The patient was brought into the Operating Room. Anesthesia had seen the
patient. Preop Decadron was administered 10 mg IV for stress dosing.
She received preoperative 2 g of IV Ancef along with Cipro for wound prophylaxis
and UTI prophylaxis.
She then got a general anesthetic with awake fiberoptic intubation. Once
asleep, she was then positioned on the Jackson table supine, Mayfield pins were
utilized along with the Mayfield adapter. She was then sandwiched into place
and the table was rotated prone. We took the dorsal part of the table off and
the body was padded as required in all regions of her body including the chest,
pelvis, legs and arms. Arms were tucked at the sides.
We then prepped and draped the occipital and cervical spine in the usual sterile
fashion. We dissected open the skin from the occiput all the way down to C7.
We lifted the muscle off the lamina from C3 down to C6, and we also took muscle
off the C2 vertebral arch along with the C1 arch very carefully staying away
from the vertebral artery on the cephalic end. We exposed the skull also at the
We then brought in the intraoperative navigation and we clamped onto C3 and we
registered five points on C2. We then confirmed our accuracy. We then further
refined this with surface matching. Our error margin was 0.2 mm on the surface
match combined with the pairwise matching of five points. We confirmed our
registrations of C2 by correlating it with well known points on the C2 dorsal
surface. Once this was completed, we then cannulated the C2 pedicle on the
right and left-hand sides.
We had to avoid the vertebral artery. As a result, on the one slide we decided
to place a short 14 mm length screw, however on the other side where we got nice
clearance above the arch of the vertebral artery, we were able to get an 18 mm
length 4.0 diameter pedicle screw of C2. We got excellent bony purchase despite
her osteopenia from the rheumatoid disease and Prednisone use. We then drilled
pilot holes for lateral mass screws using the navigation from C3 down to C6. We
then drilled with sequential drilling and drilled 14 mm length screws and tapped
and inserted appropriate length screws for the lateral masses. We then applied
our midline plate and we then ensured that it would be in good position.
We then proceeded under microscope and we did a high-speed bur of the C1 arch.
We were careful to stay away from the vertebral artery and we were able to burr
down the whole arch and the arch was removed for bone graft. No complications
occurred. We then drilled the midline plate onto the bone using sequential
drilling. The middle screws on the top end we were able to drill 10 mm length
screws, 10 x 4.0 mm diameter bone screws were inserted on the north end and
ventrally we went down to 6 mm. We were careful to get just past the bicortical
surface. No CSF leaks occurred during bone plate insertion. We then applied
two rods that were contoured into cervical lordosis to provide her a nice
cervical arch. We then placed in our blocking caps and we did our final
tightening with the torque antitorque. We then brought in our high-speed bur
along with the microscope and we drilled two troughs going from C2 all the way
down to C6 bilaterally. We then lifted off the laminas bilaterally, and we then
morselized the bone graft. We brought in the intraoperative ultrasound. There
was a nice cord pulsation and the spinal cord was free of any compression from
the ventral surface. We then packed in our bone graft. We washed the spine out
thoroughly. We also burred down the facet joints for spinal fusion from the
occiput all the way down to C6.
It was decided to not go all the way down to T2 given that she would have no
movement whatsoever, especially with her young age of 66.
We then closed the fascia with a subfascial drain and we then closed the
subcutaneous layer with 2-0 with deep interrupted stitches followed by a running
to reinforce it, staples for the skin. Dressings were applied. The patient
tolerated the procedure well. We applied a collar onto her neck and she was
then taken out of the Mayfield pins. She can be activity as tolerated in the
ESTIMATED BLOOD LOSS:
Henry Ahn, MD, FRCSC
University of Toronto
Spine Orthopaedic Surgery
T: 416-864-6005 F:416-864-5340
cc: Henry Ahn, MD, FRCSC
55 Queen Street East
Toronto ON M5C 1R6