Neurosurgery Outlines. Paul E. Kaloostian

      Fig. 2.12 Intraoperative image demonstrating positioning of retractors for multilevel thoracic pathology. The retractors are expanded in the rostral–caudal direction. This is followed by electrocautery to visualize the lamina and achieve decompression. (Source: Minimally invasive thoracic decompression for multilevel thoracic pathology. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).

      Fig. 2.13 Image demonstrating relevant anatomy to thoracic outlet decompression. This anatomy is visualized after the anterior and middle scalene is divided, decompressing the brachial plexus. (Source: Authors’ preferred technique. In: Mackinnon S, ed. Nerve Surgery. 1st ed. Thieme; 2015).

      Fig. 2.14 Postoperative MRI of thoracic reveals proper decompression of cord and spinal canal following a thoracoscopic diskectomy (a). Postoperative CT scan of thoracic reveals bony resection achieved during diskectomy (b). (Source: Technique for thoracoscopic diskectomy. In: Kim D, Choi G, Lee S, et al, eds. Endoscopic Spine Surgery. 2nd ed. Thieme; 2018).

      c. Remove the thick ligamentum flavum and any bone spurs with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak

      d. Perform appropriate foraminotomy with Kerrison rongeurs as needed for appropriate decompression of nerve roots

      12. Perform spinal fusion with instrumentation:

      a. Place pedicle screws over two segments above and two segments below the problem level involved with connecting rods bilaterally, in addition to bone grafting, to fuse these segments

      13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative drains that can be removed after 2 to 3 days

      Pitfalls

      • Reduction in range of motion and mobility of fused spinal segments

      • Intraoperative CSF leak

      • Blood clot (deep vein thrombosis, or more severe pulmonary embolism)

      • Damage to spinal nerves and/or cord

      • Postoperative weakness or numbness or continued pain

      • Postoperative wound infection

      • Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life

      • Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection

      • Loss of sensation

      • Progressive kyphosis

      • Residual spinal compression

      • Problems with bowel/bladder control

      Prognosis

      • Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities.

      • Pain medications for postsurgical pain.

      • Catheter placed in bladder and removed 1 to 2 days after surgery

      • Physical therapy and occupational therapy will be needed postoperatively, immediately and as outpatient to regain strength

      • Brace placed after discharge to immobilize to increase rate of healing