C5-thoracic1 anterior cervical discectomy and fusion with iliac bone grafting

Here is another spine case scrub by me awhile ago. I have to write and post it now or else i might forget it later.
Anterior cervical discectomy and fusion (ACDF) with iliac bone grafting is a surgical procedure to treat nerve root os spinal cord compression by decompressing the spinal cord and nerve root of the cervical spine in order to stabilize the corresponding vertebrae.
To prevent the vertebrae from collapsing and to increase stability the open space is often filled with bone graft, taken from the pelvis or cardiac bone.

picture of vertebrae and disc: normal and herniated situation

The surgeon will completely remove the disc as well as the arthritic bone spurs. The disc material, pressing on the spinal nerve or spinal cord, is then completely removed.

overview of acdf

PROCEDURE	ANTERIOR CERVICAL DISCECTOMY AND FUSION WITH ILIAC BONE GRAFTING
POSITION	Supine
EQUIPMENT / ACCESSORIES	Gel Pad Elastoplast- to secure patient shoulder position Image Intensifier (II) Lead Screen Diathermy Machine Suction Machine Medtronic console (SB) Microscope (SB)
SKIN PREPARATION	CETRIMIDE 1% POVIDONE IODINE Tincture
PHARMACEUTICALS	Infiltration for Bone Grafting: Marcaine 0.5% 10mls Xylocaine 1% 10 mls Adrenaline 1:1000 10 units
DRAPE	Universal Drape Ioban 6640 x 2 ABD sheet for X-ray lateral view ABD sheet to cover the lead screen
INSTRUMENTS / SUPPLEMENTARY SET	Laminectomy Set Spine Supplementary Set Casper Cervical Distractor ACDF Trimline(colorful one) Colibri Spinal Nerve Root Retractor Set Korros Punch Ortholegend attachement and cables (SB)
LOOSE INSTRUMENTS	Small Mallet Small Curved Osteotome Small Homman X 2
VENDOR SET (JandJ)	1. CSLP Set 2. Vectra Set 3. Bengal Set
CONSUMABLES	Raytex Gauze Penny Towel Peanut Harrington Patties (SB) Gelfoam Large Blade 10 X 2 Blade 15 X 1 Spinal Needle G.22 (black) 50mls Syringe 20mls Syringe Insulin Syringe Green Needle Lantern Drain Burr (SB)
SUTURES	Vicryl 1 Vicryl 2-0 Monocryl 3-0
DRESSING	Steristrips Aquagel Ag Small (for the neck) Primapore (Pelvis) Tegaderm to secure the drain
REMARKS	1 suction only

Proper draping for anterior cervical spine surgery with iliac bone graft:

1. Mayo cover to use on mayo stand.

2. Top first (head part, check drawing)

3.  Bottom Drape (check drawing) – to paste drape on patient just below iliac crest

4. Back Table Drape (blue drape) – from patient below the neck to just above patient iliac crest

6. Sides X 2 (check drawing)

7. Ioban 6640 X 2

8.  ABD Sheet + 2 Blunt Towel Clips for X-ray Lateral 

9. Dressing Towel to cover the cautery and sucker tubings

steps in draping

Procedure (again this steps varies on which doctor your assisting)

Harvesting of bone graft:

1. Infiltration of local anestesia

2. Blade 10 to skin

3. Gillies toothed and monopolar to dissect the muscle to bone

---once the iliac bone is exposed

4. penny becker to separate some tissue or muscle to the bone

5. Small homman to help to retract the muscle to the bone

6. Small Oscillating saw

7. Curved Osteotome

8. Mallet

---secure/keep the harvested bone in a gollipot

9. Wash with saline (op-site)

10. Pack with Large gelfoam- to close the incision site after the acdf procedure using Vicryl 1-0 to suture the muscle, vicryl 2-0 for fascia or subcutaneous and monocryl 3-0 to close the skin. The incision site then will cover with steri-strips and primapore it might or not needed for the pressure dressing.

ACDF Procedure:

1. New Blade 10 to skin

2. Monopolar and Gillies toothed forceps

3. Hand held retractor (coddman retractor - on spine supplementary set).

---Dissect and expose the cervical disc.

4. Trimline Retractor - ask the surgeon if what size or color that they are going to use. You may give the whole set so as to surgeon will choose which color he want. Load the blade into trimline handle and give the surgeon X 2 with same blade size. Once the surgeon already place the blade on the operative site he will ask for the trimline retractor frame to secure the blades on place.

metronic trimline acdf instrument set

handle, blades (purple color) and retractor frame

when surgeon ask for the trimline retractor attached
the blades from the handle by pressing downward
the button at the handle and slide in the blade

5. Give bended spinal needle gauge 22 (black) surgeon may need 2 of this.

6. Blade 15 - inside knife to cut the disc or soft tissues

6. Pituitary Rongeur to remove the disc and arthritic bone

7. Casper Pins X 2 load it on the Casper pins screw driver.

green handle (casper pin screw driver) Purple pin (casper pin) 2 knots (casper pins cover) and pin distractor holder

8. give the distractor pin retractor

9. load the knot to the casper pin screw driver and give to the surgeon X 2

10. Pituitary Rongeur

11. Kerrison Punch 1 or 2

---clean the kerrison punch and pituitary rongeur once every use of the surgeon. to remove the bone, disc and tissues that the surgeon removing from the cervical bone.

12. nerve retractor

13. Peanut loaded in a allies X 2

14. Give the bone graft in a gollipot together with the long tissue forceps non-toothed.

15. Bone Punch followed by Mallet to secure the bone in place.

---standby the mc donald
---once the bone is secure in place the surgeon then will choose plates to place on patient cervical spine to more secure the bone.
16. The surge on may or may not ask for the awl at this time. (creating a landmark for drilling)

awl

17. 2.5 Drill bit
18. drill sleeve (in this instrument you ask first the surgeon if what screw are their going to use, if it is variables or fixed screws)

Difference between Fixed Drill Sleeve and Variables Sleeve

variables sleeve notice the color coded and the name of the instrument on its handle

fixed angle drill sleeve

19. Depth Gauge- to measure the exact screw size.

spine depth gauge

20. Screw Driver/ Screws confirm with the type of screws. wo types of screws variables and fixed screws.

check the color of the screws

---once all screws are put up, wash the excision site, they will do final x-ray to make sure the proper placement of the bone screws and plates.

21. Lantern drain

22. Close with Vicryl 1-0 for the muscle 

22. Vicrly 2-0 fascia or subQ

24. Monocryl 3-0 skin

25. Steristrip

26. Aquacel AG (do not cut)

27. Scure the lantern drain with Tegaderm.