What considerations regarding patient positioning setup and surgical technique are important when performing a cervical TDR compared with an anterior cervical discectomy and fusion ACDF

Patient positioning for ACDF and cervical TDR is identical with the exception of routine use of the C-arm for a cervical TDR. One may consider turning the operating room table 180° to facilitate use of the C-arm and navigation around anesthesia equipment and personnel. Using cloth tape to pull the shoulders inferiorly is particularly important to allow for adequate visualization of the lower cervical levels, particularly at the C6-C7 level. Prior to prepping, it is important to check that the operative level is easily visualized using the C-arm. One should always be prepared to convert the procedure to an ACDF. The position of the neck should be similar to the preoperative neutral lateral radiograph and remain fixed throughout the procedure to avoid improper sagittal alignment of the spine.

Figure 71-5. A and B, The ProDisc-C artificial disc (Synthes Spine). (From Slipman CW, Derby R, Simeone FA, et al. Interventional Spine: An Algorithmic Approach. Edinburgh: Saunders; 2007.)

Fluoroscopy may be used to select the appropriate incision location. The surgical approach is identical to an ACDF. However, because a plate is not used, less of each vertebral body needs to be exposed and dissection can be limited to the disc space itself. It is critical that the midline is established early in the procedure using the uncovertebral joints, as well as with fluoroscopy. It is critical to ensure that the head is positioned straight up and down and that the fluoroscopic views obtained are true AP and lateral views of the cervical spine. Once midline is established and dissection of the uncovertebral joints is completed, distraction pins are placed in the midline. Distraction pins are typically placed under fluoroscopic guidance on the lateral view. It is critical that the pins are placed at the center of the vertebral body and parallel to the disc at the operative level because parallel distraction is important for appropriate placement of the cervical TDR. Complete discectomy and foraminotomy with removal of all osteophytes is critical prior to prosthesis insertion.

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