Imaging

• Be certain that all required studies are at your disposal
  
• Carefully review all imaging studies for side and/or level of operation, relevant anatomic variants, previous surgeries, etc.
  
• Review preoperative planning/navigation studies
  
• Make certain all navigation studies and plans are successfully uploaded and merged to the computer workstation

Preoperative Work-up

• Follow the internist/cardiologist recommendations; that is, preoperative beta-blockade, prophylactic antibiotics coverage for heart valves, cessation of anticoagulation, postoperative myocardial infarction rule out (troponin/electrocardiogram)
  
• Review all allergies and medications (check for anticoagulation)

Booking/Scheduling

• Check for correctness of procedure, side, time, equipment, etc.
  
• Ensure that all implants, grafts, and hardware are available
  
• Contact neurology/neurophysiology, if appropriate

Co-surgeons/Consult Services

• Discuss case with co-surgeons or relevant surgical consult services well in advance of the procedure

Anesthesia

• Discuss case with the anesthesia team with regard to type of anesthesia, blood pressure parameters, length of case, positioning issues, intraoperative monitoring, endotracheal tube position, etc.

Imaging

• Hang all relevant images on the light box
  
• Check navigation workstation images early
  
• Check fluoroscopy set-up
  
  
  
  • Consider C-arm and monitor position
    
  • Have comfortable lead vests available

• Check operating room (OR) table set-up prior to transferring patient; that is, reverse table (most craniotomies), bolsters (prone cases), Wilson frame (Mizuho OSI, Union City, CA), U-bars, Yasargil (Leyla) bar attachment (Aesculap, Inc., Center Valley, PA), bean-bag (lateral cases), cooling blanket (vascular cases), etc.
  
• Ensure appropriate patient position and padding prior to head pinning
  
• Protect all lines during patient manipulation
  
• Strap patient well prior to bed manipulation
  
• Center the operative field under the overhead lamps

Microscope

• Balance the microscope for any case where dura might be exposed or at risk
  
• Check for appropriate optic attachments and video recording devices
  
• Test all monitors and recording devices before scrubbing
  
• Look through all eyepieces and adjust each eyepiece accordingly
  
• Check lamp and light intensity
  
• Consider location of the microscope base relative to other equipment and personnel at final set-up

Miscellaneous

• Loupes: have them in the room
  
• Headlight: put the base in the appropriate location and test the lamp
  
• Foley catheter placement (longer cases)
  
• Arterial line
  
• Antibiotics (administer 20 to 30 minutes prior to incision)
  
• Stero id s (±)
  
• Mannitol (±): discuss timing of administration with anesthesia
  
• Spinal drain (±): if necessary, ensure that the drain is working after final positioning and discuss management with anesthesia
  
• Graft harvest (±): if necessary, be certain to leave this area exposed for preparation and draping
  
• Intraoperative angiogram (±): if necessary, leave the groin exposed for preparation and draping

• Obtain immediate postoperative examination in the OR whenever possible
  
• Steroid taper should be tailored to the pathology/procedure
  
• Continue prophylactic antibiotics for 24 hours
  
• Follow medical recommendations (beta-blockage, stress dose steroids, diabetes insipidus watch, myocardial infarct “rule-out,” etc.)
  
• Resume appropriate preoperative medications as soon as possible
  
• Consider deep vein thrombosis prophylaxis in any patient who might remain immobile several days postoperatively