Preparation

Set the observer's pupillary distance to 70 mm on the scope

Monitoring

SSEPs, no need for prepositions most of the time

Medications

Ketamine per protocol, 10g of mannitol, no dexamethasone, no Lasix. 

Positioning

Standard posterior cervical position. Prone in pins. Flexing without elevation (no military tuck).

Bed is a flat Jackson with jelly rolls oriented lengthwise.

Place a folded blanket under the most rostral part of the jelly rolls to give the part under the shoulders some lift. 

Pinning

Pin to 80 lbs. Standard pin positioning. Single pin above pinna at superior temporal line.  Double pin centered above pinna at superior temporal line.

Prep

Relatively hair-sparing shave but not super small shave. There should be about 1 cm of skin showing between the hair edge and the incision on both sides. 

Lido with epi off the field. Prep once, give local, prep again. 

Standard draping

Approach

Skin and Muscle - standard. Blade through skin, Bovie through dermis to midline raphe. He likes to expose occiput first then C1. Okay to Bovie right up to foramen magnum. Expose to accommodate a 3x3 cm craniotomy. He uses Tenotomy scissors to separate fascia from the underside of the top of the C1 lamina.

Bone - make two dime-sized holes with the M8 at the upper corners of the crani. Use the B1 with the footplate to turn the crani. Take a Pen 1 and separate the dura from the bone with the cup side, leave under the bony edge, and use the M8 to drill the bony edge. Especially chase the corners of the foramen magnum.

Dura - use 15 blade to start the incision then carry it out with a Woodson. Standard Y shaped incision.Tie a Neurolon suture at the apex. 

Closure

Use Alloderm for the patch. Double-needle 5-0 Prolene for the suture. Start at the bottom. Throws at the bottom should be very near the edge of the graft and dural edge. Less important at the top. Take big bites at the top. 

Muscle and fascia with 2-0 Poly. Skin with 3-0 baseball Nylon. 

Dressing with Primapore. 

Postop orders

Ketamine drip, acute pain consult. Foley out in OR. Dex 4q6. Cap 150. Standard Dilaudid/oxy. Floor monitored bed.