Operative Planning

• Biopsy proven pathology
  
• Staging of disease
  
• Life expectancy dictates extent of the procedure, unless to prevent paraplegia
  
• Cardiac and medical clearance
  
• Pulmonary status
  
  
  
  
  • What type of exposure will patient tolerate
    
  • What level disease defines surgical options
  
  
• Embolization
  
• Localization
  
  
  
  
  • Preoperative placement of radiopaque localizing implant (such as Guglielmi detachable coils placed into costotransverse junction, metallic pin placed on transverse process [so it does not migrate])
    
  • Make identification of level easier if there is no clear intraoperative localizer with intraoperative fluoro (such as isolated epidural disease in the mid-thoracic spine with no obvious local landmarks like a compression fracture, large unique osteophyte, etc.)
  
  
• Consideration of less invasive palliative treatments
  
  
  
  
  • Vertebroplasty/kyphoplasty
    
  • Radiation therapy alone or as stereotactic radiosurgery
    
  • Pain stimulator
    
  • Pain pump

• Computed tomography scan (bone windows)
  
• Magnetic resonance imaging
  
• Spine x-rays

Equipment

• Fluoro compatible table
  
• Fluoro unit
  
  
  
  
  • Multiaxial reconstruction unit
  
  
• Exposure determines retractors

Operating Room Set-up

• Equipment
  
  
  
  
  • Fluoro (Best: isocentric or O-arm [Medtronic] type unit that allows axial, sagittal, and coronal reconstructions)
    
  • Spinal table (Best: Jackson or Allen [Allen Medical Systems, Acton, MA] type table that allows for fluoro through table rather than standard operating room table with central pedestal and bolsters)
    
  • Minimally invasive set-up (if used) locked to opposite side as surgical side
    
  • Anesthesia at head, nursing table at feet
  
  
• Anesthetic issues
  
  
  
  
  • Single lumen tube
    
  • If monitoring motor evoked potentials, then recommend total intravenous anesthesia or minimal inhalational
    
    
    
    
    • Small (1 mg/hr vecuronium if strong potentials)
    
    
  • Large bore catheters
    
    
    
    
    • Central line
      
    • Introducer, if possible
      
    • Not groin line unless for a-line
    
    
  • Multiple units packed red blood cells in operating room before start
    
    
    
    
    • Be prepared for massive transfusion, including factor and even factor 7 transfusion
      
    • No postoperative or intraoperative use of nonsteroidal anti-inflammatory drugs
      
    • No blood recycling use (some use leukocyte filter, we do not trust it to remove all tumor prior to blood return)
      
    • Antibiotics on board prior to incision