PREOPERATIVE DIAGNOSIS: Herniated disc at C6-7 with a left C7 foraminal stenosis, cervical radiculopathy.
POSTOPERATIVE DIAGNOSIS: Herniated disc at C6-7 with a left C7 foraminal stenosis, cervical radiculopathy.
OPERATION PERFORMED: Anterior cervical diskectomy at C6-7 with removal of osteophytes with allograft fusion, with instrumentation Zephyr plating system with intraoperative SSEP monitoring.
SURGEON: John Doe, MD
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
ESTIMATED BLOOD LOSS: 50 mL.
INDICATIONS FOR OPERATION: This is a (XX)-year-old female who presents with severe left cervical radiculopathy. The patient has tried conservative treatments to include Medrol Dosepak, oral pain medications, physical therapy with no relief. The patient’s MRI revealed a herniated disc at C6-7 with left C7 foraminal stenosis.
DESCRIPTION OF OPERATION: The patient was brought to the operating room. After endotracheal intubation, the patient’s neck was placed in slight extension. All areas were properly padded, including the elbows and wrists bilaterally. The knees were slightly flexed. A Foley catheter was placed.
Intraoperative fluoroscopy was brought in to verify the C6-7 level. The right side of the neck was marked using a marking pen, roughly measuring 2.5 cm. The area was properly prepped and draped.
An incision was made using a 15-blade through the skin layer. Subcutaneous tissue was dissected until the platysma was identified. The platysma was then further dissected through the subcutaneous tissue, both superiorly and inferiorly. Then, a self-retaining retractor was placed within the wound. The platysmal layer was incised in the direction of the vertical fibers. The muscle layer was spread to identify the medial border of the sternocleidomastoid muscle. The fascial layer, medial to the sternocleidomastoid muscle, was dissected using tenotomy scissors.
Blunt dissection was also done. The carotid pulse could be palpated laterally. Using the Cloward handheld, the esophagus and trachea were retracted medially. The carotid was retracted laterally, and the anterior portion of the cervical spine could be palpated. After more careful dissection, the anterior portion of the spine, along with the C6-7 disc space, was identified. The spinal needle was placed in the C6-7 disc space, and an intraoperative fluoroscopy image was obtained to verify the C6-7 disc space. At that time, 0.1 mL of indigo carmine was injected along the disc space.
Then, attention was placed to further dissection, dissecting and clearing the C6 and C7 bodies. The medial border of the longus colli muscle was coagulated using monopolar cautery and the periosteal elevator. Then, the Shadow-Line retractor was placed within the wound, retracting the longus colli along the C6 and C7 bodies bilaterally. The Caspar pins were placed into the C6 and C7 bodies using the drill. The C6-7 disc space was distracted, and an intraoperative fluoroscopy image was obtained, verifying good placement of both Caspar pins, and distraction of the C6-7 disc space.
Up until this point, the dissection was done with magnification loupe and illumination. At this point, the intraoperative microscope was brought in. Using a 15-blade, the disc space was incised. This material was removed using straight disc rongeurs. Using 2 and 3-mm Kerrison rongeurs, the inferior osteophytes of the C6 and the superior osteophytes of the C7 bodies were removed to create a rectangular opening in the C6-7 disc space, using up and downgoing curettes, and further disc material was removed. Then, using the QD-11 3-mm Anspach drill. the end plates of C6 and C7 were drilled to create a rectangular disc space, roughly measuring 6 mm.
Careful dissection was done through the posterior longitudinal ligament with microhooks. There appeared to be significant compression of the epidural space. Using 1-mm Kerrison rongeurs, the osteophytes posteriorly at the C6 and C7 bodies were removed. Careful dissection with microhook and microdisk dissector was done through the posterior longitudinal ligament until dura was identified. The posterior longitudinal ligament was incised using 1 and 2-mm Kerrison rongeurs. There appeared to be significant degenerative disease, bilaterally at the foramen, left worse than right.
Attention was placed to the first of the left foramen. Using the 1-mm Kerrison rongeurs, the foramen was freed from debris. There appeared to be a large, free disc fragment in the left C7 foramen, which was removed using the microcup. Once the posterior longitudinal ligament was incised in its entirety, there appeared to be dura visualized through the C6-7 interspace. The foramen bilaterally was assessed with the microhook. Both appeared to be wide-opened. The wound was thoroughly irrigated. The depth was measured to be 18 mm and then attention was placed to the allograft.
A 7-mm with allograft was drilled using the saw and QD-11 3-mm Anspach drill. It measured 15 mm in length. After the graft was properly measured and sized, it was tapped into the C6-7 disc space with no difficulty. The distraction was removed. Then, the Caspar pins were removed at that time.
The 22.5 Zephyr plate was used. It was slightly bent and placed over the C6-7 interspace. Then, initially the right C6 screw was drilled using under-the-drill guide. A 4-mm/13-mm screw was placed. Then, the inferior C7 screw was drilled and a 13-mm/4-mm screw was placed. An intraoperative fluoroscopy image was obtained, verifying good placement of the plate and both screws. The screws were tightened, and then attention was placed to the left C7 screw, which was drilled using the drill guide. Once again, a 13-mm/4-mm screw was placed into that hole. Then, the superior left C6 drill hole was drilled, and a 13-mm/4-mm screw was placed.
Once the screws were all tightened, an intraoperative fluoroscopy image was obtained, verifying good placement of all four screws and plate. The Zephyr plating system was locked using the locking screwdriver. The wound was thoroughly irrigated. The Caspar retractors were removed. Under careful visualization of the microscope, all hemostasis was controlled with bipolar cautery. Once there was no evidence of hemostasis, the microscope was removed.
The platysma was approximated with inverted #3-0 Vicryl sutures. The subcutaneous tissue was approximated with a running #4-0 Vicryl in subcuticular fashion. Steri-Strips were applied. The patient was extubated and placed in an Aspen collar. The patient appeared to be moving all extremities well. There were no complications. There was 50 mL of blood loss.
