The Kissing Carotid Variant: Case Insights and Surgical Precautions in Anterior Cervical Discectomy and Fusion (ACDF)

"Kissing" carotid arteries is a rare anatomical variant that describes the medialization of the internal and/or common carotid vasculature. While most patients remain asymptomatic, concerns for this anomaly arise during anterior surgical approaches. A 73-year-old female patient presented to our orthopedic spine clinic with neck and radicular pain in her right hand in the C7 distribution. Cervical MRI revealed a right paracentral disc extrusion at C6-C7, causing moderate to severe spinal canal stenosis and right foraminal stenosis. Severe central stenosis was also noted at C4-C5, and moderate central stenosis with severe left foraminal stenosis at C3-C4. The common and internal carotid arteries were noted to have significant medialization along the anterior cervical spine beginning caudally at C7 and extending cephalad to the C4 vertebral body. Typically, an anterior cervical discectomy and fusion (ACDF) is preferred to address the underlying cervical pathology. Due to the anatomical variant potentially obfuscating the anterior cervical surgical approach, preoperative planning is critical. Additional imaging may be necessary to better clarify surgical planes. In this case, the patient eventually underwent a C4-C7 ACDF without intraoperative complications. This case report highlights the potential risks and complications associated with aberrant carotid artery anatomy in patients undergoing ACDF. Although carotid injury in ACDF is rare, patients with aberrant carotids may be at increased risk of complications, such as postoperative stroke and direct incidental arteriotomy with excessive bleeding. While no immediate intraoperative complications occurred in this case, recognition of this variant and comprehensive surgical planning prior to surgery are crucial to mitigate potential intraoperative and postoperative morbidity.