Operative Planning

• Review imaging: magnetic resonance imaging, computed tomography (CT), radiographs, or CT myelogram
  
• Note location within the spinal canal: cervical location most common
  
• Identify ventral-to-dorsal and rostral-to-caudal extents of the lesion
  
• These lesions frequently extend laterally through the intervertebral foramen into the extraforaminal region to become dumb bell-shaped tumors
  
• Consider preoperative fluoroscopic localization of level in thoracic lesions; otherwise, intraoperative radiographs are used to identify the correct level

Equipment

• Basic spine tray
  
• High-speed drill (Midas Rex with AM-8 bit [Medtronic])
  
• Operating microscope with bridge
  
• Somatosensory evoked potential or direct motor evoked potential monitoring may be used in tumors causing severe spinal cord or cauda equina compression

Anesthetic Issues

• Arterial line for blood pressure monitoring
  
• Intravenous dexamethasone and antibiotic prophylaxis (cefazolin 1 to 2 g) administered preoperatively
  
• In cases of severe cord compression make sure blood pressure does not fall below baseline during induction to prevent ischemic cord injury

Positioning

• For posterior approaches, patient prone with pressure points well padded
  
• Mayfield head fixation in cervical lesions

Posterior Cervical Approach

• For lesions of the cervical cord or cervicothoracic junction

• For lesions of the thoracic cord, cervicothoracic junction, or thoracolumbar junction

Retropleural Thoracotomy, Costotransversectomy, Lateral Extracavitary, and Transthoracic Approaches

• For anteriorly and anterolaterally located thoracic tumors

Posterior Lumbar Approach

• For lesions of the lumbar cord, thoracolumbar junction, or conus

Retroperitoneal Approach

• For anteriorly and anterolaterally located thoracolumbar and lumbar tumors