PROCEDURE: Bilateral C3 through C6, T4 and T7 laminectomies for evacuation of epidural abscess.
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DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room where she was properly identified and marked. General endotracheal anesthesia was induced and she was rolled to a prone position on bolsters on the operating table with the head secured in the Mayfield frame. The neck was gently flexed and all pressure points were carefully padded. Neuromonitoring leads were placed and signals remained stable throughout the procedure. The cervical and thoracic regions of the spine were then sterilely prepped and draped. The patient's safety time-out was performed. The cervical incision was marked in the midline from C3 through C6 and the skin was infiltrated with local anesthetic. The incision was opened with a #10 blade and bleeding points were coagulated with monopolar cautery. Dissection then proceeded in the midline to expose the posterior elements and self-retaining retractors were placed. A lateral cervical spine x-ray confirmed the proper levels. The lamina was then drilled with an AM-8 cutting burr on the Midas Rex drill and the posterior elements were then gently lifted away from the thecal sac using a 1-mm Kerrison punch to divide the ligaments. There was prompt flow of a large volume of liquified pus from the epidural space. Cultures were sent for Gram stain, which returned showing white blood cells and gram-positive cocci. The patient was given additional IV antibiotics. The pus was then thoroughly irrigated from the epidural space and the ligamentum flavum was excised with 2-mm Kerrison punch. A small ventricular catheter was then gently passed inferiorly in the epidural space without resistance. Additional pus was irrigated from the epidural space inferiorly. Ultimately, the return was relatively clear. Hemostasis was confirmed at this level and then the second vertical linear midline incision was then placed overlying the T4 spinous process. This was exposed along with the lamina using subperiosteal dissection and monopolar cautery. The spinous process and lamina were then removed using the drill and rongeurs. There was also epidural pus in this location, but less. This was irrigated with saline and then the epidural catheter was again passed into the epidural space and irrigated with antibiotic-containing saline until clear. Hemostasis was confirmed at this level and then the third incision was made overlying the T7 spinous process, which was removed along with the lamina in a similar fashion. There was no significant epidural abscess noted at this level. A sample of spinous process bone was sent to pathology from each incision. Once again, the catheter was passed inferiorly and the return was quite clear. At this point, the wounds were irrigated with a large volume of antibiotic-containing saline and meticulous hemostasis was obtained. A small JP drain was placed into each incision and was brought out through a separate stab incision. Vancomycin powder was applied to the wounds. The incisions were then closed in anatomic layers using interrupted Vicryl and skin staples. Marcaine 0.5% was applied to the wounds prior to skin closure. Dry sterile dressings were placed and the patient was then taken to the intensive care unit postoperatively in satisfactory condition. There were no intraoperative complications and the procedure was well tolerated. There were no neuromonitoring changes throughout.
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DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was taken to the operating room where she was properly identified and marked. General endotracheal anesthesia was induced and she was rolled to a prone position on bolsters on the operating table with the head secured in the Mayfield frame. The neck was gently flexed and all pressure points were carefully padded. Neuromonitoring leads were placed and signals remained stable throughout the procedure. The cervical and thoracic regions of the spine were then sterilely prepped and draped. The patient's safety time-out was performed. The cervical incision was marked in the midline from C3 through C6 and the skin was infiltrated with local anesthetic. The incision was opened with a #10 blade and bleeding points were coagulated with monopolar cautery. Dissection then proceeded in the midline to expose the posterior elements and self-retaining retractors were placed. A lateral cervical spine x-ray confirmed the proper levels. The lamina was then drilled with an AM-8 cutting burr on the Midas Rex drill and the posterior elements were then gently lifted away from the thecal sac using a 1-mm Kerrison punch to divide the ligaments. There was prompt flow of a large volume of liquified pus from the epidural space. Cultures were sent for Gram stain, which returned showing white blood cells and gram-positive cocci. The patient was given additional IV antibiotics. The pus was then thoroughly irrigated from the epidural space and the ligamentum flavum was excised with 2-mm Kerrison punch. A small ventricular catheter was then gently passed inferiorly in the epidural space without resistance. Additional pus was irrigated from the epidural space inferiorly. Ultimately, the return was relatively clear. Hemostasis was confirmed at this level and then the second vertical linear midline incision was then placed overlying the T4 spinous process. This was exposed along with the lamina using subperiosteal dissection and monopolar cautery. The spinous process and lamina were then removed using the drill and rongeurs. There was also epidural pus in this location, but less. This was irrigated with saline and then the epidural catheter was again passed into the epidural space and irrigated with antibiotic-containing saline until clear. Hemostasis was confirmed at this level and then the third incision was made overlying the T7 spinous process, which was removed along with the lamina in a similar fashion. There was no significant epidural abscess noted at this level. A sample of spinous process bone was sent to pathology from each incision. Once again, the catheter was passed inferiorly and the return was quite clear. At this point, the wounds were irrigated with a large volume of antibiotic-containing saline and meticulous hemostasis was obtained. A small JP drain was placed into each incision and was brought out through a separate stab incision. Vancomycin powder was applied to the wounds. The incisions were then closed in anatomic layers using interrupted Vicryl and skin staples. Marcaine 0.5% was applied to the wounds prior to skin closure. Dry sterile dressings were placed and the patient was then taken to the intensive care unit postoperatively in satisfactory condition. There were no intraoperative complications and the procedure was well tolerated. There were no neuromonitoring changes throughout.
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