Operative Planning

• Review imaging (computed tomography, radiographs, myelogram, magnetic resonance imaging)
  
• Penetrating injuries of the cervical spine require evaluation of the carotid and vertebral arteries with angiography
  
• Early surgery within the first week following injury is associated with high complication rates; delayed surgery is preferred unless there is progressive neurologic deterioration.
  
• Dorsal approach is most commonly used for penetrating spinal wounds, but a transpedicular approach may be utilized for anterolateral and lateral extrinsic mass lesions:
  
  
  
  
  • Anterior approaches to the thoracic and lumbar spine usually do not offer wide enough exposure to the dural sac for cases that require intradural exploration and dural repair; anterior approaches are best reserved for instances of masses causing extrinsic dural compression
    
  • The following discussion concerns decompression, with stabilization procedures covered elsewhere

Special Equipment

• Spinal tray
  
• High-speed drill optional
  
• Mayfield head holder

• Arterial line for blood pressure monitoring
  
• Intravenous antibiotic prophylaxis (cefazolin 2 g or vancomycin 1 g for adults) should be given 30 minutes prior to incision
  
• There is no clinical evidence to support use of preoperative steroids

Positioning

• Patient in prone position
  
• Head fixation with Mayfield head holder for posterior cervical approaches

Planning of Incision and Laminectomy

• Midline incision centered over the level(s) of injury and allowing exposure of several levels rostral to injury
  
• Paraspinal muscles are reflected in the subperiosteal plane: avoid plunging into the spinal canal through a bony defect with the Bovie cautery.
  
• A wide laminectomy is performed to expose the entry site of the missile into the dura and to provide decompression of the spinal cord at levels rostral to the penetrating injury.
  
• Facet joints are preserved.

Dural Opening

• If intradural exploration is indicated, the dura is opened further with a midline incision to expose the injured segment of the spinal cord.
  
• The dural opening is maintained with tacking sutures.
  
• A midline myelotomy is used to gain access to an intramedullary hematoma or mass; deviation from the midline causes injury to the posterior columns.
  
• The intramedullary clot is removed with suction, irrigation, and minimal manipulation of the spinal cord tissue.

Closure

• Dura is closed with a running suture, without constriction of the dural contents.
  
• Dural defects that cannot be primarily repaired may be closed with patch grafting of harvested fascia lata or thoracodorsal fascia.
  
• Inaccessible dural defects in the ventral dural sac are not explored.
  
• Muscle and fascia are closed in layers with Vicryl sutures.
  
• Skin is closed with staples.

• Continue prophylactic antibiotics for 24 hours