A Outpatient Evaluation and Management 1 Obtain focused history and performs focused neurological exam describe key physical exam maneuvers (cervical nerve root function) C5 primary motion shoulder abduction elbow flexion (palm up) tested muscles deltoid biceps sensory lateral arm below deltoid reflex biceps C6 primary motion elbow flexion (thumb up) wrist extension tested muscles brachioradialis ECRL sensory thumb and radial hand reflex brachioradialis C7 primary motion elbow extension wrist flexion tested muscles triceps FCR sensory fingers 2, 3, 4 reflex triceps C8 primary motion finger flexion tested muscles FDS sensory finger 5 reflex none T1 primary motion finger abduction tested muscles interossei (ulnar n.) sensory medial elbow reflex none 2 Appropriately interprets basic imaging studies radiographs AP and Lateral views oblique view shows foraminal narrowing flexion-extension views instability rigidity sagittal plane deformity 3 Appropriately orders and interprets advanced imaging studies MRI central stenosis foraminal stenosis identifies nerve root anatomy CT-myelography invasive procedure that shows anatomy typically used in cases where MRI is contraindicated 4 Prescribes and manages nonoperative treatment medical management attempts medical management of cervical radiculopathy (NSAIDs, gabapentin) orders appropriate diagnostic and therapuetic selective nerve root or epidural steroid injections<br> attempts trial of physical therapy 5 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 6 Provides, modifies and adjusts procedure and patient specific post-operative management and rehabilitation postop: 2-3 Week postoperative visit wound check diagnose and management of early complications<br /> postop: ~ 6 week postoperative visit remove soft collar diagnosis and management of late complications<br /> postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Provides complex non-operative treatment individualized care, shared decision making, comprehensive informed consent 2 Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for complex cases multilevel stenosis with deformity 3 Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for complex cases multi-level stenosis with deformity C Preoperative History and Physical 1 Neurological exam need to carefully document neurological status of bilateral upper extremities strength, sensation, reflexes, and primary symptoms 2 Screen medical studies to identify any contraindications for surgery 3 Order basic imaging studies order triplanar radiographs 4 Perform operative consent describe complications of surgery including postoperative hematoma postoperative dysphagia infection esophageal perforation Horners syndrome symptomatic recurrent laryngeal nerve palsy instrumentation backout
E Preoperative Plan 1 Radiographic templating template plate size and levels of fusion 2 Execute surgical walkthrough describe the steps of the procedure to the attending prior to the start of the case describe the potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation Loupes or operating microscope 2 Room setup and equipment standard OR table fluoroscopy 3 Patient positioning supine position Gardner-Wells tongs 15 pounds of traction adduct arms tuck and tape arms to the side G Dissection to Platysma 1 Identify landmarks and draw transverse incision. identify the hyoid bone at C3 thyroid cartilage over C4-C5 cricoid cartilage over C6 use the sternal notch and the midpoint of the chin as midline anatomic markers 2 Make skin incision make a transverse incision that extends from the midline to the middle of the sternocleidomastoid muscle this is used to expose one to three levels left sided approach is more common because of the more consistent course of the recurrent laryngeal nerve 3 Create plane undermine the skin and the subcutaneous tissue superiorly and inferiorly divide the platysma in line with the skin incision H Dissection to Anterior Verterbral Bodies 1 Divide the platysma create defect with mosquito clamp elevate and divide platysma with Bovie cautery 2 Divide deep cervical fascia retract the strap muscles medially and the sternocleidomastoid laterally push the muscle belly of the sternocleidomastoid medially to ensure that the proper plane is developed perform blunt dissection through the pretracheal fascia be aware that the superior, middle and inferior thyroid arteries are housed in the pre-tracheal fascia directly anterior to the C3, C5 and below the C6 vertebra respectively 3 Identify the left recurrent laryngeal nerve ascends after curving around the aortic arch along the tracheoesophageal groove the nerve is more along the midline than the right RLN 4 Mobilize deep structures mobilize the carotid sheath laterally feel pulse to confirm it is lateral move the trachea and the esophagus medially 5 Determine vertebral level take a lateral radiograph to determine the appropriate level 6 Expose verteba elevate the longus colli muscle with cob elevator or curette I Diskectomy 1 Place caspar pins and distract across disk space. 2 Sharply incise the anterior annulus and remove the ALL 3 Remove disc material until PLL visualized use curets and rongeurs to perform the diskectomy to the uncovertebral joints laterally these joints are recognized by the upcurving of the endplate at the uncus 4 Clear endplates use a burr to remove any anterior osteophytes from the endplates 5 Lateralize discectomy J Decompression of Spinal Cord and Nerve Roots 1 Remove Posterior Longitudinal Ligament use curets and rongeurs to perform the diskectomy through PLL posteriorly the PLL is recognized by the vertical orientation of its fibers 2 Perform Bilateral Foraminotomy always work from lateral to medial K Interbody Graft Placement 1 Open up the disk space use skeletal traction, lamina spreaders or vertebral screws to distract the disk space 2mm greater than preexisting disk height or a total of 5mm overdistraction of the disk space more than 4 mm from preexisting disk height can result in graft collapse and pseudoarthrosis 2 Create vascular channels burr the endplates to create a flat surface on both sides of the intervertebral space create 3 to 4 mm holes in the middle of the endplates 3 Place graft place autograft and inset 2 mm beyond the vertebral bodies graft should be stable to compression after the removal of skeletal traction L Anterior Cervical Plate Fixation 1 Select appropriately sized plate plate should span from the middle or proximal portion of the superior vertebra to the middle or inferior portion of the distal vertebra 2 Create a contoured surface use a burr to remove osteophytes from the anterior aspect of the vertebra 3 Fix plate to the spine use screws to fix plate to the spine angle the screws away from the graft to increase rigidity in flexion and extension 4 Confirm placement of screws and plate with fluoroscopy N Wound Closure 1 irrigation, hemostasis, and drain place drain in the deep space 2 deep closure use 3-0 vicryl 3 superficial closure 4-0 monocryl 4 dressing and immediate immobilization place bulky dressing and soft collar
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids DVT prophylaxis pain control advance diet as tolerated check appropriate labs foley out when ambulating wound care remove dressings POD 2 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy keep collar on at all times 4 Discharges patient appropriately pain meds outpatient PT schedule follow up 2 weeks R Complex Patient Care 1 Completes comprehensive pre-operative planning with alternatives and criteria for acceptable intraoperative result for highly complex cases revision surgery 2 Develops unique complex postoperative management plans when indicated