Anterior Cervical Corpectomy and Fusion

Indication. Corpectomy is reserved for retrovertebral cord compression — pathology lying behind the vertebral body that cannot be reached and removed through the disc spaces alone. The decision is anatomical: if the compressive lesion spans a vertebral body rather than sitting within a disc space, discectomy will leave residual compression and persistent myelopathy, and corpectomy is required for direct, complete decompression of the cord.

Absolute indications — multilevel retrovertebral cord compression from a large central disc-osteophyte complex that cannot be addressed by discectomy alone; ossification of the posterior longitudinal ligament (OPLL) spanning one or more vertebral bodies with myelopathy; a cervical burst fracture with a retropulsed posterior wall fragment causing cord compression; a primary or metastatic tumour involving the vertebral body with neurological deficit or instability; and pyogenic or tuberculous spondylodiscitis with vertebral body destruction and an abscess causing cord compression. Relative indications — progressive cervical myelopathy with imaging evidence of retrovertebral pathology; a failed anterior cervical discectomy and fusion at an adjacent level with new retrovertebral compression; and a kyphotic deformity secondary to vertebral body collapse requiring anterior column reconstruction. Contraindications. Absolute: active systemic infection unrelated to the spine; severe untreated medical comorbidities precluding anterior cervical surgery; and inability to tolerate prone positioning for supplemental posterior surgery when required. Relative: previous anterior cervical surgery with extensive scarring (consider a posterior or staged approach); isolated radiculopathy without myelopathy (ACDF is usually sufficient); and poor bone quality precluding reliable screw fixation (consider a posterior-only approach). Consent specifically for recurrent laryngeal nerve palsy (hoarseness, 2-5 percent, higher on the right below C6), vertebral artery injury (less than 1 percent but potentially a posterior circulation stroke), dural tear and CSF leak (3-8 percent, higher in OPLL), dysphagia (almost universal in the first week, 5-10 percent persistent beyond 6 weeks), graft or cage dislodgement (3-10 percent, higher in multilevel constructs without posterior support), and pseudarthrosis (5-15 percent, higher in smokers and multilevel constructs). Setup. Supine on a radiolucent table, head neutral or in slight extension, shoulders taped down to clear the lower cervical spine on fluoroscopy, with slight reverse Trendelenburg to reduce venous bleeding. General endotracheal anaesthesia with somatosensory and motor evoked potential monitoring; the tube is taped to the contralateral side and a nasogastric tube may be placed to help identify the oesophagus.

The goal is direct, complete decompression of the cord by removing the vertebral body back to the posterior longitudinal ligament across its full width, then reconstructing the anterior column with a structural strut or cage and an anterior plate. The exposure is the Smith-Robinson approach, laid out in full as the opening steps below — it is the heart of the operation.

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Rehabilitation | Phase | Timing | Collar and activity | Monitoring | |-------|--------|----------------------|------------| | Immediate | Day 0-2 | Soft collar for comfort; drain removed at 24-48 h if output is low; early mobilisation with physiotherapy | Neurological monitoring in recovery and HDU for 24 h; swallow assessment before oral intake if retraction was extensive | | Early | Week 2-6 | Gradual weaning of the collar as pain and swelling subside; active neck range of motion within comfort; progressive upper-limb strengthening; smoking cessation | Serial radiographs at 2 and 6 weeks to assess graft position | | Late | Month 3-12 | Rigid collar or halo for 6-12 weeks in high-risk constructs; return to light work at 6-12 weeks and heavy manual work at 4-6 months | Dynamic radiographs or CT at 3 and 6 months to assess fusion; full fusion expected by 6-12 months | Dysphagia is almost universal in the first week; persistent dysphagia beyond 6 weeks warrants a swallow study and consideration of plate prominence or scar tethering as the cause. Complications

Why corpectomy, not discectomy. Retrovertebral pathology — a large central disc-osteophyte, OPLL, a burst fragment, tumour or infection — lies behind the vertebral body and cannot be reached through the disc spaces alone. Attempting to retrieve it through a discectomy risks incomplete decompression and persistent myelopathy. Corpectomy gives direct visualisation of the entire posterior longitudinal ligament across the affected levels and removes the compressive lesion under vision, which is why it is preferred for focal retrovertebral disease and for restoring lordosis when there is kyphotic collapse. Reconstruction options and outcomes. Structural autograft (fibula or iliac crest) remains the gold standard with fusion rates greater than 90 percent in single-level corpectomy. Expandable cages with osteoinductive packing achieve comparable fusion rates with shorter operative time and no donor-site morbidity. Anterior plating alone is sufficient for one- or two-level corpectomy; three or more levels have higher failure rates without posterior supplementation.

Posterior alternatives. Long-segment congenital or ossified stenosis over many levels without kyphosis can be decompressed posteriorly with laminoplasty or laminectomy and fusion, sparing the morbidity of a long anterior construct. Anterior corpectomy is reserved when the cord is draped over focal anterior pathology, when lordosis must be restored, or when an anterior tumour or infection must be directly excised. Reducing endotracheal cuff pressure after retractor placement is a simple, evidence-supported manoeuvre that lowers the incidence of postoperative laryngeal dysfunction and recurrent laryngeal nerve symptoms in anterior cervical surgery.