Preoperative Patient Care A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam interpret neurological exam describe key physical exam maneuvers (lumbar nerve root function) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests extends examination to nonspinal differential diagnostic possibilities vascular claudication hip arthritis 2 Appropriately orders and interprets advanced imaging studies myelogram CT MRI findings central stenosis foraminal stenosis identifies nerve root anatomy correlates clinical and imaging findings to form clinical diagnosis 3 Prescribes and manages nonoperative treatment medical management attempts medical management of lumbar 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 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 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: ~ 3 month postoperative visit repeat xrays of lumbar spine look for evidence of fusion advance spine restrictions and activity levels diagnosis and management of late complications postop: 1 year postoperative visit repeat xrays of lumbar spine to identify fusion B 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 4 Capable of surgically treating simple complications drainage of hematoma debridement of infection C Preoperative H & P 1 Obtains basic preoperative history and physical exam need to carefully document neurological status of bilateral lower extremities strength, sensation, reflexes, and primary symptoms 2 Order basic imaging studies order biplanar films of the spine 3 Screen medical studies to identify and contraindications for surgery confirms no recent infection contraindicating surgery (UTI) 4 Perform operative consent documents failure of nonoperative measures such as physical therapy and epidural streoid injections describe complications of surgery including persistent radiculopathy due to inadequate decompression dural tear iatragenic nerve root injury segmental instability due to aggressive facet capsule and joint excision superficial, deep wound infection meralgia parasthetica due to compression of LFCN Operative Techniques E Preoperative Plan 1 Identifies area of decompression on preoperative imaging 2 Template instrumentation on preoperative imaging studies. 3 Surgical walkthrough describe steps to the attending verbally prior to the start of the case list potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Lumbar Instrumented Fusion System Interbody fusion device Autologous or allograft bone for fusion 2 Room setup and equipment table radiolucent Jackson spine flat top table neuromonitoring neuromonitoring leads to upper and lower extremities C-arm c-arm perpendicular to table microscope microscope in from opposite side of C-arm 3 Patient positioning prone with arms at 90° max abduction and flexion to prevent axillary nerve injury foam padding on chest so that nipples are pointing midline straight down pads over ASIS and gel pads on knees foley in place bilateral TED hose and SCDs G Superficial Dissection 1 Localize level of incision with anatomic or radiographic landmarks 2 Make midline incision. midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae) ~3-4cm in length for single level 3 Dissect subcutaneous tissue down to fascia insert cerebellar retractors x2 for fascial exposure 4 Cauterize lumbodorsal fascia over spinous processes to just lateral of midline H Deep Dissection 1 Perform subperiosteal dissection perform dissection with Cobb along spinous processes perform dissection of lamina from a cranial to caudal direction 2 Place probe under lamina to identify level radiographically 3 Expose the facet capsules use Cobb to strip laterally along lamina until facet capsules exposed 4 Dissect out transverse process dissect paraspinal muscle from intertransverse membrane 5 Place deep retractors for better visualization I Central Decompression 1 Remove spinous processes of operative levels with rongeur save as bone graft for fusion 2 Remove lamina and identify origin of ligamentum flavum begin with decompression into canal into inferior half of lamina of cephalad vertebrae first with small curette burr lamina and to thin and then complete resection with Kerrison rongeurs 3 Resect ligamentum flavum gently retract ligamentum flavum with woodsen elevator resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae resect ligamentum from superior lamina of inferior lamina use Kerrison to resect caudad lamina from inferior vertebra use woodsen to protect dura and nerve roots during entire resection of ligamentum flavum J Multilevel Lateral Recess Decompression 1 Perform medial facetectomy decompress medial aspect of facet on each side (2-3 mm of medial facet) 2 Decompress lateral recess locating pedicle key to safe decompression kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized identify osteophytes that could impinge exiting nerve root around pedicle undercut remaining superior facet using kerrison rongeur if not fusing no more than 50% superior facet should be resected 3 Confirm exiting and descending nerve roots are well decompressed descending nerve root should be visualized 4 Check to make sure no disc herniation. Dural sac/nerve root may be retracted to see if there is bulging disc is present K Interbody Fusion (Optional) 1 Retract dura and place introducer into disc space confirm position with fluoroscopy 2 Clear endplates 3 Place interbody device L Pedicle Screw Placement, Deformity Correction, Instumentation 1 Identify and prepare starting point. landmark for pedicle screws is inferolateral aspect of the intersection of facet and transverse process for sacrum landmark is base of facet at S1 (superolatral to sacral foramen) decorticate entry site with burr 2 Place pedicle finder and confirm intra-osseous position place gearshift probe into pedicle track ~30mm until significant resistance is felt (anterior cortex of vertebral body) insert balltip probe to check floor, medial, inferior walls of pedicle check for canal/nerve root once markers confirmed in correct locations advance gearshift 40-50mm 3 Insert pedicle screws identify proper length tap 5mm and recheck with balltip probe insert pedicle screws (i.e. L4, 6.5x50mm screws; L5, 7.5x40mm screws) 4 Confirm proper position of pedicle screws 5 Radiographs confirm position of radiographs with AP and lateral imaging 6 EMG (optional) EMG test all screws to ensure no pedicle wall breach 7 Place rods and finalize instrumentation place 2 contoured rods (i.e. 6.0mm rods, use hand benders) for desired lordosis into screw tulips insert set screws place any final distraction/compression and lock set screws N Arthrodesis Preparation and Wound Closure 1 Decorticate transverse process to faciliate posterolateral fusion decorticate surrounding transverse processes, facet joints, and pars with burr 2 Pack posterolateral gutters with autologous/allograft graft (performed after pedicle screws and rods are placed) 3 Irrigation & hemostatis flush out spine with saline bulb irrigation can use betadine wound lavage or vancomycin powder to decrease infection risk obtains appropriate hemostasis use Floseal for hemostasis 4 Place hemovac drain under fascia 5 Close Fascia close fascia with 0-vicryl need water tight closure and need to decrease dead space for hematoma 6 Superficial closure subcutaneous with 2-0 vicryl skin closure with buried 3-0 monocryl 7 Dressing soft incision dressings over spine Postoperative Patient Care O Peroperative Inpatient Management 1 Writes appropriate admission orders IV fluids antibiotics pain meds DVT prophylaxis advance diet when flatus has returned wound care changes dressing on POD #2 identify CSF leak foley catheter out when ambulating 2 Appropriately orders and interprets basic imaging studies review postoperative radiographs and identifies mal-positioned pedicle screws 3 Appropriate medical management and medical consultation 4 Inpatient PT weight-bearing as tolerated, physical and occupational therapy no heavy lifting and limited flexion/extension 5 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R 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
A Intermediate Evaluation and Management 1 Obtain focused history and performs focused exam interpret neurological exam describe key physical exam maneuvers (lumbar nerve root function) concomitant and associated orthopaedic injuries differential diagnosis and physical exam tests extends examination to nonspinal differential diagnostic possibilities vascular claudication hip arthritis 2 Appropriately orders and interprets advanced imaging studies myelogram CT MRI findings central stenosis foraminal stenosis identifies nerve root anatomy correlates clinical and imaging findings to form clinical diagnosis 3 Prescribes and manages nonoperative treatment medical management attempts medical management of lumbar 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 4 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 5 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: ~ 3 month postoperative visit repeat xrays of lumbar spine look for evidence of fusion advance spine restrictions and activity levels diagnosis and management of late complications postop: 1 year postoperative visit repeat xrays of lumbar spine to identify fusion B 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 4 Capable of surgically treating simple complications drainage of hematoma debridement of infection C Preoperative H & P 1 Obtains basic preoperative history and physical exam need to carefully document neurological status of bilateral lower extremities strength, sensation, reflexes, and primary symptoms 2 Order basic imaging studies order biplanar films of the spine 3 Screen medical studies to identify and contraindications for surgery confirms no recent infection contraindicating surgery (UTI) 4 Perform operative consent documents failure of nonoperative measures such as physical therapy and epidural streoid injections describe complications of surgery including persistent radiculopathy due to inadequate decompression dural tear iatragenic nerve root injury segmental instability due to aggressive facet capsule and joint excision superficial, deep wound infection meralgia parasthetica due to compression of LFCN
E Preoperative Plan 1 Identifies area of decompression on preoperative imaging 2 Template instrumentation on preoperative imaging studies. 3 Surgical walkthrough describe steps to the attending verbally prior to the start of the case list potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Lumbar Instrumented Fusion System Interbody fusion device Autologous or allograft bone for fusion 2 Room setup and equipment table radiolucent Jackson spine flat top table neuromonitoring neuromonitoring leads to upper and lower extremities C-arm c-arm perpendicular to table microscope microscope in from opposite side of C-arm 3 Patient positioning prone with arms at 90° max abduction and flexion to prevent axillary nerve injury foam padding on chest so that nipples are pointing midline straight down pads over ASIS and gel pads on knees foley in place bilateral TED hose and SCDs G Superficial Dissection 1 Localize level of incision with anatomic or radiographic landmarks 2 Make midline incision. midline incision with 10blade overlying the spinous processes between paraspinal muscles (erector spinae) ~3-4cm in length for single level 3 Dissect subcutaneous tissue down to fascia insert cerebellar retractors x2 for fascial exposure 4 Cauterize lumbodorsal fascia over spinous processes to just lateral of midline H Deep Dissection 1 Perform subperiosteal dissection perform dissection with Cobb along spinous processes perform dissection of lamina from a cranial to caudal direction 2 Place probe under lamina to identify level radiographically 3 Expose the facet capsules use Cobb to strip laterally along lamina until facet capsules exposed 4 Dissect out transverse process dissect paraspinal muscle from intertransverse membrane 5 Place deep retractors for better visualization I Central Decompression 1 Remove spinous processes of operative levels with rongeur save as bone graft for fusion 2 Remove lamina and identify origin of ligamentum flavum begin with decompression into canal into inferior half of lamina of cephalad vertebrae first with small curette burr lamina and to thin and then complete resection with Kerrison rongeurs 3 Resect ligamentum flavum gently retract ligamentum flavum with woodsen elevator resect remaining lamina and ligamentum with Kerrison rongeur of cephalad vertebrae resect ligamentum from superior lamina of inferior lamina use Kerrison to resect caudad lamina from inferior vertebra use woodsen to protect dura and nerve roots during entire resection of ligamentum flavum J Multilevel Lateral Recess Decompression 1 Perform medial facetectomy decompress medial aspect of facet on each side (2-3 mm of medial facet) 2 Decompress lateral recess locating pedicle key to safe decompression kerrison to undercut medial edge of superior facet of caudad vertebra until medial edge of pedicle visualized identify osteophytes that could impinge exiting nerve root around pedicle undercut remaining superior facet using kerrison rongeur if not fusing no more than 50% superior facet should be resected 3 Confirm exiting and descending nerve roots are well decompressed descending nerve root should be visualized 4 Check to make sure no disc herniation. Dural sac/nerve root may be retracted to see if there is bulging disc is present K Interbody Fusion (Optional) 1 Retract dura and place introducer into disc space confirm position with fluoroscopy 2 Clear endplates 3 Place interbody device L Pedicle Screw Placement, Deformity Correction, Instumentation 1 Identify and prepare starting point. landmark for pedicle screws is inferolateral aspect of the intersection of facet and transverse process for sacrum landmark is base of facet at S1 (superolatral to sacral foramen) decorticate entry site with burr 2 Place pedicle finder and confirm intra-osseous position place gearshift probe into pedicle track ~30mm until significant resistance is felt (anterior cortex of vertebral body) insert balltip probe to check floor, medial, inferior walls of pedicle check for canal/nerve root once markers confirmed in correct locations advance gearshift 40-50mm 3 Insert pedicle screws identify proper length tap 5mm and recheck with balltip probe insert pedicle screws (i.e. L4, 6.5x50mm screws; L5, 7.5x40mm screws) 4 Confirm proper position of pedicle screws 5 Radiographs confirm position of radiographs with AP and lateral imaging 6 EMG (optional) EMG test all screws to ensure no pedicle wall breach 7 Place rods and finalize instrumentation place 2 contoured rods (i.e. 6.0mm rods, use hand benders) for desired lordosis into screw tulips insert set screws place any final distraction/compression and lock set screws N Arthrodesis Preparation and Wound Closure 1 Decorticate transverse process to faciliate posterolateral fusion decorticate surrounding transverse processes, facet joints, and pars with burr 2 Pack posterolateral gutters with autologous/allograft graft (performed after pedicle screws and rods are placed) 3 Irrigation & hemostatis flush out spine with saline bulb irrigation can use betadine wound lavage or vancomycin powder to decrease infection risk obtains appropriate hemostasis use Floseal for hemostasis 4 Place hemovac drain under fascia 5 Close Fascia close fascia with 0-vicryl need water tight closure and need to decrease dead space for hematoma 6 Superficial closure subcutaneous with 2-0 vicryl skin closure with buried 3-0 monocryl 7 Dressing soft incision dressings over spine
O Peroperative Inpatient Management 1 Writes appropriate admission orders IV fluids antibiotics pain meds DVT prophylaxis advance diet when flatus has returned wound care changes dressing on POD #2 identify CSF leak foley catheter out when ambulating 2 Appropriately orders and interprets basic imaging studies review postoperative radiographs and identifies mal-positioned pedicle screws 3 Appropriate medical management and medical consultation 4 Inpatient PT weight-bearing as tolerated, physical and occupational therapy no heavy lifting and limited flexion/extension 5 Discharges patient appropriately pain meds wound care outpatient PT schedule follow up in 2 weeks R 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