Neurosurgery Outlines - Paul E. Kaloostian Surgical Outlines

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Trade. 3rd ed. Thieme; 2016).

      Surgical Procedure

      1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 12 days

      2. Appropriate intubation and sedation

      3. Horizontal skin incision 1 to 2 inches on either side of spine

      4. Split thin muscle underlying skin

      5. Enter the plane between sternocleidomastoid muscle and strap muscle

      6. (Anterior) Enter into the plane between trachea/esophagus and carotid sheath

      7. Disect away thin fascia

      8. Locate disk (preoperative imaging match/intraoperative fluoroscopy)

      9. Remove disk by cutting annulus fibrosis and nucleus pulposus

      10. Remove entire disk including cartilage endplates to reveal cortical bone

      11. Remove ligamentous tissue front to back to allow access to spinal canal

      12. (Posterior) Incision on midline, behind neck

      13. Elevate paraspinal muscles

      14. Confirm correct level (discussed above)

      15. Remove small portion of facet joint with burr drill, expose nerve root, gently move to side to expose disk herniation

      16. Insert bone graft and implant cage into evacuated space

      17. Attach small plate to spine with screws in each vertebral bone

      18. Clean surgical site, exit, and suture

      Pitfalls

      • Loss of neck mobility by ~30%

      • Instrumentation failure

      • Bone graft failure

      • Intraoperative CSF leak

      • Blood clot (deep vein thrombosis, or more severe pulmonary embolism)

      • Damage to spinal nerves and/or cord

      • Postoperative weakness or numbness or continued pain

      • Postoperative wound infection

      • Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life

      Prognosis

      • Most patient are hospitalized for 1 to 2 days, then return home with strict orders of minimal sudden head/neck movement

      • Typically, 4 to 6 weeks post operation most patients are able to return to normal day-to-day activities

      • Full fusion (formation of hard bone) may take 12 to 18 months

      • PT and OT

      1.2.2 Posterior Cervical Foraminotomy/Posterior Cervical Decompression

      Symptoms and Signs

      • Mild to moderate neck pain

      • Radicular sensory loss in arm(s)

      • Radicular pain in arm(s)

      • Myotomal weakness in arm(s)

      • Myelopathy (dropping objects, cannot button shirt, gait imbalance, and urinary incontinence)

      Surgical Pathology

      • Cervical herniated nucleus pulposus

      • Foraminal stenosis

      • Cord compression

      Diagnostic Modalities

      • X-ray of cervical spine to assess for alignment, fracture, and degenerative disease

      • CT of cervical spine to assess for bony anatomy regarding alignment, fracture, and degenerative disease

      • MRI of cervical spine to assess for nerve root or cord compression

      • Dynamic X-ray of cervical spine to look for instability (in patients without severe cord compression)

      Differential Diagnosis

      • Degenerative disease

      • Traumatic nerve root compression

      Treatment Options

      • Exhaust all conservative routes with PT, aqua therapy, chiropractic, acupuncture, epidural steroid injections, and medical management (if possible, prior to surgical intervention)

      • Surgical decompression with or without stabilization via posterior decompression and foraminotomy (at appropriate indicated levels based on imaging studies)

      Indications for Surgical Intervention

      • Intractable radicular arm pain

      • Intractable weakness and/or numbness in arms in radicular fashion

      • Cord compression with or without myelopathy

      Surgical Procedure for Posterior Cervical Spine

      1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/other anticoagulants for at least 2 weeks preoperatively

      2. Appropriate intubation and sedation

      3. Place the patient prone in neutral position with Mayfield head holder

      4. Time out performed

      5. Incision along posterior cervical spine midline

      6. Subperiosteal dissection of muscles down to bone performed at appropriate level (see ▶Fig. 1.9)

      7. X-ray/fluoroscopic confirmation with two people for appropriate level (see ▶Fig. 1.10)

      8. Laminectomy and foraminotomy unilaterally or bilaterally, if needed, depending on diagnosis and indication for surgery (see ▶Fig. 1.11)

      a. Use pituitary rongeur/Kerrison rongeur and high-speed drill

      Fig. 1.9 Fluoroscopy reveals trajectory of tube for cervical decompression. Identify the facet joint before placing parallel to disk space at that level. (Source: Minimally invasive tubular posterior cervical decompressive techniques. In: Vaccaro A, Albert T, eds. Spine Surgery: Tricks of the Trade. 3rd ed. Thieme; 2016).

      9. Once spinal cord and/or nerve roots are decompressed, obtain X-ray confirming appropriate levels decompressed

      10. If stabilization is planned, then instrumentation and fusion can be performed

      11. Muscle and skin closure with drain placed (if necessary)

      Pitfalls

      • Intraoperative CSF leak

      • Blood clot (deep vein thrombosis, or more severe pulmonary embolism)

      • Damage to spinal nerves and/or cord

      • Postoperative weakness or numbness or continued pain

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