Keywords
CervicalPosteriorSurgeryPositioningSetupComplicationsMayfieldEquipmentEvaluationIntroduction
Surgical positioning of patients who are to undergo posterior cervical surgery is complicated and needs to be performed correctly to achieve successful surgical outcomes and avoid intraoperative and postoperative complications. There are a variety of indications for posterior cervical surgery including posterior cervical decompression via laminoplasty or laminectomy, nerve root decompression through foraminotomies, and various instrumented fusions including occipitocervical, atlantoaxial, and/or subaxial fusion. During these cervical operations, the patients are placed in nonphysiologic conditions for extended periods of time that would not be tolerated by an awake individual. In order to achieve the best postoperative outcomes, it is vital to understand potential pitfalls, mechanisms, and etiologies of the various complications. While the overall risk of complication is low, the morbidities and possible mortality can be potentially devastating.
Initial Evaluation
A thorough preoperative evaluation needs to be performed by both the surgeon and anesthesia team to ensure safety during intubation and positioning. Preoperative safe ranges of cervical motion that do not produce or reproduce symptoms need to be determined, especially in myelopathic patients. In cases of severe myelopathy, the anesthesia team may need to consider awake fiber-optic intubation [1]. It is also important in patients with spinal cord injury or myelopathy to ensure hypotensive anesthesia is avoided. Anesthesia should maintain the mean arterial pressure (MAP) at 80 mm Hg to ensure adequate spinal cord blood flow during surgery. In these patients, arterial lines should be placed in order to better monitor and control the MAP. The position of the neck during the surgery is determined by the operation being performed. Patients undergoing both occiput-C2 and subaxial procedures need the chin to be flexed in order to allow adequate visualization of the occipitocervical junction and reduce the overlap of the facets and laminae inferiorly to facilitate decompression [1]. In the case of fusion, the patient’s neck should be placed in neutral to slight extension to create the desired post-fusion lordosis [1]. Any protracted placement of the cervical spine in hyperflexion or hyperextension can contribute to underlying spinal cord injury. In myelopathic patients, neuromonitoring sensory evoked and motor evoked potentials are frequently used. Pre-positioning signals can be obtained and repeated post-positioning to assure no neurologic injury with neck manipulation or hyperextension.
Room Setup and Equipment (Fig. 4.1)
Radiolucent bed with a sheet folded placed on top
Gel rolls x2
Mayfield head rest and pins with betadine ointment
A 4-inch cloth tape
Pillow case
Towel clips
Small foam donuts x4
Gray foam pad x2
Large C-arm machine
Long back table
Bovie and bipolar machines
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