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Anterior Cervical Diskectomy and Fusion

Preoperative Patient Care

A

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

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

5

Makes informed decision to proceed with operative treatment

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

6

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 soft collar
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
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
C

Preoperative History and Physical

1

Neurological exam

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

2

Screen medical studies to identify any contraindications for surgery

3

Order basic imaging studies

  • order triplanar radiographs

4

Perform operative consent

  • describe complications of surgery including
  • postoperative hematoma
  • postoperative dysphagia
  • infection
  • esophageal perforation
  • Horners syndrome
  • symptomatic recurrent laryngeal nerve palsy
  • instrumentation backout

Operative Techniques

E

Preoperative Plan

1

Radiographic templating

  • template plate 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

2

Room setup and equipment

  • standard OR table
  • fluoroscopy

3

Patient positioning

  • supine position
  • Gardner-Wells tongs
  • 15 pounds of traction
  • adduct arms
  • tuck and tape arms to the side
G

Dissection to Platysma

1

Identify landmarks and draw transverse incision.

  • identify the hyoid bone at C3
  • thyroid cartilage over C4-C5
  • cricoid cartilage over C6
  • use the sternal notch and the midpoint of the chin as midline anatomic markers

2

Make skin incision

  • make a transverse incision that extends from the midline to the middle of the sternocleidomastoid muscle
  • this is used to expose one to three levels
  • left sided approach is more common because of the more consistent course of the recurrent laryngeal nerve

3

Create plane

  • undermine the skin and the subcutaneous tissue superiorly and inferiorly
  • divide the platysma in line with the skin incision
H

Dissection to Anterior Verterbral Bodies

1

Divide the platysma

  • create defect with mosquito clamp
  • elevate and divide platysma with Bovie cautery

2

Divide deep cervical fascia

  • retract the strap muscles medially and the sternocleidomastoid laterally
  • push the muscle belly of the sternocleidomastoid medially to ensure that the proper plane is developed
  • perform blunt dissection through the pretracheal fascia
  • be aware that the superior, middle and inferior thyroid arteries are housed in the pre-tracheal fascia directly anterior to the C3, C5 and below the C6 vertebra respectively

3

Identify the left recurrent laryngeal nerve

  • ascends after curving around the aortic arch along the tracheoesophageal groove
  • the nerve is more along the midline than the right RLN

4

Mobilize deep structures

  • mobilize the carotid sheath laterally
  • feel pulse to confirm it is lateral
  • move the trachea and the esophagus medially

5

Determine vertebral level

  • take a lateral radiograph to determine the appropriate level

6

Expose verteba

  • elevate the longus colli muscle with cob elevator or curette
I

Diskectomy

1

Place caspar pins and distract across disk space.

2

Sharply incise the anterior annulus and remove the ALL

3

Remove disc material until PLL visualized

  • use curets and rongeurs to perform the diskectomy to the uncovertebral joints laterally
  • these joints are recognized by the upcurving of the endplate at the uncus

4

Clear endplates

  • use a burr to remove any anterior osteophytes from the endplates

5

Lateralize discectomy

J

Decompression of Spinal Cord and Nerve Roots

1

Remove Posterior Longitudinal Ligament

  • use curets and rongeurs to perform the diskectomy through PLL posteriorly
  • the PLL is recognized by the vertical orientation of its fibers

2

Perform Bilateral Foraminotomy

  • always work from lateral to medial
K

Interbody Graft Placement

1

Open up the disk space

  • use skeletal traction, lamina spreaders or vertebral screws to distract the disk space 2mm greater than preexisting disk height or a total of 5mm
  • overdistraction of the disk space more than 4 mm from preexisting disk height can result in graft collapse and pseudoarthrosis

2

Create vascular channels

  • burr the endplates to create a flat surface on both sides of the intervertebral space
  • create 3 to 4 mm holes in the middle of the endplates

3

Place graft

  • place autograft and inset 2 mm beyond the vertebral bodies
  • graft should be stable to compression after the removal of skeletal traction
L

Anterior Cervical Plate Fixation

1

Select appropriately sized plate

  • plate should span from the middle or proximal portion of the superior vertebra to the middle or inferior portion of the distal vertebra

2

Create a contoured surface

  • use a burr to remove osteophytes from the anterior aspect of the vertebra

3

Fix plate to the spine

  • use screws to fix plate to the spine
  • angle the screws away from the graft to increase rigidity in flexion and extension

4

Confirm placement of screws and plate with fluoroscopy

N

Wound Closure

1

irrigation, hemostasis, and drain

  • place drain in the deep space

2

deep closure

  • use 3-0 vicryl

3

superficial closure

  • 4-0 monocryl

4

dressing and immediate immobilization

  • place bulky dressing and soft collar

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

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

2

Appropriate medical management and medical consultation

3

Inpatient physical therapy

  • keep collar on at all times

4

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up 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

 

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