Based on CT and MRI imaging, a plan should be prepared to determine:
The size and optimal location of implants used
Whether spinal cord decompression is necessary and if so, the amount of tissue to remove in order to achieve sufficient spinal cord decompression
Every case will be unique, and we will here illustrate just one example.
Use of dexamethasone
Administration of dexamethasone (10 mg bolus, 4 mg every 6 hours) is recommended as soon as ESCC causing neurologic deficit is diagnosed. Dexamethasone should be stopped or tapered as soon as spinal cord decompression is completed.
Embolization procedures are recommended to reduce operative blood loss in hyper vascular tumors. , especially for larger resections.
A consideration is given to use pedicle or laminar screws when doing an occiput to C2 fusion as oftentimes the starting point for the pars screws may compromise the facet joint.
Lateral mass screws vs. pedicle screws C3-C7
Fixation can be achieved with either lateral mass screws, pedicle screws or combination of the two.
Because lateral mass fixation is generally sufficient, and carries less risk, pedicle screw fixation is limited to rare cases where lateral mass fixation would be insufficient or not possible. A pedicle screw is most often used in C7 if instrumented.
The rod should be bent to align with the lordosis achieved during positioning.
The rod is inserted into the screw heads and the screw heads are tightened with the inner nuts.
If posterior decompression is performed, only one rod is inserted to facilitate access to the spinal canal.
For non-fusion surgeries, consideration should be given to using large diameter rods (4.0 mm) to prevent rod fracture.
Life expectancy and performance status should be used to determine whether bone grafting is indicated.
For patients with good prognosis and a long life-expectancy, posterior fusion may optionally be performed using allograft and/or local autograft.
The facet capsule is excised, and the joint cartilage surfaces are denuded/curetted.
Pieces of bone graft (autograft, allograft) are inserted into the decorticated facet joint for fusion.
Patients are made to sit up in the bed on the first day after surgery. Bracing is optional but preferably omitted for patient comfort. Patients with intact neurological status are made to stand and walk on the first day after surgery.
Patients can be discharged when medically stable or sent to a rehabilitation center if further care is necessary.
During admission adequate caloric intake of a high-quality diet should be monitored.
Patients are generally followed with periodical x-rays and (optionally) MR imaging at 6 weeks, 3 months, 6 months, and 1 year to monitor for tumor recurrence and hardware failure.
Postoperative radiation is required to avoid tumor recurrence. SBRT is usually initiated within two weeks following surgery. Conventional radiotherapy is usually initiated 2-4 weeks after surgery to reduce the risk of wound healing disturbances.
The radiation modality is selected based on tumor histology and history of prior radiation.