Читать книгу Neurosurgery Outlines - Paul E. Kaloostian - Страница 89

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks

2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist

3. Patient placed in supine position with all pressure points padded

4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)

5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed

6. Make an incision on medial border of right sternocleidomastoid, extending down over manubrium

7. Perform median sternotomy with sternal saw (see ▶Fig. 2.10)

8. Mobilize sternocleidomastoid laterally and trachea/esophagus medially, exposing anterior cervicothoracic spine

9. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma:

a. Using Leksell rongeurs and hand-held high-speed drill, remove disk material at the affected level

b. Remove the thick ligamentum and any bone spurs with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak

Fig. 2.10 Intraoperative images demonstrating anterior cervicothoracic view. (a, b) Represent the incision position for a transsternal approach to a T1 corpectomy. (c, d) The exposure of the ventral cervicothoracic junction using retractors, following a sternotomy. (Source: Cervicothoracic corpectomy. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).

c. Perform complete decompression of anterior cord with Kerrison rongeurs as needed for appropriate decompression of nerve roots

d. Irrigate surgical site

10. Perform spinal fusion with instrumentation (if necessary, most often not needed):

a. Perform reconstruction with expandable cage and autograft

b. Perform screw-plate fixation

11. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative Jackson-Pratt drains:

a. Achieve closure of sternum with sternal wires