Surgical Details of the Procedure
1. The patient is placed supine (face up) on the operating room table.
2. After anesthesia is induced, the area from the upper torso to the chin line from “table to table” is prepped and draped in the normal sterile fashion.
3. The previously performed MRI is viewed to recheck the assessment of level of pathology.
4. A needle is placed at the level of the pathology with flouroscopy performed to judge the correct site of the incision.
5. A horizontal skin incision is made approximately 5 cm in length lateral to the trachea on the right sidewith a No 15 blade.
6. The Bovie cautery is used to dissection through the subcutaneous tissues until the platysma muscle is appreciated.
7. The platysma muscle is then carefully incised with the bovie cautery with care taken to avoid penetrating deeper into the neck space.
8. Platysma flaps are then raised by grasping the cut edges of the platysma and used sharp dissection with a scissors to free the muscle fibers from the underlying fascia.
9. If multiple layers of cervical spine fusion are planned, care must be taken to thoroughly release the platysma to allow adequate exposure.
10. Once the platysma has been released, careful blunt dissection is done into the deep space of the neck to gently sweep the more lateral structures of the carotid sheath (carotid artery, jugular vein, and vagus nerve) away from the prevertebral fascia of the spine.
11. In addition, the esophagus is bluntly but carefully dissected away and laterally from the spine.
12. Once the tissue planes have been elucidated, a self-retaining retractor is placed horizontally in the wound to visually expose the structures.
13. A second check to ascertain that the operation is being performed at the correct level is done by again placing a needle into the vertebral bodies and using flouroscopy to obtain a visual record of which cervical vertebra have been exposed.
14. The pins used for the distracting mechanism are then inserted both cephalad and caudal to the area of pathology by hammering them securely into the vertebral bodies.
15. The distracting scaffold is then attached to the pins and ratcheted open to spread the inter-vertebral areas and to expose the disc space, which is easily visualized as a glistening white waxy type material.
16. A pituitary grasper or similar instrument such as a Decker graspher is used to grasp and pull out the disc material.
17. To facilitate easy removal the osteophytic (bony) ridge on the lower border of the involved vertebral bodies is removed via grinding.
18. As the intervertebral disc is removed in pieces superficially to deep, care is taken to visualize any posterior osteophytes (bony spurs) that might be projecting deep toward the spinal cord.
19. If present, the osteophytes are carefully eliminated with the drill, with care taken to not tear the dura on the anterior of the spinal cord, which is easily visualized by its white, glistening fibers running vertically.
20. Once the bony obstructions have been removed a diligent search is made for any herniated disc remnants, which are removed.
21. The upper and lower borders of the vertebral bodies are then ground such that the intravertebral space is smoothly rectangular to facilitate the placement of the bone graft.
22. The anterior surface of the vertebral bodies are also smoothed with the grinder to allow the titanium plate to sit evenly.
23. The site is then inspected for bleeding and meticulous care is made to obtain hemostasis with surgicel or like hemostatic agents.
24. The bone graft is then sized so that if will fit snugly into the intravertebral space.
25. It is gently tapped into place with a small bone mallet
26. The retracting ratchet is then released to allow the vertebral bodies to full contact the bone graft
26. After the bone graft has been placed, the titanium plate is then placed on the anterior surface of the previously ground verterbral bodies.
27. The plate screws are then inserted into the vertebral bodies with at least two screws placed cephalad and caudal, with care being taken to place the screws so that they are slightly “splayed” to help retard loosening.
28. Flouroscopy is used again to view radiographically the positioning of the vertebral bodies, plate, and screws.
29. Again, a meticulous inspection of the site is performed to insure hemostasis
28. The soft tissue retractor is then removed, allowing the esophagus and contents of the carotid sheath to return to normal anatomic position
29. The cut edges of the platysma are then reapproximated using an absorbably suture such as a 2-0 Vicryl
30. The dermis and epidermis is then closed using a standard subcuticular stitch such as a 4-0 Maxon.
31. Steri-strips may be applied to the incision