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Patient PositioningMarking the Entry PointTechnique for a right sided C5-C6 disc herniation

1 – Patient Positioning › Top of page

Cervical-1The patient is in supine position with the neck in gentle extension and the head held by a horseshoe-shaped pillow, under general anaesthesia.

2 – Marking the Entry Point › Top of page

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A special localization device with two arms is used with the fluoroscopic image intensifier to determine the point of the skin incision. The target disc is centred on the monitor screen of the image intensifier. The localization device is placed in position and its position modified until the two arms are projected onto the disc.

Cervical-3The point of incision is marked on the skin and the direction of the operating light is adjusted to the direction of the approach i.e. to the orientation plane of the disc. This direction is a landmark throughout the operation.

3 – Technique for a right sided C5-C6 disc herniation › Top of page

The surgeon stands on the side of the prolapse. After setting up the image intensifier (which will be left on throughout the procedure), identifying the target level, scrubbing the skin, and draping, the skin incision is made. This incision is fairly horizontal, attempting to follow one of the folds of skin. It is centred on the anterior limit of the sternocleidomastoid muscle.

Cervical-9Cervical-9
Haemostasis is achieved using bipolar coagulation. The subcutaneous tissues are dissected using scissors, and the platysma muscle is cut horizontally. The anterior edge of the sternocleidomastoid is exposed, the superficial layer of cervical fascia is sectioned and the posterior face of the sternocleidomastoid is dissected until the omo-hyoid muscle and the pre-tracheal fascia are exposed. From there, the dissection is carried out using the gloved finger, separating the carotid vascular axis on the outside from the visceral axis inside. The anterior surface of the cervical column is thus exposed, and Faraboeuf retractors are used to complete the dissection and cut the deep cervical fascia. The longus colli muscle is thus exposed. The level is checked again using a needle inserted into the damaged disk. In order to expose the anterior surface of the vertebral column and the uncovertebral joint laterally, we prefer to coagulate and cut the medial edge of the longus colli muscle rather than to retract its aponeurosis, which we consider to be a higher risk for the sympathetic trunk located in this fascia, slightly more lateral at the anterior surface of the longus colli muscle. The speculum is inserted between the two retractor blades, with the medial blade protecting the esophagus and the lateral blade the carotid artery. Once the obturator has been withdrawn, the internal part of the ENDOSPINE® is attached to the speculum and the rest of the procedure is carried out under endoscopic control. Drilling begins at the level of the disk or slightly above it, following the direction of the disk in an anteroposterior direction. This drilling is extended in order to obtain a hole of approximately 8 mm. The soft tissues are resected using a Kerrison forceps or a disk forceps.

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Once the posterior edge of the vertebral body has been reached and the posterior longitudinal ligament has been exposed, the bone resection is extended laterally using the 2 mm Kerrison forceps.

Cervical-8 Using a hook, the hernia is dissected and removed using a disk forceps.

Cervical-8Another disc fragment is removed using the Kerrison forceps. In most of the cases, the foraminotomy is completed, using drill and 2mm Kerrison rongeur, from lateral to medial, removing the remaining part of the uncus which is close to the vertebral artery. As the blunt posterior part of Kerrison is in direction of the artery, there is no danger to damage it.

Cervical-10Finally the nerve root is completely decompressed and exposed from the spinal canal to the vertebral artery. Soft tissues adherant to the sheath of nerve root must be left to avoid a dural tear.

Cervical-10Then the surgical cavity is washed out and a cotton swab is inserted in order to ensure perfect haemostasis.

Cervical-10Cervical-10The platysma muscle is sutured using a Vicryl suture, and then the skin is closed using Vicryl 4.0 intradermal sutures. A waterproof dressing is applied.