Overview
The choice of approach should be dictated by the site of the primary pathology (Campbell). The posterior midline approach gives access to the spinous processes, laminae and facets at all levels and allows wide decompression of the canal and many fusion techniques. Posterior approaches are rarely indicated when the anterior column is the site of infection or metastatic disease: the posterior elements are usually uninvolved and provide stability, and removing them (laminectomy) may cause subluxation, dislocation or angulation and worsen neurologic deficit (Campbell). The middle and lower cervical spine is most commonly exposed anteriorly, medial to the carotid sheath (Campbell).
Anterior Approach to the Middle and Lower Cervical Spine (C3-C7)
Planning (Campbell)
Skeletal traction is suggested; spinal cord monitoring at the surgeon's discretion.
Incision: transverse for one- and two-level procedures, longitudinal for three or more levels. In multilevel procedures center the incision over the middle disc or vertebral body of the construct.
Level: about three to four fingerbreadths above the clavicle for C3-5, two to three fingerbreadths for C5-7; alternatively estimate from the lateral radiograph. C2-3 can occasionally be reached in long, thin necks when a line through the C2-3 disc passes below the mandibular angle.
Side: the authors choose by surgeon handedness. The right recurrent laryngeal nerve has a shorter, more lateral course (passing under the subclavian artery) and is vulnerable if the inferior thyroid vessels are not ligated laterally or retraction is not intermittent; the left nerve ascends more vertically in the tracheoesophageal groove. A lower injury rate with a left-sided approach has not been proven.
Vocal cord paralysis from recurrent laryngeal nerve injury is the most frequent complication of this approach.
Technique 44.8 (Southwick and Robinson) (Campbell)
Center a transverse incision over the medial border of the sternocleidomastoid; infiltrate skin and subcutaneous tissue with 1:500,000 epinephrine for hemostasis.
Incise the platysma in line with the skin incision, or vertically for more exposure.
Identify the anterior border of the sternocleidomastoid, incise the superficial layer of the deep cervical fascia longitudinally and palpate the carotid pulse.
Carefully divide the middle layer of the deep cervical fascia enclosing the omohyoid, medial to the carotid sheath.
Retract the sternocleidomastoid and carotid sheath laterally and palpate the anterior spine. Identify the esophagus behind the trachea and retract the trachea, esophagus and thyroid medially.
Bluntly divide the deep layers (pretracheal and prevertebral fascia) over the longus colli.
Reflect the longus colli subperiosteally from the anterior spine laterally to the level of the uncovertebral joints; this exposure is sufficient for wide debridement and grafting.
Close over a drain to prevent hematoma and possible airway obstruction.
Approximate the platysma and skin.
Anterolateral approach (C2-C7) (Campbell)
Passes between the sternocleidomastoid and the internal jugular vein, exposing the transverse processes and vertebral artery for an oblique (wedge) corpectomy without grafting in unilateral myeloradiculopathy without instability, mainly in elderly patients and smokers.
Risks: vertebral artery and veins, cranial nerve XI and the sympathetic chain (Horner syndrome in up to 4%). The sympathetic chain lies on average 11.6 mm from the medial border of the longus colli and is most at risk when the longus colli is sectioned transversely.
Posterior Approach to the Upper Cervical Spine (Occiput to C2)
Technique 44.23 (Campbell)
Position prone on a turning frame with skeletal tongs, avoiding pressure on the eyes, or use a three-point head holder.
Secure drapes to the neck with stay sutures or staples.
Make a midline longitudinal incision from the occiput to C2; infiltrate with 1:500,000 epinephrine.
Expose the posterior elements subperiosteally with electrocautery and elevators; insert self-retaining retractors.
Deepen the incision through the thin white median raphe to avoid cutting muscle; the raphe wanders and does not follow a straight line. In children, do not expose unnecessary levels (including the occiput) to avoid spontaneous fusion.
Do not dissect more than 1.5 cm lateral on either side of the midline at C1, to protect the vertebral arteries.
Expose the occiput and the spinous process of C2; the C1 ring lies deep between them.
Identify the posterior tubercle of C1 and begin subperiosteal dissection. The ring is often thin; pressure can fracture it or the instrument can slip through the atlanto-occipital membrane. The dura is vulnerable at the superior and inferior edges of the ring.
The second cervical ganglion lies about 1.5 cm lateral on the C1 lamina in the vertebral artery groove; there is little indication for dissection lateral to this groove.
Penetrating the atlanto-occipital membrane at the superior border of C1 lateral to 1.5 cm risks the vertebral artery.
Below C2, the lateral margins of the facet joints are the safe lateral limit.
Perform the intended procedure and close in layers over a drain.
Anatomic study (Gupta): at least 1.5 cm of the C1 posterior arch can be exposed safely without mobilizing the vertebral artery; mobilization gives another 10 mm in either direction (Campbell).
Posterior Approach to the Middle and Lower Cervical Spine (C3-C7)
Technique 44.24 (Campbell)
Position prone with tongs or a three-point head fixation device attached to the table.
Palpate the prominent C2 and C7 spinous processes; check preoperative radiographs for posterior element deficiencies such as occult spina bifida.
Make a midline incision over the appropriate vertebrae and infiltrate with 1:500,000 epinephrine.
Deepen in the midline with electrocautery, staying within the median raphe (nuchal ligament) to avoid the vascular muscle; keep the tissues under tension with self-retaining retractors.
Detach ligamentous attachments and expose the posterior elements subperiosteally to the lateral edge of the facet joints, the lateral limit of dissection.
Pack each level with a taped sponge to reduce blood loss.
Expose the spinous processes distal to proximal: muscles strip cleanly in the acute angle between their insertions and bone, whereas dissection in the opposite direction follows the fibers into muscle and increases bleeding.
Posterior Approach to the Thoracic Spine (T1-T12)
Technique 44.25 (Campbell)
Position prone on a padded spinal frame.
Make a long midline incision; infiltrate skin, subcutaneous tissue and erector spinae down to the laminae with 1:500,000 epinephrine.
Deepen through the superficial and lumbodorsal fasciae to the tips of the spinous processes.
Reflect the erector spinae subperiosteally, distal to proximal, to the tips of the transverse processes.
Repeat for the desired levels and on both sides if needed.
Pack each segment with a taped sponge immediately after exposure.
Obtain a radiograph to confirm the level.
Close in layers over a suction drain.
Costotransversectomy (Technique 44.26) (Campbell)
Indicated for biopsy or local debridement; it gives direct access to transverse processes and pedicles and limited access to the vertebral bodies.
Make a straight longitudinal incision about 6 cm lateral to the spinous processes (or a curved incision with its apex lateral), over the groove between the paraspinal mass and the rib angle.
Divide the trapezius, latissimus dorsi and lumbodorsal fascia longitudinally; detach the paraspinal muscles from the ribs and transverse processes and retract them medially.
Expose the transverse process and posterior rib subperiosteally; resect 5-7.5 cm of rib, usually transected about 9 cm lateral to the vertebra at its angle.
Stay subperiosteal and extrapleural and protect the intercostal neurovascular bundle; the nerve roots exit at the superior part of the foramina.
Follow the pedicle anteriorly to the vertebral body and elevate the parietal pleura and sympathetic trunk to expose the anterolateral body; widen by removing the transverse process, pedicle and facet as needed.
Fill the wound with saline and inflate the lungs to check for air leaks; close over a drain and obtain a chest radiograph to exclude pneumothorax.
Posterior Approach to the Lumbar and Lumbosacral Spine
Technique 44.27: Midline approach, L1 to sacrum (Campbell)
Position prone or kneeling on a padded frame with the abdomen hanging free: lower intra-abdominal pressure collapses the epidural venous plexus and reduces bleeding.
Make a midline incision over the involved segments and infiltrate with 1:500,000 epinephrine.
Divide skin, subcutaneous tissue and lumbodorsal fascia in the midline to the tips of the spinous processes; keep tension with self-retaining retractors.
Expose the posterior elements subperiosteally, distal to proximal, with electrocautery and elevators.
Pack each segment with a taped sponge.
Repeat on the opposite side if needed.
Confirm the level with a permanent intraoperative radiograph.
Close in layers over a drain.
Technique 44.29 (Wagoner) (Campbell)
Incise the supraspinous ligament precisely over the tips of the spinous processes and strip the muscles subperiosteally from the lateral surface of each process, distal to proximal, using a blunt elevator placed at the junction of the spinous process and lamina. Staying on bone keeps the dissection in a relatively avascular field away from the internal muscular arterial branches.
Technique 44.28: Paraspinal approach (Wiltse and Spencer) (Campbell)
Useful for far-lateral disc herniation, "far out" syndrome and pedicle screw insertion.
Position prone or kneeling with the abdomen free.
Make a midline skin incision centered over the involved lower lumbar segment; infiltrate with epinephrine.
Retract skin and subcutaneous tissue laterally to the lumbodorsal fascia.
Incise the fascia about 2 cm lateral to the midline.
Enter the natural cleavage plane between the multifidus and longissimus; with blunt finger dissection palpate the facet joints (L4-5) and insert Gelpi retractors.
Separate the transverse fibers of the multifidus from their fascial attachments.
Expose the transverse processes, facets and laminae subperiosteally. Do not dissect anterior to the transverse processes, where the exiting spinal nerves lie.
Control bleeding from the lumbar vessels at the base of the transverse processes with bipolar cautery.
Perform unilateral or bilateral decompression and fusion.
Close over a suction drain and suture the skin flaps to the fascia to eliminate dead space.
Minimally Invasive Posterior Approaches (Campbell)
Any posterior approach can be performed through dilators and a tubular retractor when only a limited field (lateral recess, canal, foramen) is needed.
Incision placement is critical: a 2-cm error with a 20-mm retractor is a 100% error. Planning from MRI/CT and fluoroscopic localization is mandatory.
Pitfalls
Wrong-level surgery: always confirm the level radiographically (Campbell).
Lateral dissection beyond 1.5 cm at C1 endangers the vertebral artery (Campbell).
Dissecting proximal to distal along the spinous processes increases muscle bleeding (Campbell).
Dissection anterior to the lumbar transverse processes endangers the exiting nerves (Campbell).
Hematoma after anterior cervical surgery can obstruct the airway; use a drain (Campbell).
References
Campion CE. Approaches to the cervical, thoracic, and lumbar spine. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 44, Techniques 44.8, 44.9, 44.23-44.29.