Operative Planning

• Location (cervical, thoracic, lumbar) helps determine risks and morbidity of different approaches
  
• Biopsy proven pathology
  
• Staging of disease
  
  
  
  
  • Life expectancy should exceed 3 months, unless to prevent paraplegia
  
  
• Cardiac and medical clearance
  
  
  
  
  • What type of exposure will patient tolerate
    
  • What level of disease defines surgical options
  
  
• Type of decompression/resection
  
  
  
  
  • Palliative
    
    
    
    
    • Start within tumor to the margin of solid bone
      
    • Decompress to dura
      
    • Ventral stabilization
      
    • Cement
      
      
      
      
      • Bone rarely fuses in cancer cases.
      
      
    • Titanium (not stainless) for vertebral body replacement if cage used
      
      
      
      
      • Expandible cage
    
    
  • Oncological
    
    
    
    
    • Spondylectomy or vertebrectomy
      
    • Clean margins
      
    • Complete removal: may be after posterior first stage procedure to remove the dorsal component of the vertebral segment
  
  
• Embolization
  
  
  
  
  • Necessary for renal cell, thyroid, myeloma/plasmacytoma
    
  • May be beneficial for other lesions
  
  
• Localization
  
  
  
  
  • Preoperative placement of radiopaque localizing implant (such as Guglielmi detachable coils [Target Therapeutics, Fremont, CA] placed into costotransverse junction, metallic pin placed on transverse process [so it does not migrate])
    
  • Make identification of level easier if there is no clear intraoperative localizer with intraoperative fluoro (such as isolated epidural disease in the mid-thoracic spine with no obvious local landmarks like a compression fracture, large unique osteophyte, etc.)

• Computed tomography scan (bone windows)
  
• Magnetic resonance imaging
  
• Spine x-rays

Operating Room Set-up

• Equipment
  
  
  
  
  • Fluoro compatible table
    
  • Fluoro unit
    
    
    
    
    • Multiaxial reconstruction unit
  
  
• General anesthetic issues
  
  
  
  
  • If motor evoked potentials monitoring, then recommend total intravenous anesthesia or minimal inhalational
    
    
    
    
    • Small (1 mg/hr) vecuronium if strong potentials
    
    
  • Large bore catheters
    
    
    
    
    • Central line
      
    • Introducer, if possible
      
    • Not groin line unless for a-line
    
    
  • Multiple units packed red blood cells in operating room before start
    
    
    
    
    • Be prepared for massive transfusion, including factor and even factor 7 transfusion
    
    
  • Although some advocate using cell saver with tumors using leukocyte filter, but the authors do not recommend this.
    
  • Keep all metallic artifact-generating wires out of the fluoro field circum-ferentially

Cervical