Anterior Retropharyngeal Approach Research Articles

Anterior retropharyngeal approach (ARPA) for high cervical spine.

One of the major challenges in operating on the spine lies in taking an anterior approach for the high cervical spine. In patients with a short neck, Klippel-Fiel syndrome or when the C3 vertebra is high in relation to the hyoid bone, it will be difficult to access the C3 body. The transoral route is a highly contaminated zone, and therefore, no instrumentation or grafts can be placed through it. The anterior retropharyngeal approach (ARPA) for the high cervical spine. The anterior retropharyngeal approach is an excellent approach for the high cervical spine where instrumentation is needed. This route provides wide exposure of the C1-C3 region, avoiding the contaminated of the oral cavity.

Transcervical, retropharyngeal odontoidectomy - Anatomical considerations.

Anterior craniocervical junction lesions have always been a challenge for neurosurgeons. Presenting with lower cranial nerve dysfunction and symptoms of brainstem compression, decompression is often required. While posterior approaches offer indirect ventral brainstem decompression, direct decompression via odontoidectomy is necessary when they fail. The transoral and endoscopic endonasal approaches have been explored but come with their own limitations and risks. A novel retropharyngeal approach to the cervical spine has shown promising results with reduced complications. This study aims to explore the feasibility and potential advantages of the anterior retropharyngeal approach for accessing the odontoid process. To investigate the anatomical aspects of the anterior retropharyngeal approach, a paramedian skin incision was performed below the submandibular gland on two cadaveric specimens. The subcutaneous tissue followed by the platysma is dissected, and the superficial fascial layer is opened. The plane between the vascular sheath laterally and the pharyngeal structures medially is entered below the branching point of the facial vein and internal jugular vein. After reaching the prevertebral plane, further dissection cranially is done in a blunt fashion below the superior pharyngeal nerve and artery. Various anatomical aspects were highlighted during this approach. The anterior, submandibular retropharyngeal approach to the cervical spine was performed successfully on two cadavers highlighting relevant anatomical structures, including the carotid artery and the glossopharyngeal, hypoglossal, and vagus nerves. This approach offered wide exposure, avoidance of oropharyngeal contamination, and potential benefit in repairing cerebrospinal fluid fistulas. For accessing the craniocervical junction, the anterior retropharyngeal approach is a viable technique that offers many advantages. However, when employing this approach, surgeons must have adequate anatomical knowledge and technical proficiency to ensure better outcomes. Further studies are needed to enhance our anatomical variations understanding and reduce intraoperative risks.

Modified anterior retropharyngeal approach for C2-C3 disc herniation.

C2-C3 disc herniations are rare, but occur more frequent in the elderly population. As the classical anterior Cloward approach to these lesions is not optimal, we propose an alternative modified retropharyngeal approach to these disc herniations that were successfully utilized in two patients. Two patients with C2-C3 disc herniations underwent anterior cervical surgery utilizing the modified retropharyngeal approach. Surgery was successful is two cases with C2-C3 disc herniation and no patient sustained a perioperative complication. Our modified anterior retropharyngeal approach for C2-C3 disc herniations resulted in good outcomes without perioperative complications.

Atlantoaxial Dislocation: Surgical Outcome following Anterior Retropharyngeal Approach to Odontoid with or without Fixation

Abstract Introduction Atlantoaxial dislocation (AAD) refers to a loss of stability between the atlas and axis vertebra. The conventional transoral approach and the anterior retropharyngeal approach (ARPA) are adequate for the upper cervical vertebral segments. This study was undertaken to evaluate the usefulness of the ARPA to the odontoid in patients of AAD. Materials and Methods The study was undertaken on 20 patients admitted in Nil Ratan Sircar Medical College and Hospital, Kolkata, India, with functional disability secondary to AAD. These patients underwent surgery through ARPA to odontoid with or without fixation. Patients were analyzed between October 2014 and September 2016. Results Maximum number of patients belonged to third decade of life. The male to female ratio was 1.5. The mean duration of symptoms was 10.86 months. Weakness of the upper and lower limbs predominated. About 65% patients had axial neck pain. Nine patients (45%) in total had difficulty in either bowel or bladder. Five patients presented with fracture odontoid and pannus formation of the odontoid process, while six had basilar invagination. One patient underwent anterior odontoid screw fixation and the other 19 patients underwent anterior retropharyngeal odontoidectomy with posterior fixation. Two patients expired in the present study. Most of the patients had improvement in Nurick grade during follow-up. Five patients had transient throat pain and dysphagia. Three patients had superficial surgical site infection. One patient had postoperative cerebrospinal fluid leak. Conclusion The ARPA to odontoid is a feasible approach for decompression and fixation of the odontoid in AAD cases.

Surgery for craniovertebral junction pathologies: minimally invasive anterior submandibular retropharyngeal key-hole approach

BackgroundOur objective was to develop a new, minimally invasive surgical technique for the resolution of craniovertebral junction pathologies, which can eliminate the complications of the previous methods, like liquor-leakage, velopharyngeal insufficiency and wound-dehiscence associated with the transoral or lateral approaches.MethodsDuring the first stage of the operation, three patients underwent occipito-cervical dorsal fusion, while the fourth patient received C1–C2 fusion according to Harms. C1–C2 decompressive laminectomy was performed in all four cases. Ventral C1–C2 decompression with microscope assisted minimally invasive anterior submandibular retropharyngeal key-hole approach (MIS ASR) method was performed in the second stage. The MIS ASR—similarly to the traditional anterior retropharyngeal surgery—preserves the hard and soft palates, yet can be performed through a 25 mm wide incision with the use of only one retractor.ResultsThe MIS ASR approach was a success in all four cases, there were no intra- and postoperative complications. This method, compared to the transoral approach, provided on average 23% (4.56 cm2/6.05 cm2) smaller dural decompression area; nonetheless, the entire pathology could be removed in all cases. After the surgery, all patients have shown significant neurological improvement.ConclusionBased on the outcome of these four cases we think that the MIS ASR approach is a safe alternative to the traditional methods while improving patient safety by reducing the risk of complications.

Retropharyngeal approach in cervical disc hernias

Aim: High-level disc hernias are rare pathologies encountered in clinical practice. Treatment is more difficult than other cervical disc hernias. In this study, we aimed to convey our clinical experience in C2-3 and C3-4 disc herniations, also presenting the complications we encountered during surgical treatment. Methods: In this retrospective cohort study, we reviewed the clinical and radiological records of 42 patients we operated between 2010-2019. Magnetic resonance imaging, computed tomography and direct radiographs were utilized as imaging modalities. Anterior retropharyngeal approach was the preferred surgical method. The modified Japanese Orthopedic Association (mJOA) score and Nurick Scale were used in clinical follow-up and physical examination of these patients. Results: Among all patients, the most common symptom was severe pain radiating from the neck to the occipital region. The mean age was 54.14 years. The average mJOA scores were 15.1 in the preoperative period and 17 in the postoperative sixth month. We observed that 83.3% of our patients had an mJOA recovery rate of fifty percent and above. All but seven patients’ complaints improved well after treatment. There was a negative correlation between symptom duration and recovery rate (P=0.003, Correlation Coefficient r=-0.449). The rate of recovery was lower in patients with a longer duration of symptoms. Three of our patients developed difficulty in swallowing after the operation and recovered within four weeks with diet and exercise. Conclusion: We determined that retropharyngeal approach is a safe option for disc hernias at the upper cervical level. However, long operation time and excessive retraction during surgery may lead to complications such as difficulty in swallowing due to the stretching of the neural structures.

Simplified four-step retropharyngeal approach for the upper cervical spine: technical note.

In this paper, we propose a simplified four-step retropharyngeal approach, whose aim is getting straight to the upper cervical spine minimizing complications. While the classical retropharyngeal approach includes about 11 steps, ours is a four-step approach: patient positioning, skin-platysma incision, hyoid bone superolateral dissection and retropharyngeal blunt exposure. We avoid several steps of the classical anterior retropharyngeal approach, particularly dissection of submandibular gland, facial veins, external carotid artery and thyroid artery, bellies of the digastric muscle, hypoglossal nerve, thyrohyoid membrane and the internal branch of superior laryngeal nerve. We have adopted this technique for five patients: two patients had a C2-C3 herniated disk with myelopathy, two patients had unstable Hangman fracture with no bone fusion after 2-month treatment with rigid collar, and one patient had a C2-C3 osteophyte with dysphagia. The intraoperative time needed for reaching the retropharyngeal space was 15 (first case), 9 (second case), 7min (third case-illustrative case-and fourth case), 8min (fifth case). No complications occurred. Our simplification, avoiding several steps, is simple, effective, safe, and rapid and requires a simple learning curve.

Anterior retropharyngeal cage distraction with atlantoaxial plate-screw fixation for basilar invagination with atlantoaxial dislocation

The unilateral submandibular anterior retropharyngeal approach in properly selected patients offers the possibility to expose both atlantoaxial joints adequately, abrade the endplates, and graft the joint spaces. The supine position in extension permits the use of wedge-shaped cages, which reduce the invagination and correct the dislocation. Adequate bone stock is available to rigidly fix the joints using an anterior plate-screw construct without any risk to the vertebral arteries. The approach preserves the posterior tension band and the C2 root. The technique is quick, simple, and safe, and results in solid fusion of the joints over time.The video can be found here: https://youtu.be/tT6j3Czy6tc

The full-endoscopic uniportal technique for decompression of the anterior craniocervical junction using the retropharyngeal approach: an anatomical feasibility study in human cadavers and review of the literature.

Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard-the transoral approach-there is also increasing experience with the endoscopic transnasal technique. Other alternative methods are also being developed to reduce technical and perioperative problems. The aim of this anatomical study was to investigate the feasibility of the full-endoscopic uniportal technique with a retropharyngeal approach for decompression of the craniocervical junction, taking into consideration the specific advantages and disadvantages compared with conventional methods and the currently available data in the literature. Five fresh adult cadavers were operated on. The endoscope used has a shaft cross-section of 6.9 × 5.9 mm and a 25° viewing angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. An anterior retropharyngeal approach was used. The anatomical structures of the anterior craniocervical junction were dissected and the bulbomedullary junction was decompressed. The planned steps of the operation were performed in all cadavers. The retropharyngeal approach allowed the target region to be accessed easily. The anatomical structures of the anterior craniocervical junction could be identified and dissected. The bulbomedullary junction could be adequately decompressed. No resections of the anterior arch of the atlas were necessary in the odontoidectomy. Using the full-endoscopic uniportal technique with an anterior retropharyngeal approach, the craniocervical region can be adequately reached, dissected, and decompressed. This is a minimally invasive technique with the known advantages of an endoscopic procedure under continuous irrigation. The retropharyngeal approach allows direct, sterile access. The instruments are available for clinical use and have been established for years in other operations of the entire spine.

Full-endoscopic uniportal retropharyngeal odontoidectomy for anterior craniocervical infection

Background: Infections of the anterior craniocervical junction may require surgery. There are various techniques with individual advantages and disadvantages. This study evaluates the full-endoscopic uniportal technique via the anterior retropharyngeal approach for odontoidectomy, decompression, and debridement.Material and methods: Three patients with an infection of the anterior craniocervical junction with retrodental involvement were operated on between 2014 and 2016 using the full-endoscopic uniportal technique. Posterior stabilization was also performed with the same procedure for all patients.Results: The operation was technically satisfactory in all cases. No problems due to swelling of the pharyngeal soft tissue occurred. No other complications were observed. All patients had a satisfactory outcome with stable regression of the myelopathy symptoms and/or complete healing of the infection. The follow-up images showed sufficient decompression of bone and soft tissues in all cases.Conclusions: The full-endoscopic uniportal technique with an anterior retropharyngeal approach can be an adequate and minimally invasive surgical technique for odontoidectomy, decompression, and debridement in infections of the craniocervical junction and can reduce access-related problems. The transoral, transnasal, and retropharyngeal approaches have different surgical fields due to the access trajectories, which must be taken into consideration depending on the anatomy and pathology when selecting a suitable technique.

Full-endoscopic Uniportal Odontoidectomy and Decompression of the Anterior Cervicomedullary Junction Using the Retropharyngeal Approach.

A study of a series of consecutive full-endoscopic uniportal decompressions of the anterior craniocervical junction with retropharyngeal approach. The aim of this study was to evaluate the direct anterior decompression of the craniocervical junction in patients with bulbomedullary compression using a full-endoscopic uniportal technique via an anterolateral retropharyngeal approach. Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard - the transoral approach - there is increasing experience with the endoscopic transnasal technique. Other alternative procedures are also being developed. Between 2013 and 2016, eight patients with basilar impression, retrodental pannus, or retrodental infection were operated in the full-endoscopic uniportal technique with a retropharyngeal approach. Anterior decompression of the bulbomedullary junction with odontoidectomy was performed. All patients additionally underwent posterior stabilization. Imaging and clinical data were collected in follow-up examinations for 1 year. The bulbomedullary junction was adequately decompressed. No problems due to swelling of pharyngeal soft tissue occurred. One patient required revision due to secondary bleeding. No other complications were observed. All patients had a good clinical outcome with stable regression of the myelopathy symptoms and/or healing of the infection. The imaging follow-up showed sufficient decompression of bone and soft tissue in all cases. No evidence was found of increasing instability or failure of posterior fusion. In the operated patients, the full-endoscopic uniportal surgical technique with anterior retropharyngeal approach was found to be a sufficient and minimally invasive method with the known advantages of an endoscopic procedure under continuous irrigation. It should not be viewed only as competition for other surgical techniques - due to its individual technical parameters, it can also be considered to be an alternative or complementary procedure. 4.

Anterior retropharyngeal plate screw fixation with bilateral anterior transarticular screws for odontoid fractures ... a new comprehensive technique

Introduction: A certain group of odontoid fractures (Anderson and D’ Alonzo Type-2) are usually offered surgical treatment. Common surgical option is an anterior odontoid screw. Some of the fractures are not suitable for anterior odontoid screw (anterior oblique, displaced distal fragments and those with atlantoaxial instability) and these are usually offered posterior transarticular screws (Magerl’s) or posterior atlantoaxial screw rod/plate fixation (Goel-Harms technique). Posterior surgery involves atlantoaxial fixation with an indirect attempt to reduce and fuse the fracture . Posterior surgery has a risk of injury to the vertebral arteries, hemorrhage from the paravertebral venous plexus and the C2 root ganglion.Methods: A direct anterior submandibular retropharyangeal approach with open reduction and fixation (ORIF) using a customized variable screw placement (VSP) plate was used to realign and fix the fracture fragments in compression mode under direct vision. Twenty patients of type-II odontoid fractures (unsuitable for anterior odontoid screw) underwent an anterior retropharyngeal approach with anterior variable screw position (VSP) plate and screw fixation and eight amongst them, who had associated atlantoaxial instability underwent additional bilateral anterior transarticular screws.Results: All patients treated by this technique had 100% fracture site bone union without any implant failure. Longest follow-up has been for 3 years.Conclusion: Anterior retropharyangeal approach allows direct fracture fragment realignment under vision with an opportunity to fix in compression mode using the VSP plate, which ensures early fusion across the type-II odontoid fracture. Any associated instability can be treated by additional bilateral anterior transarticular screws. The approach is simple and safe without any risk to the vertebral arteries and biomechanically appealing.

Clinical experience of anterior cervical approaches in the treatment of cervical neurogenic tumor of the peripheral nerve

Objective To investigate the clinical effect of using anterior cervical approaches in the treatment of cervical neurogenic tumor of the peripheral nerve from different parts. Methods A retrospective review of 22 cases of cervical neurogenic tumor of peripheral nerves was performed, who were admitted to Department of Neurosurgery, Beijing Friendship Hospital, Capital Medical University from January 2009 to January 2015.All 22 patients underwent microsurgical operations with anterior approach of sternocleidomastoid muscle in 10 cases, posterior approach of sternocleidomastoid muscle in 4 cases, anterior cervical retropharyngeal approach in 3 cases, trans-oral approach in 2 cases, and supraclavicular approach in 3 cases. Results The tumors in all 22 cases were totally resected.No surgical complications such as cerebrospinal fluid leakage were observed except 2 cases which developed hoarseness postoperatively that improved that after neurotrophic treatment. All cases were followed up for 12-84 month with a mean 48.3±18.7 month.Recurrence occurred in 1 case which underwent 2nd operation. Conclusion It seems safe and effective to select appropriate approaches corresponding to various tumor locations in the treatment of cervical neurogenic tumors of peripheral nerves. Key words: Head and neck neoplasm; Neurogenic neoplasms; Microsurgery; Treatment outcome

Anterior Cervical Plating for An Axis Tear Drop Fracture: Case Report

Axis tear drop fractures are infrequent injuries attributed to hyper extension and flexion of neck. In unstable tear drop fractures there will be posterior displacement of vertebral body, anterior longitudinal ligament disruption and anterior rotation of antero-inferior vertebral body fragment. Most of the unstable tear drop fractures are associated with neurological deficit due to incomplete spinal cord injuries like anterior cord syndrome. We present a case of traumatic unstable C2 flexion tear drop fracture without neurological deficit. We have treated the patient successfully with anterior cervical plating and tricortical bone grafting after removal of tear drop fragment and discectomy. This patient was mobilized on next day after surgery and neck mobilization started after 3 weeks. The patient in our study was followed up for 6 years and found to have no sequlae related to the injury. Unstable tear drop fracture needs to be fixed irrespective of the presence or absence of neurological deficit. Open reduction internal fixation with low profile plate and tricortical bone graft, shaped to fit the defect and disc space, through high anterior retropharyngeal approach is a promising treatment for unstable tear drop fractures.

Anterior facetal realignment and distraction for atlanto-axial subluxation with basilar invagination …. a technical note

Unilateral anterior retropharyngeal approach was used in a case of basilar invagination with atlanto-axial instability. This approach provided easy access to both atlanto-axial joints. Wedge-shaped titanium cages were used to distract the joints and reduce the basilar invagination. Titanium plates with screws were used to fix the lateral mass of atlas with the body of axis, bilaterally. The anterior atlanto-axial joint distraction procedure has not been described in literature before seems to be an easy option in selected cases of craniovertebral anomalies and needs to be investigated by more surgeons.

Single-stage Anterior Release and Sequential Posterior Fusion for Irreducible Atlantoaxial Dislocation

A retrospective study. To introduce the method of single-stage anterior release and reduction with posterior fusion in irreducible atlantoaxial dislocation (IAAD) and to evaluate the clinical effects of this surgery. In previous clinical studies, several techniques have been introduced to manage IAAD. But all these treatments have intrinsic disadvantages. A single-stage anterior release and reduction with posterior fusion can offer a new alternative which can avoid these disadvantages. From January 2003 to January 2009, 22 cases of IAAD were diagnosed consecutively. Anterior atlantoaxial release was performed through anterior retropharyngeal approach, after traction reduction conducted on the monitoring of C-arm fluoroscopy. C1-C2 were then fixed posteriorly and fused by single stage. Neurological status was evaluated using the Japanese Orthopaedic Association scoring system. All patients were observed for an average of 32 months, ranging from 15 to 40 months. All cases achieved anatomic reduction and solid fusion. The Japanese Orthopaedic Association score of 12 patients with myelopathy improved from 8.3 to 13.9, 6 months postoperatively, and the mean improving rate was 87.5%. No graft or implant-related complications were observed in any patient during the entire follow-up period. The method of single-stage anterior release and reduction with posterior fusion is an effective method for management of IAAD, proving its value as a technique for achieving complete reduction with solid bony fusion.

Aneurysmal bone cyst of C2 treated with novel anterior reconstruction and stabilization.

Aneurysmal bone cysts (ABC) form 1% of primary bone tumors. Reported incidence rates are no more than 1.4 to 1,00,000. ABC of spine frequently involves posterior elements and commonly affects the lumbar spine (45%). We present a case of C2 ABC for the challenges it poses due to the rarity of the lesion, tedious to access location, dilemmas relating to the suitable approach for tumor resection and technically demanding stabilization and reconstruction strategy post resection. Clinical data analysis was performed to discuss a method of novel anterior column reconstruction following resection of a C2 aneurysmal bone cyst in a 8 year old child with anterior and posterior elements being involved. An 8-year-old girl with an aneurysmal bone cyst of the C2 vertebra underwent staged surgery following pre-operative embolisation. First a posterior approach tumor excision with posterior instrumented fusion was performed. Following which, using a modified anterior retropharyngeal approach anterior tumor excision and fibular graft reconstruction between the C1 lateral mass and C2 body was performed. Complete tumor clearance and stable reconstruction was successfully achieved in our patient. Patient showed excellent clinical outcome with radiological fusion. Preoperative embolisation in the treatment of ABC has supplemental advantage by reducing blood loss. Modified anterior retropharyngeal approach allows satisfactory clearance for C1-2 lesion and fibular strut graft between the C1 lateral mass and C2 body can provide a stable graft placement with good chance of fusion. Instability and spinal deformity, whether preexisting or post-excision, should be corrected with reconstruction and stabilization to offer best chance of cure in such cases.

Anterior Cervical Plating for An Axis Tear Drop Fracture: Case Report

Axis tear drop fractures are infrequent injuries attributed to hyper extension and flexion of neck. In unstable tear drop fractures there will be posterior displacement of vertebral body, anterior longitudinal ligament disruption and anterior rotation of antero-inferior vertebral body fragment. Most of the unstable tear drop fractures are associated with neurological deficit due to incomplete spinal cord injuries like anterior cord syndrome. We present a case of traumatic unstable C2 flexion tear drop fracture without neurological deficit. We have treated the patient successfully with anterior cervical plating and tricortical bone grafting after removal of tear drop fragment and discectomy. This patient was mobilized on next day after surgery and neck mobilization started after 3 weeks. The patient in our study was followed up for 6 years and found to have no sequlae related to the injury. Unstable tear drop fracture needs to be fixed irrespective of the presence or absence of neurological deficit. Open reduction internal fixation with low profile plate and tricortical bone graft, shaped to fit the defect and disc space, through high anterior retropharyngeal approach is a promising treatment for unstable tear drop fractures.

Anterior Retropharyngeal Reduction and Sequential Posterior Fusion for Atlantoaxial Rotatory Fixation With Locked C1-C2 Lateral Facet.

Retrospective case series. To introduce a new type of atlantoaxial rotatory fixation (AARF) with a locked C1-C2 lateral facet and evaluate its therapeutic strategy. AARF presenting with torticollis and limited neck motion is commonly seen in teenagers. Fielding and Hawkins' classification is generally applied to AARF. Although conservative treatment is effective for acute AARF, it is often unsuccessful for chronic AARF, which ultimately requires surgery. We introduce a new type of chronic AARF with a locked C1-C2 lateral facet that does not fit into Fielding and Hawkins' classification and describe the appropriate treatment. Eight patients who had chronic AARF with a unilaterally locked C1-C2 lateral facet were referred to our clinic. Reduction had failed after traction for 3 to 4 weeks. After open release and reduction using the anterior retropharyngeal approach, we applied posterior C1-C2 transpedicular screw fixation with an autologous iliac bone graft for stage I or II. The anterior retropharyngeal approach provided direct access to the C1-C2 locked lateral facet. The patient in an overall poor condition (stage II) underwent delayed posterior C1-C2 arthrodesis. The others (stage I) underwent immediate posterior C1-C2 arthrodesis. All patients were followed up for an average of 14.8 months (5-37 mo). Three-dimensional computed tomography revealed C1-C-2 arthrodesis bone graft fusion after an average of 3.1 months (2-4 mo). There was no recurrence of symptoms and no dislocations or internal fixation device loosening or breakage. AARF with a locked C1-C2 lateral facet is a new type of AARF that cannot be classified using Fielding and Hawkins' classification. The anterior retropharyngeal approach for the release and reduction of AARF, followed by posterior C1-C2 arthrodesis is an effective therapeutic strategy for AARF with a locked C1-C2 lateral facet. 4.

Anatomic considerations of the anterior upper cervical spine during decompression and instrumentation: a cadaveric based study

We evaluated the anatomical considerations specific to the high anterior retropharyngeal approach to the cervical spine. Surgical exposure of the anterior upper cervical spine can sometimes be challenging due to the surrounding neurovascular structures. Using three adult cadavers, we performed high anterior retropharyngeal cervical dissection of the left and right side for a total of six approaches (six sides). During the dissection, all important neurovascular elements were noted and photographed, and anatomical relationships to the spinal vertebral bodies and disc spaces were analyzed. There are certain anatomic considerations that are unique to the high anterior cervical spine. The unique structures include the hypoglossal nerve and the superior thyroid artery/nerve. Only the superior thyroid artery in this region has numerous anatomical variations. Awareness of other structures, including the carotid artery, recurrent laryngeal nerve, and esophagus also remains important. Awareness of the anatomical structures in the anterior upper cervical spine is essential for performing safe anterior upper cervical spinal surgery, avoiding serious complications.