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Name:
Cervical Spine C1-C2 Fusion
Description:
Cervical Spine C1-C2 Fusion
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https://cadmoremediastorage.blob.core.windows.net/551cb9a3-ba85-46d7-91fb-58c150f464a2/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H14M09S
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https://stream.cadmore.media/player/551cb9a3-ba85-46d7-91fb-58c150f464a2
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/551cb9a3-ba85-46d7-91fb-58c150f464a2/2_ Cervical Spine C1-C2 Fusion- v1 - bdf.mov?sv=2019-02-02&sr=c&sig=WYph6iCxPptNwLCYlKS9558dvqtstmKr1dnm8TqrRIo%3D&st=2024-11-21T17%3A27%3A10Z&se=2024-11-21T19%3A32%3A10Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
HAN JO KIM: My name is Han Jo Kim, and I'm an attending Spine Surgeon at the Hospital for Special Surgery. We'll be going through the C1-2 fusion today. A standard posterior incision is made, and we really focus on trying to go through the nuclal ligament
HAN JO KIM: which will allow you to have an avascular plane. I frequently palpate the bony prominence of C2 as well as the lamina of C1 if possible. Usually the C1 lamina is more deep and also a little bit of the base of the oxaput is going to be exposed as well. Here I'm palpating C1 lamina as well as a C2 spinous process, ensuring that my dissection
HAN JO KIM: does not go deep to this. Sometimes what could happen is under the section, you could end up plunging into the thecal sac and having a durable tear, uh, and usually use it using the bone as a guide is the best way to avoid that. After the exposure of the most dorsal aspect of the C1 lamina is done, as well as a base of the oxaput,
HAN JO KIM: I place McCulloch retractors in and then continue to perform a sub periosteal dissection here, and I convert now to bipolars. I do not like to use the Bovie on the C-1 lamina, especially on the superior aspect because the vertebral artery anatomy, as well. Of course pre operatively you would obtain a CT angiogram or an MRI to evaluate the vertebral artery anatomy to ensure that your, the vertebralur artery anatomy is favorable for this type of approach.
HAN JO KIM: Ensure that there are no anomalies, and after the plane is made, again, you may have to reposition the McCulloch retractors. There you could see the venous plexus, which could bleed tremendously. Usually I try to develop a plane between the venous plexus as well and the posterior soft tissues and the muscles. If it starts to bleed, I bipolar it very, very lightly, I do not go deep into it,
HAN JO KIM: and if that doesn't work, I don't usually waste time on trying to stop it with the bipolar or electrocautery, I utilize a Floseal or some sort of a gel matrix thrombin agent with Surgicil. Again, I reposition the McCulloch from time to time, once a little bit more of the sub-periosteal dissection is performed
HAN JO KIM: so then I can really push back the soft tissues. Then what I do is feel for the superior aspect of the C-2 lamina as well as the medial aspect of the pedicle, and that'll tell me where the optimal starting point would be for my C-2 screw. So here I made a burr hole to start my C-2 screw and then I use a pediatric sized pedicle probe to place my C-2 screws, ensure that the trajectory is, usually straight up and down
HAN JO KIM: or slightly angulated, proximally, and obviously here, palpating with the ball tip freerer, I could see that where the superior aspect of the C-2 lamina is as well as the medial wall of the pedicle and this will also guide my trajectory to ensure that it's optimal. Before this, as far as the CT scan for preoperative planning,
HAN JO KIM: I would have to ensure that there is no high riding vertebral artery at this level. If there is, I would have to place a shorter screw. Here in this case, you can see that I'm already down to 25, almost 30. I like to utilize this over a drill since once the cancellous tract is identified, it goes down pretty easily.
HAN JO KIM: A drill I would be concerned about um, injuring the transverse foramen or any of the cortical walls and be more easily breached with a drill so I prefer to use the pedicle probe if possible, and then I palpate to make sure that we're have all floors and then get a, get a length with the right angle retractor.
HAN JO KIM: Here you can see I, after I had placed down the pedicle probe down to 30 millimeters, the tip of the pedicle probe is thinner than the ball tip feeler and for this reason then I set the drill to the depth that I placed the pedicle probe for and then I will drill the hole to ensure that I get a good feel of the whole tract. Then we focus on the C-1 screw and here what I do is identify the lateral mass and it's easy to get into the venous plexus at this level.
HAN JO KIM: If it bleeds, the best thing to do would be to let go of your retractor and oftentimes, oftentimes because it's venous bleeding, it'll stop on its own after you place a little bit of compression with, again, a gel matrix or Sertasil. Here, then I use a burr to identify my starting point for the C-1 lateral mass and a little bit of the inferior aspect of the C-1 lamina is drilled so that the shaft of the screw can sit at this level.
HAN JO KIM: Pre operatively I have templated the depth that I wanted to make this screw and then I place this steri strip to ensure that the depth is identified there. That's the white tape around the drill. And after this is done, I retract the nerve distally and then the starting hole that I made with the drill and the burr is then utilized with this to identify and to make the C-1 screw tract. The next step after this is then to
HAN JO KIM: utilize a ball tip freer to ensure that it's a good tract, ensure that there are no breaches. For people who are extremely osteoporotic, I may consider getting bi cortical fixation and making a screw just one or two millimeters longer than when I measured to be the floor or the anterior cortex.
HAN JO KIM: Here I use a right angle to measure the screw, and you can see here once you let go of the soft tissues there and the venous plexus, the bleeding could stop. After this, we then have to prepare for the C-1-2 articular surface fusion, and here you could see I am identifying the C, identifying the C-1-2 facet joint here.
HAN JO KIM: You get a good view of the facet joint there and I use a freer to identify this joint. Once this is identified, then I use a burr to burr down the cartilage as well as to get to good cancellous bone, and after that is completed, I then place some Biologics, in this case, I'm utilizing an ACS sponge with BMP into the joint.
HAN JO KIM: Then of course, the inferior aspect of the C-1 lateral mass is burred down as well with a similar maneuver to allow for good bony bleeding surfaces for fusion. Here a little bit of venous bleeding, I try to attempt to stop with bipolar and again, if it does not stop, I would not work, waste too much time trying to do that. I would, uh, just place some gel matrix thrombin with surgicil.
HAN JO KIM: That seems to work well. After this, I'll place some DBM, um, or some other type of bone graft. Sometimes there could be some autograft or bone shavings that could be utilized as well, but here it is, just some DBM. I prefer not to utilize iliac crest
HAN JO KIM: if we could use the biologics. And then sometimes the bone graft, is not tamped down as much as you like and a good trick is to utilize a cottonnoid to push down the additional elements into the joint and to ensure that it's stuffed in appropriately and packed into the joint
HAN JO KIM: in there. Now we could focus on placing our screws, the tracks have been made. Notice I don't place the screws until the fusion surface is made and the reason why is because the space is very small and placement of the screws will not allow for the will, will, not allow for enough space for you to prepare the C1-2 to join for fusion.
HAN JO KIM: And here, the screws are placed after the fusion bed is prepared because the tulips would be otherwise too big and would not allow for adequate placement, adequate bone fusion preparation. Here you can see how well the Surgisil works for allowing for hemostasis. You can also notice at the bottom of the screen, the muscles they are attached to the C-2 spine spinous prosthesis are not dissected off at all, and they try to be preserved as much as possible.
HAN JO KIM: This is an important element of the exposure to ensure that there is no sacrifice to the integrity of the extensor muscles of the neck. Then I palpate again to identify our C-1 screw hole
HAN JO KIM: and then protect the C-2 nerve root as we place down our screw. The freer is useful since the width of the freer is going to be plenty to cover the screw shaft as it goes down. Now you can see here with the two tulips placed, it would be very hard to prepare the C-1-2 fusion beds so that's why I prepare this fusion bed prior to placement of the screws.
HAN JO KIM: Again, a little bit of bleeding from the venous plexus and could be controlled with a combination of Flowsil or Surgiflow, whichever you prefer. With a Surgiflow, I'm going to template a rod to get the desired length. I may or may not decide to bend a little bit of Lordosis into this rod, it would depend on the type of case we are performing
HAN JO KIM: and if there is any deformity at the C-1-2 level. There's the Flowsil and Surgisil again to control the bleeding, screws have been placed bilaterally here, template a rod.
HAN JO KIM: I try to keep the rod length proximally to the C-1 screw as small as possible since the OC1 joint will allow for flexion and extension, I would worry about the base of the Oxput hitting a long rod, so I try to make the rod as short as possible above C-1. And there you could see I just approximate it to where the tulip is there.
HAN JO KIM: We provisionally tighten here before we take x-rays to confirm the location of the implants and the overall alignment.
Segment:0 .
HAN JO KIM: My name is Han Jo Kim, and I'm an attending Spine Surgeon at the Hospital for Special Surgery. We'll be going through the C1-2 fusion today. A standard posterior incision is made, and we really focus on trying to go through the nuclal ligament
HAN JO KIM: which will allow you to have an avascular plane. I frequently palpate the bony prominence of C2 as well as the lamina of C1 if possible. Usually the C1 lamina is more deep and also a little bit of the base of the oxaput is going to be exposed as well. Here I'm palpating C1 lamina as well as a C2 spinous process, ensuring that my dissection
HAN JO KIM: does not go deep to this. Sometimes what could happen is under the section, you could end up plunging into the thecal sac and having a durable tear, uh, and usually use it using the bone as a guide is the best way to avoid that. After the exposure of the most dorsal aspect of the C1 lamina is done, as well as a base of the oxaput,
HAN JO KIM: I place McCulloch retractors in and then continue to perform a sub periosteal dissection here, and I convert now to bipolars. I do not like to use the Bovie on the C-1 lamina, especially on the superior aspect because the vertebral artery anatomy, as well. Of course pre operatively you would obtain a CT angiogram or an MRI to evaluate the vertebral artery anatomy to ensure that your, the vertebralur artery anatomy is favorable for this type of approach.
HAN JO KIM: Ensure that there are no anomalies, and after the plane is made, again, you may have to reposition the McCulloch retractors. There you could see the venous plexus, which could bleed tremendously. Usually I try to develop a plane between the venous plexus as well and the posterior soft tissues and the muscles. If it starts to bleed, I bipolar it very, very lightly, I do not go deep into it,
HAN JO KIM: and if that doesn't work, I don't usually waste time on trying to stop it with the bipolar or electrocautery, I utilize a Floseal or some sort of a gel matrix thrombin agent with Surgicil. Again, I reposition the McCulloch from time to time, once a little bit more of the sub-periosteal dissection is performed
HAN JO KIM: so then I can really push back the soft tissues. Then what I do is feel for the superior aspect of the C-2 lamina as well as the medial aspect of the pedicle, and that'll tell me where the optimal starting point would be for my C-2 screw. So here I made a burr hole to start my C-2 screw and then I use a pediatric sized pedicle probe to place my C-2 screws, ensure that the trajectory is, usually straight up and down
HAN JO KIM: or slightly angulated, proximally, and obviously here, palpating with the ball tip freerer, I could see that where the superior aspect of the C-2 lamina is as well as the medial wall of the pedicle and this will also guide my trajectory to ensure that it's optimal. Before this, as far as the CT scan for preoperative planning,
HAN JO KIM: I would have to ensure that there is no high riding vertebral artery at this level. If there is, I would have to place a shorter screw. Here in this case, you can see that I'm already down to 25, almost 30. I like to utilize this over a drill since once the cancellous tract is identified, it goes down pretty easily.
HAN JO KIM: A drill I would be concerned about um, injuring the transverse foramen or any of the cortical walls and be more easily breached with a drill so I prefer to use the pedicle probe if possible, and then I palpate to make sure that we're have all floors and then get a, get a length with the right angle retractor.
HAN JO KIM: Here you can see I, after I had placed down the pedicle probe down to 30 millimeters, the tip of the pedicle probe is thinner than the ball tip feeler and for this reason then I set the drill to the depth that I placed the pedicle probe for and then I will drill the hole to ensure that I get a good feel of the whole tract. Then we focus on the C-1 screw and here what I do is identify the lateral mass and it's easy to get into the venous plexus at this level.
HAN JO KIM: If it bleeds, the best thing to do would be to let go of your retractor and oftentimes, oftentimes because it's venous bleeding, it'll stop on its own after you place a little bit of compression with, again, a gel matrix or Sertasil. Here, then I use a burr to identify my starting point for the C-1 lateral mass and a little bit of the inferior aspect of the C-1 lamina is drilled so that the shaft of the screw can sit at this level.
HAN JO KIM: Pre operatively I have templated the depth that I wanted to make this screw and then I place this steri strip to ensure that the depth is identified there. That's the white tape around the drill. And after this is done, I retract the nerve distally and then the starting hole that I made with the drill and the burr is then utilized with this to identify and to make the C-1 screw tract. The next step after this is then to
HAN JO KIM: utilize a ball tip freer to ensure that it's a good tract, ensure that there are no breaches. For people who are extremely osteoporotic, I may consider getting bi cortical fixation and making a screw just one or two millimeters longer than when I measured to be the floor or the anterior cortex.
HAN JO KIM: Here I use a right angle to measure the screw, and you can see here once you let go of the soft tissues there and the venous plexus, the bleeding could stop. After this, we then have to prepare for the C-1-2 articular surface fusion, and here you could see I am identifying the C, identifying the C-1-2 facet joint here.
HAN JO KIM: You get a good view of the facet joint there and I use a freer to identify this joint. Once this is identified, then I use a burr to burr down the cartilage as well as to get to good cancellous bone, and after that is completed, I then place some Biologics, in this case, I'm utilizing an ACS sponge with BMP into the joint.
HAN JO KIM: Then of course, the inferior aspect of the C-1 lateral mass is burred down as well with a similar maneuver to allow for good bony bleeding surfaces for fusion. Here a little bit of venous bleeding, I try to attempt to stop with bipolar and again, if it does not stop, I would not work, waste too much time trying to do that. I would, uh, just place some gel matrix thrombin with surgicil.
HAN JO KIM: That seems to work well. After this, I'll place some DBM, um, or some other type of bone graft. Sometimes there could be some autograft or bone shavings that could be utilized as well, but here it is, just some DBM. I prefer not to utilize iliac crest
HAN JO KIM: if we could use the biologics. And then sometimes the bone graft, is not tamped down as much as you like and a good trick is to utilize a cottonnoid to push down the additional elements into the joint and to ensure that it's stuffed in appropriately and packed into the joint
HAN JO KIM: in there. Now we could focus on placing our screws, the tracks have been made. Notice I don't place the screws until the fusion surface is made and the reason why is because the space is very small and placement of the screws will not allow for the will, will, not allow for enough space for you to prepare the C1-2 to join for fusion.
HAN JO KIM: And here, the screws are placed after the fusion bed is prepared because the tulips would be otherwise too big and would not allow for adequate placement, adequate bone fusion preparation. Here you can see how well the Surgisil works for allowing for hemostasis. You can also notice at the bottom of the screen, the muscles they are attached to the C-2 spine spinous prosthesis are not dissected off at all, and they try to be preserved as much as possible.
HAN JO KIM: This is an important element of the exposure to ensure that there is no sacrifice to the integrity of the extensor muscles of the neck. Then I palpate again to identify our C-1 screw hole
HAN JO KIM: and then protect the C-2 nerve root as we place down our screw. The freer is useful since the width of the freer is going to be plenty to cover the screw shaft as it goes down. Now you can see here with the two tulips placed, it would be very hard to prepare the C-1-2 fusion beds so that's why I prepare this fusion bed prior to placement of the screws.
HAN JO KIM: Again, a little bit of bleeding from the venous plexus and could be controlled with a combination of Flowsil or Surgiflow, whichever you prefer. With a Surgiflow, I'm going to template a rod to get the desired length. I may or may not decide to bend a little bit of Lordosis into this rod, it would depend on the type of case we are performing
HAN JO KIM: and if there is any deformity at the C-1-2 level. There's the Flowsil and Surgisil again to control the bleeding, screws have been placed bilaterally here, template a rod.
HAN JO KIM: I try to keep the rod length proximally to the C-1 screw as small as possible since the OC1 joint will allow for flexion and extension, I would worry about the base of the Oxput hitting a long rod, so I try to make the rod as short as possible above C-1. And there you could see I just approximate it to where the tulip is there.
HAN JO KIM: We provisionally tighten here before we take x-rays to confirm the location of the implants and the overall alignment.
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