Imaging

• Plain x-rays
  
  
  
  
  • Determine number of ribs for localization
    
  • Assess deformity and/or instability
  
  
• Magnetic resonance imaging (MRI)
  
  
  
  
  • Determine extent of neural element compression
  
  
• Computed tomography
  
  
  
  
  • Evaluate bony anatomy
  
  
• Computed tomography/myelogram
  
  
  
  
  • If MRI contraindicated

Operative Planning

• Patient counseling regarding risk, benefits, and postoperative course

Routine Equipment

• Basic spine tray including Kerrison rongeurs (2 to 4 mm)
  
• Cautery–monopolar and bipolar
  
• High-speed drill (e.g., Midas Rex)
  
• Headlight and loupe magnification
  
• Table-mounted retractor (Thompson-Farley versus Omni-Tract)

Special Equipment

• Cell Saver if significant blood loss anticipated in the absence of infection/neoplastic disease
  
• Microscope for intradural pathology
  
• Spinal instrumentation if reconstruction intended

• Prone table: Jackson table with Wilson frame or bolsters
  
• Make sure patient secured well in case rotation of table required
  
• Mayfield head holder versus Gardner-Wells tongs with traction
  
• Radiolucent table for intraoperative anteroposterior and lateral x-ray versus fluoroscopy

Anesthetic Issues

• Secure endotracheal tube for prone position
  
• Appropriate blood pressure monitoring
  
• Foley catheter
  
• Perioperative antibiotics 30 minutes prior to skin incision
  
• Perioperative steroids for cases of spinal cord compression
  
• Avoid any orbital compression if patient’s face placed on cushioned mask

Positioning

• Options
  
  
  
  
  • Standard prone position
    
  • Three quarter prone with side of pathology elevated

Planning of Incision

• Options
  
  
  
  
  • Extended midline incision to obtain adequate lateral exposure
    
  • A hockey stick incision allows for shorter incision length
    
  • Semicircular skin incision centered over pathologic level
    
  • Paramedian incision, ~6 cm off midline
  
  
• The side of incision is dictated by the lateralization of the pathology

Planning of Sterile Preparation

• Standard scrub and preparation

Exposure

Bone Removal and Thecal Sac Decompression

• Once the neuroforamen is identified, the ventral aspect of the canal is verified with a blunt dissecting instrument and the tissue surrounding the pedicle of interest is cleared with curettes.
  
• The pedicle is resected with high-speed drill and Kerrison rongeurs to expose the lateral canal and dural sac.
  
• The discs above and below the level of pathology are incised and resected with a combination of pituitary and Kerrison rongeurs.
  
• Resection of the ventral vertebral body/pathology is initially performed with curettes, high-speed drill, and rongeurs to create a ventral defect up to the dorsal vertebral body cortex.
  
• The remaining dorsal bone is broken in the ventral defect to decompress the dural sac.
  
• If required, the dorsal canal can be decompressed with the addition of a laminectomy with this approach.

Closure

• Irrigate operative field
  
• Inspect pleura for tears and perform primary closure if confined to the parietal pleura
  
• Insert chest tube for evidence of air leak
  
• Hemovac placed in paravertebral region
  
• Close incision in layers with reattachment of any transected muscles
  
• Staple skin

• Appropriate pain control, will usually require patient-controlled analgesia
  
• Continue antibiotics for 24 hours
  
• Chest x-ray in recovery room to rule out pneumothorax
  
• Early postoperative imaging if instrumentation inserted or instability suspected
  
• Consider external orthosis (e.g., thoracolumbosacral orthosis) for cases involving spinal reconstruction or extensive bony resection