Operative Planning

• Imaging
  
  
  
  
  • Magnetic resonance imaging (MRI)
    
  • Computed tomography (CT) myelogram if MRI is inconclusive
    
  • Flexion/extension x-rays
    
  • CT scan may be helpful/necessary to assess presence/configuration of os-teophyte and to better understand bone anatomy/quality
  
  
• Monitoring (e.g., motor evoked potentials, somatosensory evoked potentials, electromyography) may be considered depending on patient’s pathology, monitoring availability, and local/surgeon practice

Equipment

• Basic spine tray
  
• Additional helpful instruments:
  
  
  
  
  • Small “pediatric” Weitlaner retractor (blunt ideal)
    
  • Debaky forceps, vascular clips
    
  • Kittner dissector sponges
    
  • High-speed drill (Midas Rex with AM-8 bit; consider angled handpiece and diamond burr)
  
  
• Anterior cervical retractor set (e.g., Shadow-Line [V Mueller Neuro], TrimLine [Medtronic], Thompson-Farley)
  
• One- and 2-mm Kerrison punches with thin footplates

Operating Room Set-up

• Headlight
  
• Loupes
  
• Microscope
  
• Bipolar cautery and insulated-tip Bovie cautery
  
• Intraoperative x-ray and/or fluoroscopy

Anesthetic Issues

Positioning

• Head on soft padded “doughnut” in neutral position (especially if fusion to be performed)
  
• Gentle cranial extension with shoulder roll (as tolerated)
  
• Appropriate padding to prevent pressure neuropathies
  
• Arms tucked at sides. Gentle shoulder traction may be helpful but use caution to avoid/limit brachial plexus stretch.
  
• Intraoperative x-ray/fluoroscopic imaging used to confirm cervical alignment and guide incision

Planning of Sterile Scrub and Prep

• Use disposable clippers for minimal shave (if needed)
  
• Betadine detergent scrub
  
• Alcohol wipe (avoid leaving residual as potentially flammable with intraoperative sparks from cautery)
  
• Sterile towel to dry

Mark Incision

• Localization using anatomic landmarks and intraoperative x-ray
  
• Transverse curvilinear incision in skin crease for most cases
  
• Consider longitudinal incision along medial sternocleidomastoid muscle for difficult anatomy or many levels
  
• Consider injection of subcutaneous lidocaine with epinephrine (may minimize skin bleeding and patient stress)

Exposure

• Incision with #10 or #15 blade
  
• Along incision line, elevate and divide platysma sharply with Metzenbaum scissors or Bovie cautery (with attention to underlying veins)
  
• Dissect along medial border of sternocleidomastoid
  
• For lower cervical approach, identify omohyoid (usually around C5–C6, may divide if needed but can usually work above it)
  
• Identify, protect, and work medially to the carotid sheath structures
  
• Kittner dissectors and handheld Cloward retractors helpful to identify/ develop appropriate plane to expose longus coli muscles, prevertebral fasica, and underlying disc spaces and vertebral bodies
  
• Verify levels with x-ray/fluoroscopy