1. Bilateral C6-C7-T1-T2-T3-T4-T5-T6 arthrodesis, posterolateral type.
DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room where he was placed in the supine position upon a gurney and all pressure points padded. Adequate general anesthesia was induced and maintained with a combination of intravenous inhalational agents. Foley urinary catheter was placed. The patient was turned prone upon the padded laminectomy roll and the head secured with a Mayfield three-pin head holder. The head and neck were positioned in neutral position. All pressure points were meticulously padded. The cervicothoracic region was prepared with DuraPrep solution and draped in the usual sterile manner with an iodine-impregnated adhesive sheath placed over all regions of exposed skin. Intravenous cefazolin was administered for perioperative prophylactic antibiotic coverage. Intravenous dexamethasone was given as a neuroprotective agent.
The proposed linear midline skin incision was scribed on the skin with gentian violet extending between the C5 and T6; it was determined fluoroscopically. This region was infiltrated subcutaneously with 1% lidocaine with 1:100,000 units of epinephrine and skin incision created with #10 scalpel blade. The incision was carried through the skin and subcutaneous tissues till the cervicothoracic dorsal fascia was encountered. This was incised on either side of midline and the paraspinous musculature dissected from the spinous processes, laminae, and transverse processes from C6 through T6 bilaterally. Self-retaining retractors were placed.
The T3 transverse process had been completely destroyed by tumor, and a tumor was identified protruding into the paraspinous musculature at this level. Decompressive laminectomies were performed at C7-T1, T1-T2, T2-T3, T3-T4, and T4-T5 with medial facetectomies undertaken. Along the right side of the canal, from T2 through T4, a large amount of epidural tumor was identified. The T3 transverse process and pedicle had been completely destroyed by tumor, and aggressive tumor debulking undertaken in a transpedicular fashion at T3, with tumor resection extending into the upper chest. The tumor was debulked from the ventral surface of the cord and from the vertebral bodies at T3. Right-sided transpedicular corpectomies were also performed at T2 and T4, again with aggressive debulking of tumor from the ventrolateral surface of the spinal cord, cutting back to healthy-appearing bone along the left half of the vertebral bodies at T2, T3, and T4. The T3 nerve root on the right was found to be grossly infiltrated by tumor, and this root was sacrificed to afford tumor resection. Specimens were submitted for frozen and permanent section histopathology. The former demonstrated metastatic squamous cell carcinoma, consistent with lung primary.
Once spinal cord decompression had been accomplished, attention was turned to spinal reconstruction. Pedicle screws were placed bilaterally at T6 and T5 using fluoroscopic imaging to the extent possible, given the patient's body habitus and scoliosis. Stealth neuronavigation frameless stereotaxy was also utilized to assist hardware placement. On the right, at T2, T3, and T4, no pedicles were available due to tumor involvement. On the left, however, at T3 and T4, pedicle screws were placed at these pedicles and the left half of the vertebral bodies were sound and uninvolved with tumor. Bilateral pedicle screws using the Vertex system were placed at T1. Bilateral and lateral screws were placed at C6 and C7 using standard 20 degree cephalad and 20 degree lateral angulation. Custom contoured titanium rods were created with a 5.5 rod utilized in the mid thoracic spine and a 3.2 mm diameter rod used for the Vertex screws in the cervical spine as well as at T1. A "domino" connector was utilized to connect the 2 rods on either side. All connections were secured using top-loading connectors ________ manufacturer's recommendations using a counter-torque device. Excellent fixation was accomplished.
The posterolateral elements from C6 through T6 were decorticated with Midas Rex drill. Allograft cancellous bone was morselized and combined with demineralized bone matrix and bone graft grafted upon the decorticated posterolateral elements from C6 through T6 bilaterally.
The operative field was flooded with saline and an air leak noted from the cavitary lesion within the right upper lobe of the lung that was contiguous with the spine, as expected.
The wound was irrigated with copious normal saline irrigant, bacitracin solution, meticulous hemostasis achieved. The wound was closed in anatomical layers. The cervicothoracic dorsal fascia was closed with 0 Vicryl simple interrupted suture, subcutaneous tissues with 2-0 Vicryl simple interrupted inverted suture, and the skin with surgical staples. Sterile dressings were applied over the wound.
The operative drapes were taken down, the patient turned supine, general anesthesia reversed, and the patient was subsequently transported to the postanesthesia care unit, while intubated but spontaneously ventilating, for postoperative monitoring. Chest x-ray was obtained immediately upon arrival, and the patient's pulmonologist notified prior to leaving the operating room regarding possible pneumothorax and need for possible tube thoracostomy.
The patient tolerated the procedure well, and there were no intraoperative complications. Throughout the procedure, somatosensory evoked potential monitoring was maintained continuously and exhibited no changes from baseline at any time. Motor evoked potentials were likewise performed throughout and again were stable throughout.
OPERATION: Anterior cervical disk excision, interbody fusion with right anterior iliac bone graft, and anterior plate fixation, C5-6.
DESCRIPTION OF OPERATION: Under adequate general anesthesia, the patient was placed in the supine position on the OR table. Cervical halter traction was applied with a 10 pound weight drawn in neutral direction. Anterior aspect of the neck and the right anterior iliac crest area was prepped and draped in a sterile manner. A transverse skin incision was made in the anterior aspect of the right side of the neck. The incision was deepened through the subcutaneous tissue and the bleeding points were coagulated. The platysma muscle was incised in the same line of skin incision. A blunt dissection was carried out in the anterior aspect of the neck between the two fascial planes, carotid sheath laterally and tracheoesophageal sheath anteriorly. The anterior aspect of the cervical spine was approached and exposed. A spinal needle was inserted into the distal space and the x-ray was taken to identify the correct level.
The osteophyte formation in front of the anterior C5-6 area was removed with the rongeurs and the drills. Then, disk was removed with pituitary rongeurs. Disk space was severely narrowed and disk was severely degenerated. The end plates were decorticated with the curettes. Then, disk space was distracted and end plates were decorticated. Foraminal entrance was enlarged with a curette on both sides. Then, another oblique incision was made in the anterior aspect of the pelvis. The incision was deepened through the subcutaneous tissue onto the fascia. The fascia was opened over the iliac crest, and outer table of the iliac crest was exposed subperiosteally by elevating the gluteus medius muscle, the fascial attachment on the ilium.
Then, approximately 1 x 1.5 cm cortical cancellous bone plug was removed with an oscillating saw and osteotomes from the other table of the ilium. The bone graft was prepared into the approximately 1 cm width, 8 mm height, and 1.4 cm depth of the cortical cancellous bone block was prepared and this bone graft was impacted into the prepared disk space of C5-6 while the cervical spine was held in the longitudinal direction. The bone graft was securely impacted into the disk space. Then, 14 mm length of the anterior cervical plate was applied. Stryker spine plate was used. Then, by using the drill guide and drills and the tappers, screws were inserted into the C5 and C6. The x-ray was taken, AP and lateral views, to check the satisfactory position of the plate and screws.
Both wounds were irrigated with antibiotic solution. The graft bed on the right side, anterior pelvis, was prepared with bone wax and Gelfoam for hemostasis. Then, gluteus medius muscle and muscle fascia was reattached over the ilium with interrupted #1 Vicryl sutures, and the subcutaneous tissue was closed with #2-0 Vicryl sutures. Skin was closed with #4-0 subcuticular sutures and Steri-Strips were applied. Sterile dressing was applied. On the anterior neck, the platysma muscle was closed with #2-0 Vicryl sutures. Skin was closed with #4-0 subcuticular sutures. Steri-Strips were applied and sterile dressings were applied. The patient tolerated the operation well and left the OR to the recovery room in good condition. Philadelphia cervical brace was applied to the neck.
OPERATION PERFORMED: Lumbar diskography at L2-3, L3-4, and L4-5 levels.
DESCRIPTION OF OPERATION: A right-sided two-needle technique was performed at L2-3, L3-4 and L4-5, as well as an attempt made at L5-S1. An 18-gauge spinal needle was utilized through which a 22-gauge 7-inch spinal needle was advanced. Transpedicular approach was utilized. Betadine prep was used for skin disinfection. Sedation was provided by Anesthesia for conscious intravenous sedation. Skin and subcutaneous infiltration was provided by 1% lidocaine plain preservative-free. Contrast material used was Isovue-M 300 which contained approximately 0.6 mg of clindamycin to each 3 mL of Isovue dye. Results were as follows: At L2-3 level, 1 mL of contrast material was administered to confirm endpoint. The patient had pressure symptoms only. Disk morphology revealed a normal globular appearance. At L3-4 level, 1 mL of contrast material was administered to firm endpoint. The patient had 8/10 concordant pain consistent with her lower back symptomatology. Disk morphology revealed annular fissuring, also with radial tears. There also appeared to be some posterior spread of contrast, evidence of leakage in the epidural space. At L4-5 level, the patient had concordant pain, 1 mL of contrast material was administered to firm endpoint. Annular and radial tears were identified. Her pain level was noted to be 10/10. At L5-S1 level, attempt was made to access the disk; however, we were unable to access this secondary to pain and paresthesias and the patient's anatomy. Therefore, we were unable to perform diskography at the L5-S1 level. Results of three-level diskography indicate a diskogenic source for pain at the L3-4 and L4-5 levels performed consistent with findings on MRI. The patient will proceed to CT scanning and recommendation for intradiskal electrothermal therapy would be recommended at the L3-4 and L4-5 levels.
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Herniated cervical disk at C5-C6.
POSTOPERATIVE DIAGNOSIS: Herniated cervical disk at C5-C6.
OPERATION PERFORMED: Anterior cervical diskectomy and fusion at C5-C6.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General endotracheal.
DESCRIPTION OF OPERATION: The patient was placed under general endotracheal anesthetic in the supine position with the head rotated to the left. The right side of the neck was prepped and draped. An incision on the right side of the neck was made following one of the skin creases. Skin, subcutaneous tissue, and platysma were incised. Dissection was then carried out towards the anterior aspect of the cervical spine by dissecting the carotid vessels laterally and the trachea and esophagus medially. The C-arm was used for localization. Following this, insertion of the longus colli muscle was detached anterolaterally, and the anterior ligament was removed from the bodies of the C5 and C6. The annulus was incised. The distractor post was placed in the body of the C5 and C6. The interspaces were distracted. The operative microscope was brought into place. With the aid of the flat curettes, the cartilaginous plate was detached and then removed. There was evidence of rupture of the posterior ligament with the midline disk herniation and several free fragments. After careful excision of the intervertebral disk and with the aid of the operative microscope, the inferior lip of C5 was removed. The posterior ligament was then opened and small free fragments were also removed. The posterior ligament was excised. The dural sac was totally decompressed. Following this, a small ledge was created in the body of the C6 to act as a stopper for the graft. An 8 mm cornerstone graft was selected and then topped gently into place. Following this, the fusion was completed using the Atlantis plates with the screws on the body of C5 and C6. The position of the screws and plates were confirmed by fluoroscopy. Following this and after careful hemostasis, the wound was closed in layers with Vicryl, and the skin was approximated with the 4-0 Vicryl and adhesive band. The patient tolerated the procedure well.
1. Anterior cervical strut graft arthrodesis, C5-6.
DESCRIPTION OF OPERATION: The patient was brought to the operating room, induced and intubated without difficulty. She had received IV antibiotics in the holding area. The C-arm fluoroscopy unit was set up and a right-sided transverse parasagittal incision was marked off at C5-6. This area was prepped and draped in a sterile fashion. It was infiltrated with 1% Xylocaine with epinephrine and opened with a #10 blade, sharp dissection through the platysma muscle up to the anterior border of the sternocleidomastoid. Sharp and blunt dissection medial to this structure led into the prevertebral space. A handheld Cloward was used to retract the midline structures. A spinal needle was placed at the ________ C5-6 disk space and this was confirmed with a C-arm fluoroscopy unit. At this point, a Bovie cautery was used to dissect the anterior longitudinal ligament of the inferior aspect of C5 and the superior aspect of C6. Medial and lateral Rainbow retractors were placed in the field. Posts were drilled into the bodies of C5 and C6 for axial distraction. Once applied, the microscope was brought in. Under microscopic guidance, the anterior osteophytic disease was drilled away with a Midas Rex drill and the AM-35 drill bit. The disk space was entered and curettes and pituitaries were used to remove loose disk material. The endplates were then drilled down with a Midas Rex drill. A #2 Kerrison was used to remove posterior osteophytes. Decompressive foraminotomies were performed bilaterally including removal of soft disk material from the left hand side at C5-6. Once this was completed, the defect was sized. A 7 mm titanium strut graft was packed with Osteofil and tapped into place under fluoroscopic guidance. At this point, posts were removed and post holes were waxed. A 23 mm anterior cervical titanium plate was selected and secured into the bodies of C5 and C6 with 12 mm variable screws. Locking screws were tightened. Copious irrigation was followed with closure. Bleeding sites were cauterized. FloSeal was placed in the dissection area. The platysma was closed with interrupted #3-0 Vicryl sutures. The skin was closed with #4-0 subcuticular stitch. Steri-Strips were applied, and a dressing was placed on the patient's neck. She awoke in good neurologic condition and was taken to the recovery room.
OPERATION: Elective posterior fossa craniotomy and resection of right CP angle mass.
DESCRIPTION OF OPERATION: The patient was brought into the operative suite, maintained in supine position, and was endotracheally intubated by the anesthesiologist. Prophylactically, the patient received 8 mg of Decadron in addition to 1 gram of Ancef. Upon securing of the ET tube, a Foley catheter was then placed by the OR staff. After that, the patient was then rolled, left side down, onto the bean bag and placed in a 3-point Mayfield head fixation system for a lateral approach. A paramedian incision was made, right behind the mastoid, approximately 2-3 fingerbreadths behind the pinna and mastoid of the ear, straight line incision. Upon fixing of the head into this position and securing of all areas from pressure necrosis during the entire case, the patient was slightly raised approximately 10-15 degrees for preservation of venous drainage during the entire case. The area was shaved and prepped and draped in the usual sterile fashion. A midline incision in the paramedian area, described above, was marked out on the skin, and after being prepped and draped in the usual sterile fashion, infiltrated with local infiltrant consisting of approximately 15 mL of 1% lidocaine, 1:100,000 epinephrine. After draping the area, skin incision ensued with a 10-blade down to the level of the paravertebral musculature and bowing through that area down to the level of the periosteum. With the periosteal elevator, the periosteum was lifted off exposing the calvaria down almost to the level of the ring of C1 and superiorly up to the occipital bone. Self-retaining retractors were then introduced to hold back the skin edges and the muscle, and at the landmarks of the asterion, a 14-mm perforator was then used to bur down to the level of the dura. This was matured and then a small craniotomy performed, approximately 4 to 4.5 cm in diameter, with its superior margin at the asterion, transverse sinus extending down inferiorly along the lateral edge of the posterior fossa and then laterally out to the sigmoid sinus. This area was enlarged with use of the bur and drilled down in the mastoid, exposing some the air cells which were immediately waxed with bone wax for preservation of CSF contiguity and prevention of a CSF leak. At that point in time, once our bone flap was enlarged with the Midas Rex drill and in addition with small Leksell rongeurs, deep dura was opened up in a curvilinear fashion exposing the cerebellum and out to the CP angle.
At that time, the lateral medullary cistern was opened up allowing free egress of CSF. This facilitated a great amount of cerebellar relaxation. At that point in time, the Leyla retractor was then placed onto the OR table, and with the Leyla retractor blade and protection of the cerebellar hemisphere, a small retractor was then placed onto the cerebellum and lifted superomedially exposing the CP angle. Immediately, under evidence was a very large tumor adherent to the petrous ridge and to the skull base. The rest of the procedure was then performed under the microscope and with neural monitoring. Upon exposure of the tumor, the stimulation was then performed for areas along the tumor surface for rough entrance into the tumor to see where the facial nerve and trigeminal nerve are wrapped around the tumor. This did not appear to be a typical schwannoma. It seemed to be very gritty and very adherent to the neurovascular structures. Immediately evident was the PICA, which seemed to be engulfed by the tumor and running amongst the middle of it. In addition, superiorly was ICA, which was extremely adherent to the superior edge of the tumor. At that point in time, through stimulation, we found a pattern, which was nonstimulatory, and this was bipolared and small and opened and evacuated of some tumor contents with the suction dissection. This freed up some of the capsule and allowed further mobility until further dissection of the facial nerve was evident through stimulation. The facial nerve is quite splayed out over the superior and anterior extent of the tumor. We kept on debulking the tumor from within and reducing its blood supply, as it was very adherent to the skull base and to the petrous ridge margin.
At that point in time, several small biopsies were sent for frozen pathology, which came back as a meningioma with psammoma bodies. We continued debulking this tumor and decompressing it off the brainstem. Circumferentially, we surrounded it with cottonoids and continued in a superior-to-inferior direction with constant stimulation and guiding so as not to take any cranial nerves. Facial nerve has been splayed out, quite compressed, but still stimulates at approximately 0.3 mA at the brainstem. We continued debulking the tumor, now with a small CUSA as it entered into the porus. The porus is enlarged and widened out and is completely devoid of normal anatomy. There is no need to drill down a porus that is completely adherent to the facial nerve and would cause further damage to the facial nerve. We continued out in debulking the tumor and basically amputated as it enters the porus. The complete intracranial compartment has been completely devoid of tumor. The facial nerve appears intact in the field and actually has stimulation at approximately 0.3 mA at the brainstem. The trigeminal nerve has been compressed and pressed superiorly but is intact in stimulation and stimulatory. In addition, there has been no compression on IX-X-XI complex inferiorly. ICA has been freed and so has PICA from the substance of the tumor and is intact with multiple loops in the area. This may be representative because the tumor has pulled and compressed ICA at several areas. We have abandoned going into the porus and drilling out further tumor at this area. This should be followed up with radiosurgery.
At that point in time, all bleeding points were coagulated with the use of bipolar cautery. There was minimal blood loss in the intracranial compartment, and the dura was then closed partially with interrupted 4-0 Nurolon sutures. A small area, which had not come together, has a Dura-Guard patch of approximately 1 x 2 cm placed in the middle of it, and this was secured in place with 4-0 Nurolon sutures. This was tested for watertight closure with irrigation fluid into the posterior fossa compartment. At that point in time, fibrin glue was then placed over the suture line of the dura. The mastoid was waxed again for prevention of any air leaks and CSF leaks during this time. The bone was then secured back in place with three 2-hole Synthes self-drilling setscrews and 4 x 1.5 mm screws. Once the bone had been secured in place, the self-retaining retractors were then removed allowing the paravertebral muscle contents and the paracervical strap muscles to come fall back into the normal contour.
The fascia was closed with interrupted 2-0 Vicryl sutures. The superficial fascia was then closed with interrupted 3-0 Vicryl sutures, then subcutaneous closed with 3-0 Vicryl sutures, and the skin was closed with a running continuous Monocryl stitch for watertight closure. Dry sterile dressing was then placed. The patient was then removed from 3-point Mayfield head fixation system and allowed to roll back onto the OR stretcher at the side of the bed. Upon moving all of her extremities and opening and closing her eyes spontaneously, there was a slight lower facial droop noted from approximately jawline down. This seems to be somewhat worse than the preoperative status. However, her eyes are opening and closing uninhibitedly and the eyes pointing normally. In addition, the tongue was quite midline at the end of the procedure. The patient was then endotracheally extubated and transferred to the recovery room without incident.