Cervical Laminectomy Periprocedural Care

Updated: Apr 01, 2015
  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Cristian Gragnaniello, MD  more...
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Periprocedural Care

Patient Education & Consent

Patient Instructions

After surgery, patients should avoid strenuous physical activity and lifting more than 10-15 lbs (4-7 kg) for 4-6 weeks. Light aerobic activities and walking are strongly encouraged, as is normal mobilization of the neck to reduce cervical muscle spasm.

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Equipment

Standard cervical laminectomy equipment includes self-retaining retractors, osteotomes, high-speed handheld drills, rongeurs, and punches. Although not always required, surgical loupes and microscopes can be used to aid in visualization and improved illumination.

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Patient Preparation

Anesthesia

The principal danger from an anesthesiologist’s standpoint is injury to the spinal cord due to either ischemia caused by blood pressure changes or direct compression of the cord during manipulation, such as intubation. Consequently, the severity of spinal cord compression should be determined preoperatively. This is especially true in patients who have a severe spinal cord injury and loss of spinal cord blood flow autoregulation. In this situation, any drop in blood pressure will cause a corresponding loss of spinal cord perfusion pressure and possible spinal cord infarction.

Patients with significant pathology may require awake tracheal intubation. In this setting, the patient can be tested for motor function before and after intubation. For others, careful manipulation during intubation is still important, and video laryngoscopes may be used. A useful adjunct to cervical spine surgery is electrophysiology neurological monitoring (EPS), which can include somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), intraoperative electromyographic responses (EMG), nerve action potential monitoring, and direct spinal cord stimulation.

Although false-positive and false-negative results are well known with EPS, they can provide useful information in selected cases. In these patients, baseline SSEPs should be documented prior to positioning the patient, and choice of induction agents and muscle relaxants is critical to allow for recording of reliable signals. Clear communication between the surgeons, anesthesiologist, and EPS technicians is critical.

Succinylcholine should be avoided in patients with denervation injury, as it can cause acute hyperkalemia. Newer muscle relaxants such as vecuronium and rocuronium are suitable alternatives.

Positioning

Posterior cervical laminectomies are most frequently performed in the prone position and less frequently in the sitting position.

Prone position

After the patient is anesthetized in the supine position, the head is secured with a skeletal head holder before turning into the prone position. Alternatively, a horseshoe or soft head rest can be used, but rigid fixation is preferred in most cases. The endotracheal tube must be firmly secured and the eyes appropriately lubricated, with the eyelids closed and protected. If used, electrophysiology neurological monitoring is placed and baseline potentials are obtained.

The patient is then turned into the prone position onto chest rolls or a chest frame. It is important that the longitudinal axis of the spine is maintained throughout this process. Hyperextension or hyperflexion must be avoided. The patient’s chin is inspected to ensure it is free from compression, and the breasts are medially displaced to prevent pressure on the nipples. The groin, anterior superior iliac spine, and knees are appropriately padded, with the abdomen resting as free as possible to prevent venous compression, which can lead to worsened intraoperative bleeding.

Lower-extremity pulses should be checked to ensure that the abdominal aorta and femoral arteries are not compressed. A padded roll is placed under the ankles so the knees are bent and feet suspended. The upper extremities are placed by the patient’s side in the neutral position (hands facing the patient and the thumbs down), with the elbows and hands padded. The shoulders may be taped to afford adequate spinal visualization, especially during radiographic confirmation of the operative level. The head is then firmly immobilized via attachment to the bed frame.

The most common complications in the prone position are nerve palsies and compression injuries due to inappropriate positioning, exaggerated limb stretch, and inadequate padding. Simple padding with cushions, sheets, blankets, or egg-crate padding will prevent their occurrence. Brachial plexus injuries can result from excessive downward traction of the shoulders for radiographic visualization. In this case, judicious traction and removal of the tape after radiographic visualization will reduce the risk of injury.

Sitting position

Owing to the higher incidence of venous air embolism (VAE), hypotension, and the discomfort experienced by the surgeon due to maintaining an extended position, the sitting position is less frequently used today.

After the patient is anesthetized in the supine position, a right central venous or atrial catheter and precordial Doppler ultrasonic system are placed. If used, electrophysiology neurological monitoring is placed and baseline potentials obtained. The head is then secured with a skeletal head. The endotracheal tube is firmly secured and the eyes appropriately lubricated, with the eyelids closed and protected.

The surgical table is then gradually brought into the sitting position, with the knees slightly flexed to prevent nerve stretch injury. The heels and gluteal areas should be appropriately padded. The upper extremities are placed in front of the patient’s body and secured with padding at the elbows and hands. The head is then firmly immobilized via attachment to the bed frame.

The most dangerous complication in the sitting position is that of a VAE. Dehydration or blood loss leads to decreased central venous pressures, increasing the risk. Patients with a patent foramen ovale or right-to-left shunt are at an increased risk. VAEs are thought to arise from air that enters noncollapsible veins, dural sinuses, or diploid veins.

VAE causes pulmonary constriction and hypertension with reduction in peripheral resistance, a gradual fall in cardiac output, and subsequent arrest. The use of precordial Doppler ultrasonic systems, right central venous or atrial catheters, and transesophageal echocardiography (TEE) can help early detection of VAEs. TEE and Doppler are the most sensitive in detection, while treatment includes aspiration of the air through the right atrial catheter, discontinuation of nitrous oxide, and administration of pure oxygen. Bone wax, electrocautery, and full-field irrigation should be used to seal possible portals of air entry. Repositioning the patient in the left lateral decubitus position may further facilitate air removal.

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Monitoring & Follow-up

Postoperatively, patients are evaluated for adequate wound healing and improvement in preoperative function. At this time, it is important to observe for the redevelopment or worsening of symptoms or neurological function, as well as to monitor for the delayed development of kyphosis.

Owing to paraspinous muscle stripping, patients experience more pain in the immediate postoperative period than preoperatively. For this reason, patients are usually advised preoperatively regarding the likelihood of increased immediate postoperative incisional pain and muscle spasm. Postoperative pain control usually involves a combination of narcotic analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants.

A cervical collar is usually not prescribed, although some patients report that a soft cervical collar helps with maintaining support and decreasing pain.

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