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 correlates clinical and imaging findings to form clinical diagnosis 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 makes referrals to other professionals 5 Makes informed decision to proceed with operative treatment documents failure of nonoperative management describes accepted indications and contraindications for surgical intervention 6 Recommends appropriate surgical procedures considering indications and contraindications, risks and benefits for simple cases single level HNP with radiculopathy 7 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 <br> remove hard 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 H & P 1 Obtain history and perform basic axam need to carefully document neurological status of bilateral upper extremities strength, sensation, reflexes, and primary symptoms 2 Screen medical studies to identify and contraindications for surgery 3 Order basic imaging studies order triplanar radiographs 4 Perform operative consent describe complications of surgery including injury to the vertebral artery neurologic complications infection nerve root palsy dural injury postlaminectomy kyphosis instrumentation backout nerve root impingement
E Preoperative Plan 1 Radiographic templating template screw 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 jackson table with flat board and four post frame gardner wells tongs with 20 lbs of traction insulated and bipolar cautery angled cerebellar retractors high speed burr with non end cutting drill attachment multiple angled curets kerrison rongeurs 1-3 mm lateral mass and pedicle fixation screws 2 Room setup and equipment standard operating table with Gardner-Wells tongs use 15lbs of traction fluoroscopy 3 Patient positioning prone position neck in slight extension with neutral rotation G Dissect to Spinous Process 1 Determine level of instrumentation use fluoroscopy to determine the level of fusion 2 Make skin incision incise through the skin and subcutaneous tissues cauterize bleeders as they occur 3 Expose the cervical fascia incise in the midline H Clear Lamina and Lateral Masses 1 Perform a subperiosteal dissection 2 Expose the lateral recess 3 Confirm the surgical level use the C2 vertebra as the starting point and count down from there place a penfield 4 elevator into the facet joint I Placement of Lateral Mass Screws 1 Identify starting point 2 Drill pilot holes for all levels use a 2mm burr to make a small depression in the lateral mass that is 1 mm medial to the center. this is done to identify a starting point for the drill bit place a drill stop set at 12 or 14 mm depending on the size of the lateral mass place the drill onto the starting point and drill a tract with the drill angled 30 degrees lateral and 15 degrees cephalad these are drilled for placement of the lateral mass screws 3 Confirm the tract place a ball tipped probe into the tract to confirm its integrity 4 Place screws tap each screw tract to the same depth that was drilled place 3.5 mm screws of the appropriate length 5 Confirm position using fluoroscopy J Laminectomy 1 Create laminar troughs create troughs in the lamina bilaterally just medial to the lateral massses using a non end cutting burr because the likelihood of injury to the underlying dura and spinal cord are decreased stop drilling frequently and use a penfield 4 elevator to check the depth of the trough continue this process until the ligamentum flavum is visualized 2 Remove ligamentum flavum use a nerve hook to elevate the flavum resect the flavum using a 2 mm kerrison rongeur 3 Elevate lamina use leskell rongeurs to grab to the cephalad and caudad levels constant pressure should be applied to and maintained on the lamina so that no compression on any part of the cervical spinal cord occurs tease off any adhesions on the lamina 4 Check motor evoked potentials 5 Check mean arterial pressure this must be maintained to avoid ischemic injury to the cord 6 Elevate the lamina use angled curets and elevate the lamina sequentially from distal to proximal in an EN BLOC fashion K Place C7 Pedicle Screw (if required) 1 Perform laminoforaminotomy at C6-C7 use a 2-3 mm burr to create a starting point at the intersection of the midpoint of the transverse process and the lateral pars this is done so that the medial border of the pedicle can be visualized and palpated look for a pedicle blush which signifies the cancellous bone 2 Make screw tract use a pedicle awl or gearshift to to make the tract within the pedicle palpate the medial border of the of the pedicle this can assess the medial-lateral and cranio-caudal angulation of the pedicle palpate the medial border of the of the pedicle place a ball tipped probe to confirm the tract tap the tract 3 Place C7 screws place 4.0 mm screws of the appropriate length bilaterally L Fusion and Rod Placement 1 Decorticate use a high speed burr to decorticate the facet joints and the lateral aspects of the lateral masses 2 Use local bone from the laminectomy for biologic arthrodesis 3 Place Rods place the end caps place the appropriately sized rods into the screw heads perform a final tightening of the instrumentation N Wound Closure 1 Irrigation, hemostasis, and drain place subfascial drain obtain muscular hemostasis 2 Deep closure use 0 or 1 absorbable suture close the muscle and fascia in separate layers 3 Superficial closure subcutaneous tissue is closed with 2-0 vicryl close skin with buried monocryl 4 Dressing and immediate immobilization place bulky dressing and soft collar
O Perioperative Inpatient Management 1 Write comprehensive admission orders IV fluids advance diet as tolerated foley out when ambulating DVT prophylaxis pain control check appropriate labs wound care remove dressings POD 2 2 Appropriate medical management and medical consultation 3 Inpatient physical therapy hard cervical collar for six weeks keep collar on at all times 4 Discharges patient appropriately pain meds outpatient PT wound care schedule follow-up in 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