Nerve injuries in cervical spine surgery via anterior approach: a comprehensive review
Review Article

Nerve injuries in cervical spine surgery via anterior approach: a comprehensive review

Sazid Hasan1, Neal Farmer1, Isaac Arefi1, Mackenzie Hagood1, Pranav Gadangi1, Haytham Alqasmi2, Muhammad Waheed2, Abdul-Lateef Shafau2, Yasser Abusabha1, Ehab Saleh3, Jad Khalil3, Hossein Elgafy1

1Department of Orthopaedic Surgery, University of Toledo, Toledo, OH, USA; 2Department of Orthopaedic Surgery, Detroit Medical Center, Detroit, MI, USA; 3Department of Orthopaedic Surgery, Beaumont Hospital Royal Oak, Royal Oak, MI, USA

Contributions: (I) Conception and design: S Hasan, P Gadangi; (II) Administrative support: E Saleh, J Khalil, H Elgafy; (III) Provision of study materials or patients: E Saleh, J Khalil, H Elgafy; (IV) Collection and assembly of data: N Farmer, I Arefi, M Hagood, P Gadangi, H Alqasmi, M Waheed, AL Shafau, Y Abusabha; (V) Data analysis and interpretation: N Farmer, I Arefi, M Hagood, P Gadangi, H Alqasmi, M Waheed, AL Shafau, Y Abusabha; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Sazid Hasan, MD. Department of Orthopaedic Surgery, University of Toledo, 3065 Arlington Ave, Toledo, OH 43614, USA. Email: sazhasan01@gmail.com.

Abstract: Anterior cervical spine surgery is widely performed to manage degenerative, traumatic, and compressive spinal conditions. Despite its effectiveness, iatrogenic nerve injuries remain a significant concern due to the complex anatomy of the cervical region. This review offers a focused narrative on nerve injuries associated with anterior cervical approaches, including recurrent and superior laryngeal nerve palsy, C5 nerve root palsy, and hypoglossal nerve injury. Less common complications such as Parsonage-Turner syndrome (PTS), C8–T1 radiculopathy, and Horner’s syndrome are also addressed. Each injury is discussed in terms of anatomical relevance, incidence, clinical features, diagnosis, and strategies for prevention and management. A structured review of PubMed-indexed literature from the past 25 years was conducted to ensure the inclusion of current evidence. Risk factors such as multilevel surgery, revision procedures, and excessive retraction are highlighted. While many nerve injuries are self-limited, a subset may result in long-term deficits, reinforcing the need for meticulous surgical planning and intraoperative care. By increasing awareness of these complications, this review aims to inform surgical technique and reduce morbidity in anterior cervical spine surgery. This review emphasizes not only the incidence and anatomical relevance of these complications, but also underscores the importance of preventive measures such as careful retraction, intraoperative neuromonitoring, and preoperative planning. By synthesizing data across multiple studies and including rare complications such as Horner’s syndrome and PTS, this review provides a practical reference for surgeons aiming to reduce morbidity. Ultimately, the goal is to improve surgical safety and patient quality of life through heightened awareness and refinement of technique.

Keywords: Postoperative complications; anterior approach; nerve injuries; injury prevention

Submitted Mar 29, 2025. Accepted for publication Aug 15, 2025. Published online Dec 22, 2025.

doi: 10.21037/jss-25-53

Introduction

Cervical spine surgery is performed to address various pathologies, including degenerative disc disease, spinal stenosis, herniated discs, infection, tumor, and traumatic injuries. These procedures typically involve anterior, posterior, or combined approaches to decompress neural structures, stabilize vertebrae, or realign spinal deformities. Among the most common procedures for cervical spine surgery are anterior cervical discectomy and fusion (ACDF), cervical corpectomy, and posterior cervical decompression and fusion. While outcomes overall improved due to advances in surgical techniques, instrumentation, and minimally invasive methods, postoperative complications, particularly nerve injuries, remain a concern (1).

Nerve injuries following cervical spine surgery can lead to significant morbidity, including motor, sensory, and vocal deficits. The close anatomical relationship of the cervical spine to critical neural structures makes patients vulnerable to nerve injuries (2). These injuries, although often temporary, can profoundly impact on the patient’s quality of life. For example, vocal cord paralysis from recurrent laryngeal nerve (RLN) injury can result in permanent voice changes (3).

Surgeons need to understand the etiology, clinical presentation, and recovery potential of these nerve injuries. Furthermore, identifying and implementing preventive measures can significantly reduce the incidence of nerve damage. This review aims to provide a comprehensive overview of the most common nerve injuries associated with anterior cervical spine surgery, including their anatomy, incidence, diagnosis, recovery patterns, and preventive strategies in an effort to minimize associated nerve injury complications.

Methods

An advanced search of PubMed-indexed articles was conducted using variable search terms including: nerve, nerve injuries, cervical spine, surgery, anterior, anterior approach, posterior, anatomy, RLN palsy, C5 nerve root palsy, superior laryngeal nerve (SLN) palsy, hypoglossal nerve palsy, complications within the past 25 years.

Anatomy of the cervical spine

The cervical spine comprises seven vertebrae, labeled C1 through C7, which play a crucial role in supporting the head, facilitating head and neck movement, and protecting the spinal cord (4,5). The subaxial cervical vertebrae C3–C7 commonly encountered during anterior cervical procedures such as ACDF and Corpectomy possess a standard structure with vertebral bodies, transverse processes, foramen transversarium for vertebral artery and vein passage, intervertebral discs, and facet joints that enhance stability and movement. Each cervical vertebra corresponds to a pair of cervical spinal nerves C1–C8, which exit the spinal column through the intervertebral foramina, responsible for motor and sensory functions in the upper body (Figure 1) (4,6,7). Nerves C1–C7 travel through the intervertebral space above the nerve root’s corresponding vertebral body. The C8 nerve root travels through the C7–T1 intervertebral space as the spine transitions from cervical to thoracic. Understanding this anatomy is essential for minimizing nerve injury risks during surgery. The complexity of the cervical spine underscores the importance of meticulous surgical planning and technique to optimize patient outcomes during cervical spine procedures.

Figure 1 Schematic illustration of the cervical spine (C1–C7) and exiting cervical nerve roots (C1–C8).

Recognized nerve injuries following cervical spine surgery

Although their occurrence is rare, several nerve injuries have been discussed in the literature following operative treatment of cervical spine pathology. Nerves that may be injured through ACDF include the RLN, SLN, C5 nerve root, and the hypoglossal nerve. Other rare, but possible, nerve-related complications include the development of Parsonage-Turner syndrome (PTS), C8–T1 radiculopathy, and Horner’s syndrome. A summary of the nerve injuries is summarized in Table 1. A summary of cervical surgical procedures and their associated neurological complications and risk factors can be found in Table 2. Table 3 summarizes cervical nerve roots and their corresponding function.

Table 1

Summary of cervical nerve injuries

Nerve injured/syndrome Associated surgical approach Estimated incidence Clinical presentation Pathophysiology Key references
RLN Anterior cervical (especially left-sided or multilevel) 0.9–8.3% (transient), <1% (permanent) Hoarseness, dysphonia, aspiration, weak cough Retraction/stretching of RLN, ischemia Jung et al., J Neurosurg Spine 2005 (8); Heeneman, Laryngoscope 1973 (9); Rai et al., J Craniovertebr Junction Spine 2024 (10)
C5 palsy (brachial plexus root) Indirect traction, foraminal decompression 4.6–10% Deltoid/biceps weakness, preserved hand function Spinal cord shift, nerve root traction Thompson et al., Global Spine J 2017 (11); Rai et al., J Craniovertebr Junction Spine 2024 (10)
Parsonage-Turner syndrome (neuralgic amyotrophy) Postoperative (immune-mediated), not always approach-specific 0.3–1% Severe shoulder/arm pain → patchy brachial plexopathy, scapular winging Immune-mediated brachial plexus inflammation post-surgery van Alfen N, et al., PLoS One 2015 (12)
Sympathetic chain Anterior approach with excessive lateral dissection 0.1–0.5% Horner’s syndrome: ptosis, miosis, anhidrosis Injury to cervical sympathetic trunk Fountas et al., Spine (Phila Pa 1976) 2007 (13)
SLN (external branch) High cervical (C2–C4) exposure, retraction Uncertain; likely underdiagnosed Voice fatigue, loss of high-pitched voice, dysphagia (esp. in professional voice users) Retraction or transection of external SLN Tempel et al., Global Spine J 2017 (14)
Hypoglossal nerve (CN XII) High anterior/lateral (C1–C2, submandibular) <0.1% Tongue deviation, dysarthria, dysphagia Compression/stretching near carotid triangle or dissection injury Sengupta, Eur Spine J 1999 (15); Hellquist F, Brain Sci 2025 (16)
Phrenic nerve High anterolateral dissection (C3–C5 region) Very rare Dyspnea, elevated hemidiaphragm, orthopnea Direct trauma or retraction near anterior scalene Oo et al., Spinal Cord 1999; Moon et al., N Am Spine Soc J 2020 (17,18)
Spinal accessory nerve (CN XI) Far lateral or high cervical exposures Very rare Trapezius weakness, shoulder droop, difficulty shrugging Traction or transection of CN XI in posterior triangle Alonso et al., Arq Neuropsiquiatr 2000 (19); Lu, Orthopedics, 2000 (20)

CN, cranial nerve; RLN, recurrent laryngeal nerve; SLN, superior laryngeal nerve.

Table 2

Surgical procedures and associated neurological complications and risk factors

Surgical procedure Common neurological complications Risk factors Key references
ACDF Recurrent laryngeal nerve injury Left-sided approach Jung A, J Neurosurg Spine 2005 (8);
Eskander, J Bone Joint Surg Am, 2012 (21);
Yee, J Spine Surg 2020 (22);
Lu, Orthopedics, 2000 (20);
Rai et al., J Craniovertebr Junction Spine 2024 (10)
C5 palsy Multilevel procedures
Dysphagia Excessive retraction
Superior laryngeal nerve injury High cervical level (C2–C4) exposure
Anterior cervical corpectomy C5 palsy Multilevel decompression Yee, J Spine Surg 2020 (22);
Scholz, J Neurol Surg A Cent Eur Neurosurg 2018 (23);
Maduri et al., Acta Neurochir (Wien), 2020 (5)
Horner’s syndrome Excessive cord manipulation
Brachial plexopathy Lateral dissection near the sympathetic chain
Anterior foraminotomy C5–C6 nerve root injury Poor visualization Scholz, J Neurol Surg A Cent Eur Neurosurg 2018 (23);
Maduri et al., Acta Neurochir (Wien), 2020 (5)
Vertebral artery injury Foraminal stenosis
Radiculopathy exacerbation Inadequate decompression
Cervical disc arthroplasty (TDR) Recurrent laryngeal nerve injury High cervical exposure Pickett et al., J Neurosurg Spine 2006 (24)
C5 palsy Excessive neck extension
Hypoglossal nerve palsy (rare) Lateral traction near CN XII
Odontoidectomy (transoral/anterior C1–C2) Hypoglossal nerve injury High anterior exposure Tubbs et al., Childs Nerv Syst 2016 (25);
Shriver et al. Clin Neurol Neurosurg 2016 (26)
Pharyngeal plexus injury Prolonged retraction
Spinal cord injury Cranial nerve proximity
Anterior cervical osteotomy C5 palsy Overcorrection Nemani, Asian Spine J 2016 (6)
Vertebral artery injury High-level decompression
Phrenic nerve palsy Anterior scalene dissection
Multilevel anterior cervical fusion (3+ levels) Recurrent laryngeal nerve palsy Long operative time Rai et al., J Craniovertebr Junction Spine 2024 (10)
Dysphagia Traction injury
Brachial plexopathy Parsonage-Turner susceptibility

ACDF, anterior cervical discectomy and fusion; CN, cranial nerve; TDR, total disc replacement.

Table 3

Cervical nerve roots and corresponding function

Nerve root Disk level Dermatomal sensory distribution Motor function Associated reflex
C4 C3–C4 Suprascapular, supraclavicular, and top of shoulder Usually none None
C5 C4–C5 Lateral aspect of arm and forearm Shoulder abduction, elbow flexion Biceps, brachioradialis
C6 C5–C6 Anterolateral aspect of arm, forearm, hand, thumb, and forefinger Shoulder abduction, elbow flexion, forearm pronation Biceps, brachioradialis
C7 C6–C7 Dorsolateral forearm and hand, forefinger and long finger Elbow extension, wrist extension, finger extension Triceps
C8 C7–T1 Medial forearm and hand, ring and little fingers Finger abduction, finger adduction, finger flexion None or finger flexor
T1 T1–T2 Medial arm and forearm Finger abduction, finger adduction, finger flexion None or finger flexor

Adapted from the 2006 publication by Bartleson et al. in Neurologic Clinics (27). Permissions provided.

RLN

The most commonly encountered and injured nerve in the lower cervical, C6–C7, anterior cervical dissection is the RLN, as both sides enter the larynx at or inferior to this level (7,14). The right RLN loops around the subclavian artery and begins ascending more superiorly than the left RLN, which loops around the aortic arch and ascends between the trachea and esophagus. The RLN is particularly vulnerable during ligation of the right-sided inferior thyroid vessels (7). A deep understanding of the anatomical variations and risk at each level of the cervical spine is essential when conducting an anterior cervical spine procedure such as an ACDF, corpectomy, or anterior foraminotomy.

The incidence of RLN injury varies widely, with reports indicating it affects 1% to 11% of patients undergoing cervical spine procedures via anterior approach (3,22,28). Yee et al., however, found the incidence of RLN palsy to be as high as 60.9% and 5.9% in retrospective and prospective studies, respectively (22). It is possible this variation is due to retrospective studies lacking patient care contiguity and routine investigative follow-up specific for nerve injuries. Further, variation in what symptoms warrant investigation for nerve injuries were apparent between the studies included.

Risk factors include revision surgeries, extensive retraction, and multilevel procedures (29). Clinically, RLN injury manifests as hoarseness, a breathy voice, and difficulty coughing.

The RLN is particularly vulnerable to injury during anterior cervical spine surgeries involving hardware fixation, specifically ACDF with plating and corpectomies with cage insertion, followed by plating, due to its proximity to the surgical field in these approaches. The right RLN has a more variable course distally and ascends more laterally compared to the left RLN, which travels in the tracheoesophageal groove. For this reason, the cervical spine is often accessed through a left-sided Smith-Robinson approach. That being said, studies have yet to show any significant difference in injury with current data reporting 1.9% for right-sided RLN palsy during ACDF vs. 1.8% for left-sided RLN palsy (7). Once the platysma is split, blunt dissection is taken to create a surgical corridor between the sternocleidomastoid and carotid sheath laterally, and the trachea, esophagus, strap muscles, and RLN medially. A self-retaining retractor is often placed at this time and is responsible for retracting the trachea, esophagus, and the strap muscles medially and the carotid vessels and sternocleidomastoid muscle laterally, allowing access to the vertebral body and the disc. Minimally necessary retraction pressure is recommended due to the inclusion of the RLN in the medial group of structures (30,31). Injury can also occur from direct trauma, compression, or ischemia resulting from retraction during procedures, particularly at the C4–C6 levels (3).

RLN palsy may be evaluated through laryngoscopy, which can reveal vocal cord paralysis (10,28).

Surgeons are advised to minimize retraction and to deflate and inflate the endotracheal tube cuff after placement of a self-retaining retractor. Apfelbaum et al. conducted a retrospective study and concluded that the most common cause of vocal cord paralysis after anterior cervical spine surgery is compression of the RLN within the endolarynx (3). In particular, a higher incidence of RLN palsy was found in corpectomies and reoperations of ACDF, attributed to the increased presence of scar tissue and increased dissection depth needed to achieve a satisfactory outcome in these categories of spine surgery. Both of these aspects contribute to a greater time length for operation, and thus a longer period of nerve compression during retraction. They recommended monitoring the endotracheal tube cuff pressure and deflating the endotracheal tube cuff after the placement of a self-retaining retractor to maintain a just-seal pressure and reduce compression time on the RLN (3).

If encountered, initial management is conservative, with voice therapy often recommended for mild cases. In more severe or persistent cases, injection laryngoplasty or thyroplasty may be required. Most patients recover spontaneously within 6–12 months, but 1–2% may experience permanent damage. Yee et al. found the recovery rate of RLN palsy to be 83.4% (22). Of note, multilevel ACDF and corpectomy were found not to have any significant increase in rates of RLN palsy from initial procedures; however, there is a significant associated increase following secondary procedures (3,22). Increased caution should be exercised during any form of subsequent anterior neck surgeries, due to the associated increased risk of RLN injuries on account of modified anatomical location after previous operation and scar tissue formation.

SLN

The SLN may also be affected during upper anterior cervical spine surgeries, particularly when discectomy and fusion or corpectomy and grafting are performed in the same procedure. The SLN is particularly susceptible at the C3–C4 levels during dissection deep to the carotid (7,14). The SLN splits into the larger internal branch and smaller external branch before entering the thyrohyoid membrane. Above C3–C4 and below C6–C7 are regarded as safe regions regarding the SLN due to its limited variation in course (23). The external branch of the SLN is particularly vulnerable during ligation of the superior thyroid arteries at the C3–C4 levels as it courses deep to the carotid and horizontally along the inferior border of the hyoid bone (7,14,20).

The incidence of SLN injury is lower than that of RLN injury, and many cases are underdiagnosed due to subtle symptoms. Though the incidence of injury has limited support in literature, it is generally regarded as approximately 1% (29,32,33). Due to their anatomic course, the Internal SLN is especially at risk when dissecting between C3–C4, and the external SLN is at risk when dissecting between the C4–C6 levels (7,14).

Patients with SLN injury often struggle to produce high-pitched sounds and may report voice fatigue. Laryngoscopy may reveal impaired cricothyroid muscle function which is essential for pitch modulation (29).

Similar to the RLN, this nerve is often injured due to excessive retraction of medial structures with a self-retaining retractor once the plane between the carotid sheath and the sternocleidomastoid is developed. However, the nerve can also be injured during dissection near the carotid sheath at these levels, as the SLN lies medially to the sheath. The internal branch has a less variable path than the external branch and is nearly always encountered near the C3–C4 vertebrae (7,14,24). The external branch is more variable, but above C3–C4 and below C6–C7 are regarded as safe regions regarding the SLN (7).

As with RLN injury, risk factors include extensive surgical manipulation and multilevel procedures. Treatment generally consists of conservative measures such as voice rest and therapy, with surgery rarely required. Most patients recover within a few months, although some may experience persistent difficulties with pitch modulation. To prevent SLN injury, gentle retraction and minimally necessary surgical exposure are recommended (34).

C5 nerve root palsy

C5 nerve root palsy has been reported in 5% to 12.2% of cases in procedures such as ACDF and anterior cervical corpectomy and fusion (ACCF) (10,11,35). The highest incidence rate was seen in laminectomy with fusion at 12.2% and 74.5% of C5 palsy was unilateral. Anterior approaches had a lower incidence compared to posterior approaches at 5% and 6.2% respectively (11,21,22,36). In ACDF and laminoplasty male patients and those with ossification of the posterior longitudinal ligament experienced a higher incidence of C5 palsy (36).

Clinically, patients may experience shoulder pain followed by delayed postoperative weakness on exam of numerous muscles involving the shoulder, rotator cuff, anterior neck, and deep back muscles, particularly the deltoid and biceps (36-38).

C5 nerve root palsy is thought to result from overstretching or ischemia of the C5 nerve root during decompression or fusion surgeries. The presentation of the C5 palsy often occurred on the second postoperative day rather than immediately after (22).

Several risk factors may contribute to C5 nerve root palsy, including preoperative severe stenosis and multilevel decompression (37). Spinal cord ischemia and reperfusion injuries are thought to be involved in C5 palsy (36). However, the most significant predictor of C5 nerve root palsy after ACDF, found by Eskander et al., was the preoperative rotation of the spinal cord, reporting a mean rotation of 10.3 degrees in those with injury compared to a mean rotation of 2.1 degrees in those who did not (21).

Treatment focuses on physical therapy to strengthen affected muscles, with surgical revision rarely required. Most patients recover within 3–6 months, although some may experience residual weakness. Intraoperative neuromonitoring and careful decompression techniques when operating in a wide foraminotomy approach at the C4–C5 level are crucial in reducing the risk of C5 nerve injury in most anterior surgical approaches, including ACDF, corpectomies, foraminotomies (11,21,35).

Hypoglossal nerve

Hypoglossal nerve injuries are rare and occur primarily during upper (C2–C4) ACCFs (C1–C3) with a reported rate of occurrence from 0.6% to 2.5% (15,16). The higher anterior oblique approach was associated with a higher incidence rate; however, injuries were noted to also rarely occur in the Smith-Robertson standard approach.

The hypoglossal nerve originates at the hypoglossal nucleus in the medulla of the brainstem. The nerve exits the skull through the hypoglossal canal and meets the carotid sheath at the angle of the mandible. At this point, the nerve lies lateral to the carotid sheath, crosses anterior to the sheath, and travels medially toward the tongue. Due to this course, patients are at the highest risk of injury to the hypoglossal nerve during the anterior surgical approach during ACDFs and Smith-Robertson anterior approaches for osteophyte resection. The nerve can be injured commonly through excessive retraction, neck positioning, or during instrumentation at C1 (15,25,39,40). It is recommended to not use bicortical screws in the lateral mass of C1 as the internal carotid artery and hypoglossal nerve are anterior to the lateral mass and may get injured. Minimally invasive techniques, proper positioning, endotracheal intubation, and careful retraction can help reduce the risk of injury (15,25,40).

Patients with hypoglossal nerve injuries often present immediately following surgery with tongue deviation toward the injured side, dysarthria, and dysphagia (Figure 2) (15). Electromyography may be used to evaluate nerve function, and treatment usually involves supportive care, speech and swallowing therapy, with surgery reserved for severe cases. Interestingly, B12 supplementation may be used to aid in recovery from proposed boosted nerve regeneration (41,42). Recovery is variable, with some patients recovering within a few weeks to months, and others suffering permanent deficits (15,16). In the majority of patients, dysphagia resolved in 6 months (15,16).

Figure 2 Clinical photograph demonstrating tongue fasciculations to the patient’s left side, consistent with left sided hypoglossal nerve (cranial nerve XII) palsy. This image is published with the patient’s consent.

Additional rare nerve injuries

Additional nerve injuries include PTS (idiopathic brachial plexopathy) and C8–T1 radiculopathy. PTS has a prevalence rate following cervical spine surgery of 0.05–0.07 and is more commonly found in the primary care setting (12,29). It involves immune-mediated damage or inflammation of the brachial plexus (28,39). Patients experience severe shoulder pain followed by weakness and atrophy. Treatment includes physical therapy and pain management, with recovery typically spanning 1–2 years (29,43).

C8–T1 radiculopathy results from compression or stretching of the lower cervical roots during surgery, leading to hand muscle weakness and ulnar distribution numbness. Treatment is conservative, with physical therapy, but surgical revision may be needed in persistent cases (32,33). Failure of symptom relief in anterior approaches (ACDF and ACCF) for cervical radiculopathies have been reported to be as low as 11%; however, when there is persistence of radiculopathy, revision surgeries often include addition of a posterior approach to perform a complete decompression of the affected nerve(s) through laminotomies and foraminotomies (6,13,44).

Additionally, Horner’s syndrome is another rare but significant complication that may occur after cervical spine surgery. The incidence rate of Horner’s syndrome in ACDF is reported between 0.1% to 0.45% and the overall incidence of 0.02% to 4.0% (45). The sympathetic chain approaches the lateral border of the longus colli muscle at C5–C6 and is more vulnerable to injury at this level. Disruption of the sympathetic nerve pathway results in the characteristic ptosis (drooping of the upper eyelid), miosis (constriction of the pupil), and anhidrosis (absence of sweating) on the affected side of the face (Figure 3) (22). Treatment primarily focuses on symptom management, and most patients have resolution of symptoms within 6 months to 1 year while some patients may experience persistent symptoms (45-47).

Figure 3 Illustration of Horner syndrome, demonstrating the characteristic triad of ptosis (drooping eyelid), miosis (pupil constriction), and anhidrosis (reduced facial sweating).

Conclusions

In summary, nerve injuries following cervical spine surgery, including those affecting the recurrent laryngeal, superior laryngeal, C5 nerve root, and hypoglossal nerves, present notable challenges in clinical practice. Incidences vary and may reach up to 12% depending on the nerve and surgical approach. Many patients recover spontaneously, but recovery timelines are unpredictable, and permanent deficits are possible in some cases. Implementing preventive strategies such as minimizing retraction, utilizing intraoperative neuromonitoring, and thorough preoperative planning can significantly reduce the incidence of these injuries. Recognition and mitigation of nerve injuries are crucial in improving surgical outcomes and enhancing patient quality of life.

Acknowledgments

None.

Footnote

Peer Review File: Available at https://jss.amegroups.com/article/view/10.21037/jss-25-53/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-25-53/coif). J.K. has contracts from Stryker Spine, DePuy Synthes, Centinel Spine, Medtronic, Relievant, Limiflex, Fziomed, K2M, SI BONE, NuVasive, Synergy Spine, Simplify; received consulting fees from Abbott, Centinel Spine, Nevro, Globus, Medtronic, Relievant, Stryker, SI BONE, Highridge; has stock options with Medtronic, Johnson & Johnson, Globus. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Written informed consent was obtained from the patient for publication of this article and accompanying image. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Cite this article as: Hasan S, Farmer N, Arefi I, Hagood M, Gadangi P, Alqasmi H, Waheed M, Shafau AL, Abusabha Y, Saleh E, Khalil J, Elgafy H. Nerve injuries in cervical spine surgery via anterior approach: a comprehensive review. J Spine Surg 2025;11(4):1056-1064. doi: 10.21037/jss-25-53

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