Posterior Cervical Laminectomy and Fusion

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Preoperative Patient Care
Operative Techniques
E

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
F

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
G

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
H

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
I

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

J

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
K

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
L

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
N

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
Postoperative Patient Care
 

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