Operative Details and Outcome: Cervical Spondylotic Myelopathy with Cord Compression

Operative Details
Following essential fiberoptic intubation, general anesthesia was administered. The head was rigidly fixed with Mayfield pin fixation maintained in neutral position. The patient was rotated from the supine to a prone position on the Jackson table. All pressure points were carefully padded. Preoperative antibiotics and dexamethasone were administered. BrainLab dynamic reference frame was clamped onto the Mayfield head clamp. The Arcadis Siemens CT fluoroscopy unit was then brought into the field. We performed a spin-CT to obtain 3-dimensional CT-type images. These were then transferred over to the BrainLab unit for intraoperative image guidance.

Figure 5A

Figure 5B

Figure 5A-B. BrainLab in action. Upper view when we were selecting the best trajectory for C1 screws. Lower view when we were selecting the size and length of the screws for C1.

We chose a midline posterior occipital cervical approach. A high-speed coarse diamond bur was used to fashion a small suboccipital craniectomy. Then we burred down the lamina from C1 to the upper portion of T1. The decompression was completed with microsurgical punches fashioning the bilateral foraminotomies and thoroughly decompressing the cord from the skull base down to the top of T1.

We then used the BrainLab image-guided system, as well as the lateral fluoroscopy unit, to place C1 and C2 screws (32-mm partially threaded and 24-mm fully threaded Mountaineer polyaxial screws, respectively) bilaterally. We then cannulated the lateral masses from C3 to C7 and placed 14-mm screws. At T1 we placed 22-mm screws. Occipital plate and rods were placed and secured.

We placed two Crosslinking devices at C2 and C7 for additional rotational control.

We morselized the local bone graft using a bone mill. A large unit of bone morphogenic protein was injected into the collagen sponge, which was divided into 4 longitudinal strips. The morselized bone graft was placed over the collagen sponge strips and packed from the occiput down to T1 bilaterally.

The wound closed in layers. Postoperatively, the patient woke uneventfully, and moved her arms and legs satisfactorily. The neck was rigidly mobilized in a hard cervical collar.

Figure 6. Postoperative CT scan, sagittal reconstruction view.

Outcome
The patient was discharged home a few days later, walking normally with no pain and no neurological deficit. She will be seen in our outpatient clinic in 6 weeks.