Position: Supine, head slightly extended
Time: 2-4 hours (long)
Blood Loss: High (200 – 500 ml)
Post-op Pain: High (7-10)
Maintenance Paralytic: No

Preoperative preparation – Ask the surgeon if he/she is going to want the patient to move their extremities before extubation. If yes, then make sure to prepare the patient for that experience.

Intubation – Glidescope or fiberoptic intubation are often employed because the patient has an unstable C-spine. Make sure to keep the patient’s head in a neutral position!

Shared airway – The surgeon will be working in close quarters with the airway, so you’ll need to make sure you have it properly secured and have a backup plan! Your access to the airway will be limited. Because of the proximity of the surgery to the airway, there is also relatively high potential for accidental extubation by surgeons/fluoroscopy.

Approach – SSEPs & MEPs are not always monitored. Make sure to check with the surgeon and/or team prior to preparing your approach.

Time and Blood Loss – could be minimal to high depending on the surgeon and how many levels are being worked on.

Wakeup – SMOOTH wakeup is important! Coughing can cause serious bleeding. One of the pros suggests 25mg of lidocaine IV during emergence and if necessary, 10-20mg bumps of propofol while the gas wears off.

Postop – Watch closely for airway swelling and/or bleeding.

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.