 Today's topic is relatively straightforward I am sure all of you will have certain views on anterior cervical fusion and you are welcome to share your views. So the indications of anterior cervical plate fusion are many, broadly you can classify it into degenerative, neoplastic, traumatic etcetera. One of the controversial indications for doing a anterior cervical plate fusion after a single level disc is there definitely there a single level discectomy a fusion is indicated when there is narrowing of the disc space and the patient has presented with radiculopathy. So if you remove the disc the radiculopathy symptoms are likely to increase the fusion when you insert a graft or a cage into the disc space increases the size of the neural foramine. To my mind I think that would be one of the most logical indications of doing a single level disc with kyphosis is rather unusual in kyphosis what happens is either multilevel degeneration or spinal canal stenosis there you would require when you have a lordosis replaced by kyphosis in the cervical spine you will require a posterior fusion also to restitute the normal angle or curvature of the cervical spine the patient has to be put on traction the normal curvature has to be restituted to a certain degree and then this has to be followed by posterior fusion also in order to maintain the lordotic curve. If the disc space height is maintained if it is a to cause myelopathy it has to be a central disc prolapse not a lateral disc prolapse which causes radiculopathy is not it. So a central disc prolapse again associated with curvature problem or with a narrowing of the disc space you will have to do fusion that is what I believe. Then of course in cervical myelopathy when you do corpectomies one level two level corpectomies then you will have to supplement it with a rib graft if you do not believe in putting an instrumentation inside the corpectomy cavity or with the various cages you have. You have metal cages which are of standard length you have expandable cages now and you have peak cages. So any of these cages can be used but you cannot use that as a standalone method it is not approved to use a cage as a standalone because the chances of cage slippage are quite high. It has to be supplemented with cervical plate fusion again cervical radiculopathy due to osteophytic compression there in order to remove the osteophyte you may have to drill and when you drill to remove the osteophyte it is better to do a fusion procedure. Segmental OPLL with myelopathy again it is after a corpectomy and would necessitate fusion. Cervical vertebral body lesion with collapse compression due to neoplastic lesion like myeloma or tuberculosis causing collapse has to be followed by removal of the lesion and the vertebral body affected followed by cage and the plate fusion. Of course after cervical spine trauma with dysprolapse and instability the instability you will have to do a fusion procedure after dyskectomy. So the concept of anterior cervical plate fusion with fixed angle screws was first introduced by Erwin Morsher. The anterior plate fixation increases the stability of the anterior column following grafting techniques. So this is a method to strengthen the anterior column whichever concept you follow either of Dennis or the other one you strengthen the anterior column it is a semi constrained plate because you are using four screws to fix the plate and in extension it acts as a tension band which is very important to maintain the lordotic curve and as a buttress plate in fixation. So this buttressing action inflection and tension band action in extension these concepts are provided by the natural ligaments which are there and when these are weakened by doing a copectomy it is very important to replace this function with the fusion method. What is the one disadvantage of doing a fusion in the cervical spine? So adjacent segment degeneration because the cervical spine is mobile when you do a fusion procedure the likelihood of developing a secondary degeneration at the upper or lower level is higher. So the indications as explained earlier how to support the anterior column when instability persists particularly when associated with loss of height of a vertebral body following a severe wedge compression fracture following partial or total vertebral excision anterior spinal reconstruction can be done from C2 to T2 you cannot do this at the C1 C2 level or higher and for deformity correction when it is for deformity correction a standalone anterior procedure alone may not work you may have to do a circumferential fusion. So nowadays all of you are very familiar with these screws very angle screws self tapping screws or self drilling screws. So even both the Indian and the western systems have these mechanisms when it was first introduced we needed bicoartical purchase because there was no locking mechanism and the cancellous bone is weak. So if you do a non locking system with only unicoartical purchase that screw will pull out. So you need to have a locking mechanism when you do cortical purchase and locking obviously prevents migration of the screw backwards that is anteriorly you can give compression with this systems now which enhances bony fusion. So you are all familiar with this plate system I will just show a few cases multi level cervical spondylosis with ventral compression this is the CT scan osteophyte compression at this level this is C3 4 level actually C3 4 C4 5 level and C5 level so a 2 level spectromy was done and the fusion with a cage expanding cage the advantage of an expanding cage is you do not have to struggle to measure the gap distance very accurately. You can select roughly approximate one and expanded all these have a ranges how much it can expand part of the system is flush with the cage and with the help of special screw drivers you can expand this to occupy the space and they have teeth which sink into the body above and below to get a good purchase so in spite of that fusion is used. Again cervical rariculopathy here this is a younger patient you have a disc which is lateral how do you treat this what are the problems in this case one you can see that the normal curvature is lost so this patient also had osteophyte so I chose to do in this case copperctomy because both upper level lower level osteophytes were there and when you have osteophytes you have to drill the end plate quite extensively to remove the osteophyte completely and when you drill the end plates if you do a cage fusion the chances of cage sinkage is higher so I chose to do a copperctomy in this case along with peak cage yeah lots of Lordosis is there you can do a posterior approach you can add on a posterior approach to this patient but this patient is very young and came with a rariculopathy alone and in such a situation would you do both anterior and posterior so this patient was also a cricket player and he wanted to continue playing cricketer in extended period of he also had the weakness of the arm preoperatively and with extensive physiotherapies started playing again but I'm not sure whether he'll be back to very aggressive playing two areas where I had found problems is one is dancers I had one or two patients who had cervical disc in them if you do a fusion procedure certain amount of their neck flexibility in dance posture comes down if you do a profusion procedure but if you don't do a fusion procedure their rariculopathy will persist for some more time after doing a discectomy so you're caught between the devil and the deep blue sea anyway if their profession depends on their neck movements it would be preferable to do a lesser procedure and follow it up with a bigger procedure later on this of course is a straightforward indication for a corpectomy and disfusion myloma where the bone is completely destroyed and this was again followed by a corpectomy and fusion when you have lateral disc prolapse with pure radicular symptoms and that too radical a pain not weakness which approach would you prefer anterior or posterior you don't have to take out the disc also when you do a posterior approach you just unroof the neural foram and there and that gives rise to significant relief if there is a lateral disc prolapse I've done both when there is an extruded disc fragment pressing on the nerve laterally you can take it out easily but doing a discectomy from behind is a little difficult aspect and this is already extruded and it came out as a piece that was quite gratifying in this patient you have two adjoining discs which are collapsed here again the lordosis has gone to a certain extent so what I prefer to do in this patient is a single level corpectomy to level discectomy with fusion with rib graft so you have a lot of options you don't always have to use a cage you can just use a rib graft the most common complication reported for an aliac crest graft is severe persistent postoperative pain in that region so all the symptoms of the patient are transferred to the aliac crest graft site so that is the problem with an aliac because it's a trichortical graft the strength of the graft is very good the rib graft is weak but the fusion obtained both with rib graft and aliac crest is both equal so if you compare the postoperative pain the patient has often an aliac crest graft it's preferable to use a rib graft this again a very straightforward indication for fusion traumatic dysprolapse with mild listosis which you can see here the patient had no deficits but again there is no controversy about doing a fusion in such a procedure and this is a expandable cage with corpectomy followed by expandable cage and fusion so the complications are one of complications of approach you can have esophageal injury which should not happen in a routine course especially when you are using retractors with teeth or prongs you have to be very careful that you don't enjoy the esophagus blessed is to enjoy the use a prong without teeth on the esophageal side second is carotid thromboembolism you have to be careful with your lateral retraction of the carotid artery always be mindful of that especially in an older patient you have to be careful that you don't cause a thromboembolism then sympathetic chain injury is a possibility when you go lower down C67 level the chances of causing a recurrent now laryngeal now injury is there so that has to be kept in mind then if you do from the left side there are some who approach a cervical disc from the left side a thoracic duct injuries could be a possible spinal cord injury can be a problem especially when using curets the curets can slip you have to be mindful of that second when you are dealing with OPLL against spinal cord injury can be a problem so there the technique of flotation flotation of the OPLL rather than trying to excise it or drill it up completely from the chord surface so the go to the margins make it float up along with the dura that would be a safer technique to avoid the spinal cord injury and implant failure screw extrusion we discussed about that graft displacement can be a problem again when it's used standalone and failure of bony fusion or osteoporotic spine it can be a problem has anyone used that BMP protein it's supposed to cause severe bone formation like forms a bony tumor kind of mass so you have to be very careful how you use that then this is a problem though whoever has dealt with spine you can come across with this patients will have persistent symptoms are unhappy with the surgery so it's a difficult problem so you have to choose your cases correctly the level should correspond and the lesion which you are operating on should be symptomatic so the careful case selection is important