•  With the working portal appropriately docked on the level of pathology, an initial exposure can be performed. •  Often there are residual paraspinal muscle fibers that must be removed…

•  The end plate is clearly visualized. The spinous process is centered between both pedicles. The Jamshidi needle is started at the 2 o’clock position. •  The Jamshidi trocar is…

•  The patient is placed into a direct lateral position. •  It is essential that the patient be directly perpendicular to the ground to ensure true anteroposterior (AP) and lateral…

Superficial landmarks include: •  hyoid C3 •  thyroid cartilage C4–5 •  cricoid C6 •  A horizontal incision is made just medial to the sternocleidomastoid muscle (SCM). •  A decision on…

Skin Incision •  A midline incision is used over the levels that are to be resected. •  The fascia is clearly identified prior to incision. •  The fascia is then…

Step 1: Pedicle Start Point Is Identified •  The pedicle start point is identified through the working portal. This allows for medial-lateral orientation in the anteroposterior (AP) plane. •  Lateral…

•  By use of an AP fluoroscopic image, key bony landmarks are identified: – midline (spinous processes) – pedicular line (lateral edge of the pedicle) vertical horizontal – skin incision…

Exposure and Approach •  A lateral fluoroscopic image should be obtained before incision to localize the surgical level. At the L5-S1 level, the great vessels (aorta/vena cava) have bifurcated. At…

•  Subperiosteal exposure of the occiput and the C1–C2 vertebral levels is essential for instrumentation placement. •  The vertebral artery travels along the superior lateral surface of the C1 arch…