative review of the literature was performed. We include the indications for circumferential cervical approaches of the senior author (KDR). Indications for circumferential approaches include: (1) high-risk patients for pseudoarthrosis, (2) cervical deformity (e.g. , degenerative, posttraumatic, cervicothoracic kyphosis), (3) cervical spine metastases (especially those with multilevel involvement), (4) cervical spine infection, (5) unstable cervical trauma, (6) movement disorders and cerebral palsy, (7) Multiply operated patient (especially postlaminectomy kyphosis and patients with massive ossification of the posterior longitudinal ligament), and when (8) early fusion is desirable. Circumferential procedures may be useful in many different cervical spine conditions requiring surgery. Despite its advantages, particularly with reducing the risk for pseudarthrosis, the benefits of a combined approach must be weighed against the risks associated with a dual approach. With appropriate preoperative planning, intraoperative decision-making, and surgical techniques, excellent clinical outcomes can be achieved.

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BACKGROUND CONTEXT: Anterior cervical spine surgery is one of the most common spinal procedures performed around the world, but dysphagia is a frequent postoperative complication. Many factors have been associated with an increased risk of swallowing difficulties, including multilevel surgery, revision surgery, and female gender. PURPOSE: The objective of this study was to review and define potential preventative measures that can decrease the incidence of dysphagia after anterior cervical spine surgery. STUDY DESIGN: This was a systematic literature review. METHODS: A systematic review in the Medline database was performed. Articles related to dysphagia after anterior cervical spine surgery and potential preventative measures were included. RESULTS: Twenty articles met all inclusion and exclusion criteria. These articles reported several potential preventative measures to avoid postoperative dysphagia. Preoperative measures include performing tracheal exercises before the surgical procedure. Intraoperative measures can be summarized as avoiding a prolonged operative time and the use of recombinant human bone morphogenetic protein in routine anterior cervical spine surgery, using small and smoother cervical plates, using anchored spacers instead of plates, application of steroid before wound closure, performing arthroplasty instead of anterior cervical fusion for one-level disease, decreasing tracheal cuff pressure during medial retraction, using specific retractors, and changing the dissection plan. CONCLUSIONS: Current literature supports several preventative measures that may decrease the incidence of postoperative dysphagia. Although the evidence is limited and weak, most of these measures did not appear to increase other complications and can be easily incorporated into a surgical practice, especially in patients who are at high risk for postoperative dysphagia.

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OBJETIVO: Estudar os possíveis fatores associados com lesão do NLR após cirurgia de hérnia discal cervical com abordagem anterior. MÉTODOS: No período de junho/2009 a junho/2010, avaliamos 30 pacientes submetidos a tratamento cirúrgico de hérnia discal via anterior no Hospital São Lucas da PUC-RS. No pré-operatório, foi realizada a medida da circunferência cervical (ao nível da cartilagem cricóide) e da altura cervical (do ângulo da mandíbula à borda superior da clavícula). (...). Pacientes que apresentaram resultado anormal na VEL foram considerados com lesão do NLR e submetidos à reavaliação mensal até a recuperação espontânea ou no período máximo de seis meses quando a lesão foi considerada definitiva. RESULTADOS: Encontramos 3/30 (10 por cento) casos de lesões não definitivas do NLR que se recuperaram em até 120 dias pós-operatórios. Os pacientes com lesão do NLR apresentaram uma maior circunferência do pescoço, tempo cirúrgico e número de níveis operados em relação aos pacientes sem lesão do NLR. Também, pacientes com lesão do NLR apresentaram um menor comprimento do pescoço. Duas lesões ocorreram na abordagem pelo lado direito e uma pelo lado esquerdo. Todos os pacientes com lesão tiveram incisão transversa e não fizeram uso de halo craniano. CONCLUSÃO: A abordagem pelo lado direito apresentou maior índice de complicações com o NLR. Apesar de o número limitado de pacientes não permitir conclusões estatisticamente significativas, fatores anatômicos intrínsecos do paciente como pescoço curto e diâmetro do pescoço aumentado, bem como tempo cirúrgico, e dificuldades técnicas que possam aumentar o tempo cirúrgico podem estar associados com lesão do NLR. Novos estudos avaliando as variáveis acima estudadas devem ser considerados.

OBJECTIVE: To study other possible factors associated with RLN injury after anterior approach for treatment of disc herniation. METHODS: Between June 2009 and July 2010, we evaluated 30 patients underwent anterior approach for treatment of disc herniation in Hospital Sao Lucas, PUC-RS. At preoperative period, we evaluated the measure of neck circumference (at the level of the cricoid cartilage) and cervical height (angle of the jaw to the upper edge of the clavicle). At perioperative period, we evaluated the time and difficulty in endotracheal intubation, surgical time, the approach side , the number of levels operated, and the type of incision (transverse / longitudinal) and the use of the cranial halo. (...) Patients who showed injuries were followed monthly until a period of six months when injuries were considered as definitive. RESULTS: We found 3/30 (10 percent) cases of temporary RLN injury which recovered to up to 120 days post operate. Related to patients with no RLN injury, these patients had a neck circumference greater than average, their surgical time was above average, as well the number of levels operated, and the neck length was shorter than average. Two injuries occurred in the approach through the right side and one in the left side. All patients with lesion had a transverse incision and no cranial halo was used. CONCLUSION: The approach from the right side showed a higher rate of complications in the RLN. A significant statistic conclusion was not possible due to the limited patients numbers; however, anatomical factors such as short neck and increased neck diameter, surgical time and other technical difficulties that can increase surgical time may be associated with RLN injury. New studies evaluating these factors must be considered.

OBJETIVO: Estudiar los posibles factores asociados con la lesión del NLR postcirugía de hernia de disco cervical con abordaje anterior. MÉTODOS: En el periodo de Junio/2009 hasta Junio/2010 evaluamos 30 pacientes sometidos a tratamiento quirúrgico de hernia de disco por via anterior en el Hospital São Lucas de la PUC-RS.(...) Se realizó una evaluación videoendoscópica de laringe (VEL), en la búsqueda de lesión del NLR en el preoperatorio y en el décimo dia después de la cirugía. Pacientes que presentaron un resultado anormal de la VEL (asimetría de movimiento de las dobladuras al verbalizar las vocales A, E, I, O y U) fueron considerados con lesión del NLR y fueran reevaluadosmensualmente hasta la recuperación espontánea o en el periodo máximo de 6 meses, cuando la lesión fue considerada definitiva. RESULTADOS: Encontramos 3/30 (10 por ciento) casos de lesiones no definitivas del NLR que se recuperaron en hasta 120 dias postoperatorios. Los pacientes con lesión del NLR presentaban una mayor circunferencia del cuello, tiempo quirúrgico y número de niveles operados con relación a los pacientes sin lesión del NLR. También, pacientes con lesión del NLR presentaban una menor longitud del cuello. Dos lesiones ocurrieron en el abordaje por el lado derecho y una por el lado izquierdo. Todos los pacientes con lesión tuvieron incisión transversal y no hicieron (incisiones) de halo craneano. CONCLUSIÓN: El abordaje por el lado derecho presentó mayor índice de complicaciones con el NLR. A pesar de que el número limitado de pacientes no permite conclusiones estadísticas significativas, factores anatómicos intrínsecos del paciente como cuello corto y diámetro aumentado, bien como tiempo quirúrgico y dificultades técnicas que puedan aumentarlo, pueden estar asociados a lesiones en el NLR. Nuevos estudios evaluando las variables arriba estudiadas deben ser considerados.

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La elevada frecuencia de pacientes con trastornos cervicales, ha llevado a estudiar estas afecciones, cuya diferenciación de otras enfermedades en muchas ocasiones resulta difícil. En la práctica neuroquirúrgica las enfermedades cervicales y degenerativas son unas de las más frecuentes, las hernias de columna cervical representan el segundo lugar de frecuencia de la patología discal. Este trabajo está basado en la revisión de la técnica de artrodesis cervical anterior posdiscectomía y fusión utilizando la cesta roscada de titanio, sin uso de injertos óseos, placas o tornillos, el cual es continuación de una revisión realizada dada la experiencia del autor en el 2004. Se analizan los procedimientos diagnósticos más frecuentemente utilizados y los criterios para la selección del tratamiento quirúrgico. Se presenta la experiencia en 102 casos. Las principales ventajas que ofrece esta técnica son: menor instrumentación; acortamiento del tiempo quirúrgico; estabilización inmediata de la columna cervical con recuperación y deambulación precoz de los pacientes, con retorno precoz a sus actividades normales, con mínimas complicaciones y reducción de costos

Cervical spinal degenerative and discal diseases are among the most common conditions encountered in medical practice. Herniated discs are more common in patients under 40 years of age and degenerative processes are more common after that age. In this study, the most common diagnostic methods and the current criteria for surgical management are reviewed. The author presents his experience of 102 cases with cervical discal and degenerative disease treated by discectomy and fusion through anterior approach, using the titanium cage without use of bone grafts, plates or screws. The main advantages of this technique include shortening of surgical time and fewer instrumentation, immediate stabilization of the cervical spine, early functional recovery and return to normal activities within two weeks with minimal complications, and lower cost

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