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Posterior Cervical Laminectomy and Fusion

Planning

B

Preoperative Plan

1

Radiographic templating

  • template screw size and levels of fusion

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe the potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • Loupes or operating microscope
  • jackson table with flat board and four post frame
  • gardner wells tongs with 20 lbs of traction
  • insulated and bipolar cautery
  • angled cerebellar retractors
  • high speed burr with non end cutting drill attachment
  • multiple angled curets
  • kerrison rongeurs 1-3 mm
  • lateral mass and pedicle fixation screws

2

Room setup and equipment

  • standard operating table with Gardner-Wells tongs
  • use 15lbs of traction
  • fluoroscopy

3

Patient positioning

  • prone
  • position neck in slight extension with neutral rotation

Technique

D

Dissect to Spinous Process

1

Determine level of instrumentation

  • use fluoroscopy to determine the level of fusion

2

Make skin incision

  • incise through the skin and subcutaneous tissues
  • cauterize bleeders as they occur

3

Expose the cervical fascia

  • incise in the midline
E

Clear Lamina and Lateral Masses

1

Perform a subperiosteal dissection

2

Expose the lateral recess

3

Confirm the surgical level

  • use the C2 vertebra as the starting point and count down from there
  • place a penfield 4 elevator into the facet joint
F

Placement of Lateral Mass Screws

1

Identify starting point

2

Drill pilot holes for all levels

  • use a 2mm burr to make a small depression in the lateral mass that is 1 mm medial to the center.
  • this is done to identify a starting point for the drill bit
  • place a drill stop set at 12 or 14 mm depending on the size of the lateral mass
  • place the drill onto the starting point and drill a tract with the drill angled 30 degrees lateral and 15 degrees cephalad
  • these are drilled for placement of the lateral mass screws

3

Confirm the tract

  • place a ball tipped probe into the tract to confirm its integrity

4

Place screws

  • tap each screw tract to the same depth that was drilled
  • place 3.5 mm screws of the appropriate length

5

Confirm position using fluoroscopy

G

Laminectomy

1

Create laminar troughs

  • create troughs in the lamina bilaterally just medial to the lateral massses
  • using a non end cutting burr because the likelihood of injury to the underlying dura and spinal cord are decreased
  • stop drilling frequently and use a penfield 4 elevator to check the depth of the trough
  • continue this process until the ligamentum flavum is visualized

2

Remove ligamentum flavum

  • use a nerve hook to elevate the flavum
  • resect the flavum using a 2 mm kerrison rongeur

3

Elevate lamina

  • use leskell rongeurs to grab to the cephalad and caudad levels
  • constant pressure should be applied to and maintained on the lamina so that no compression on any part of the cervical spinal cord occurs
  • tease off any adhesions on the lamina

4

Check motor evoked potentials

5

Check mean arterial pressure

  • this must be maintained to avoid ischemic injury to the cord

6

Elevate the lamina

  • use angled curets and elevate the lamina sequentially from distal to proximal in an EN BLOC fashion
H

Place C7 Pedicle Screw (if required)

1

Perform laminoforaminotomy at C6-C7

  • use a 2-3 mm burr to create a starting point at the intersection of the midpoint of the transverse process and the lateral pars
  • this is done so that the medial border of the pedicle can be visualized and palpated
  • look for a pedicle blush which signifies the cancellous bone

2

Make screw tract

  • use a pedicle awl or gearshift to to make the tract within the pedicle
  • palpate the medial border of the of the pedicle
  • this can assess the medial-lateral and cranio-caudal angulation of the pedicle
  • palpate the medial border of the of the pedicle
  • place a ball tipped probe to confirm the tract
  • tap the tract

3

Place C7 screws

  • place 4.0 mm screws of the appropriate length bilaterally
I

Fusion and Rod Placement

1

Decorticate

  • use a high speed burr to decorticate the facet joints and the lateral aspects of the lateral masses

2

Use local bone from the laminectomy for biologic arthrodesis

3

Place Rods

  • place the end caps
  • place the appropriately sized rods into the screw heads
  • perform a final tightening of the instrumentation
J

Wound Closure

1

Irrigation, hemostasis, and drain

  • place subfascial drain
  • obtain muscular hemostasis

2

Deep closure

  • use 0 or 1 absorbable suture
  • close the muscle and fascia in separate layers

3

Superficial closure

  • subcutaneous tissue is closed with 2-0 vicryl
  • close skin with buried monocryl

4

Dressing and immediate immobilization

  • place bulky dressing and soft collar

Patient Care

K

Preoperative H & P

1

Obtain history and perform basic axam

  • need to carefully document neurological status of bilateral upper extremities
  • strength, sensation, reflexes, and primary symptoms

2

Screen medical studies to identify and contraindications for surgery

3

Order basic imaging studies

  • order triplanar radiographs

4

Perform operative consent

  • describe complications of surgery including
  • injury to the vertebral artery
  • neurologic complications
  • infection
  • nerve root palsy
  • dural injury
  • postlaminectomy kyphosis
  • instrumentation backout
  • nerve root impingement
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • IV fluids
  • advance diet as tolerated
  • foley out when ambulating
  • DVT prophylaxis
  • pain control
  • check appropriate labs
  • wound care
  • remove dressings POD 2

2

Appropriate medical management and medical consultation

3

Inpatient physical therapy

  • hard cervical collar for six weeks
  • keep collar on at all times

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • wound care
  • schedule follow-up in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and performs focused neurological exam

  • describe key physical exam maneuvers (cervical nerve root function)
  • C5
  • primary motion
  • shoulder abduction
  • elbow flexion (palm up)
  • tested muscles
  • deltoid
  • biceps
  • sensory
  • lateral arm below deltoid
  • reflex
  • biceps
  • C6
  • primary motion
  • elbow flexion (thumb up)
  • wrist extension
  • tested muscles
  • brachioradialis
  • ECRL
  • sensory
  • thumb and radial hand
  • reflex
  • brachioradialis
  • C7
  • primary motion
  • elbow extension
  • wrist flexion
  • tested muscles
  • triceps
  • FCR
  • sensory
  • fingers 2, 3, 4
  • reflex
  • triceps
  • C8
  • primary motion
  • finger flexion
  • tested muscles
  • FDS
  • sensory
  • finger 5
  • reflex
  • none
  • T1
  • primary motion
  • finger abduction
  • tested muscles
  • interossei (ulnar n.)
  • sensory
  • medial elbow
  • reflex
  • none

2

Appropriately interprets basic imaging studies

  • radiographs
  • AP and Lateral views
  • oblique view
  • shows foraminal narrowing
  • flexion-extension views
  • instability
  • rigidity
  • sagittal plane deformity

3

Appropriately orders and interprets advanced imaging studies

  • MRI
  • central stenosis
  • foraminal stenosis
  • identifies nerve root anatomy
  • CT
  • myelography
  • invasive procedure that shows anatomy
  • typically used in cases where MRI is contraindicated
  • correlates clinical and imaging findings to form clinical diagnosis

4

Prescribes and manages nonoperative treatment

  • medical management
  • attempts medical management of cervical radiculopathy (NSAIDs, gabapentin)
  • orders appropriate diagnostic and therapuetic selective nerve root or epidural steroid injections
  • attempts trial of physical therapy
  • makes referrals to other professionals

5

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

6

Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for simple cases

  • single level HNP with radiculopathy

7

Provides, modifies and adjusts procedure and patient specific post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • diagnose and management of early complications
  • postop: ~ 6 week postoperative visit
  • remove hard collar
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
N

Advanced Evaluation and Management

1

Provides complex non-operative treatment

  • individualized care
  • shared decision making
  • comprehensive informed consent

2

Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for complex cases

  • multilevel stenosis with deformity

3

Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for complex cases

  • multi-level stenosis with deformity
O

Complex Patient Care

1

Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for highly complex cases

  • revision surgery

2

Develops unique complex postoperative management plans when indicated

 

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