Operative Planning

• Patient counseling regarding risk, benefits, and postoperative course
  
• Appropriate 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 (CT)
    
    
    
    
    • Evaluate bony anatomy
    
    
  • CT/myelogram
    
    
    
    
    • If MRI contraindicated

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

Special Equipment

• Cell saver: if significant blood loss anticipated in the absence of infection/neoplastic disease
  
• Microscope: for intradural pathology

Operating Room Set-up

• Prone table: Jackson table with Wilson frame or bolsters
  
• Mayfield head holder versus Gardner Wells tongs with traction
  
• Intraoperative anteroposterior and lateral x-ray versus fluoroscopy

• Secure endotracheal tube for prone position
  
• Appropriate blood pressure monitoring
  
• Foley catheter for extended cases (beyond 3 hours)
  
• Perioperative antibiotics 30 minutes prior to skin incision
  
• Perioperative steroids for decompressive or intradural pathology
  
• Avoid any orbital compression if patient’s face placed on cushioned mask

Positioning

• Prone position
  
  
  
  
  • Arms tucked along side for pathology rostral to T6–T7
    
    
    
    
    • Head secured with Mayfield head holder or Gardner Wells tongs and 15 lb of traction
    
    
  • Arms placed on cushioned boards for pathology caudal to T6–T7
  
  
• Maintain exposure of posterior iliac crest if fusion intended
  
• Ensure that patient is well secured to the operative table in case rotation of the table is desired to enhance ventral visualization.

Sterile Prep

• Shave with disposable razor
  
• Standard scrub and prep

Incision Localization

• Anteroposterior x-ray used to localize spinal level
  
  
  
  
  • Requires preoperative verification of rib number

Exposure

• Midline incision
  
• Subperiosteal dissection of paraspinal muscles off spinous processes and lamina to the lateral extent of transverse process
  
• Verify level with intraoperative x-ray
  
• Placement of self retaining retractors (e.g., Weitlaner or Adson-Beckman)
  
• Clear intralaminar soft tissue with curettes/rongeurs