EMGs alone. Miele does not routinely use SSEPs.

You will need lead for this case

Call for C arm

Verify neurophys is in the room

Anesthesiology with gas only, no paralysis

Place Foley

Slide table to the head all the way, arm board as high as possible, bracket for retractor holder as low as possible. This is to accommodate the c arm. You don't want to bump into the bed post.

Transfer patient to the bed, lateral positioning, keep iliac crest at the break in the table

Place axillary roll just beneath but not in the axilla

Purple foam between lateral knee and bed, pillow between legs

Pillow between arms

Place clear ioban against iliac crest, put just over the top of the crest, second ioban at the lower costal margin

Tape above and below the break in the bed

Tape from iliac crest to base of bed, padding the common peroneal of the upper leg

Break bed by putting the back down then reverse Trendelenberg

Bring C arm in, take AP shot, centering cross dead center in the appropriate disk space, then do lateral, mark space

Prep with chloraprep

Lay out 4 towels, making sure to include spinous processes in draped out window, in case you need to make a releasing incision to feel the TP

Lights go off the top, other things go off the bottom, make sure wires aren't in the x-ray window

C-armor

Make incision

Bove until you hit fat or muscle

Dissect with your longest finger, mine is the middle, straight down towards the ground, using a sweeping motion with rotation of the tip of the finger while applying inward pressure

Once you feel the TP, ask for the black dilator (some sources call this "the Okonkwo") and place against the TP

Take a shot

Position the black dilator at the midpoint of the appropriate disk space. You can feel this as a ridge when sweeping the dilator from cranial to caudal. 

Place the K wire through the cannulated black dilator and push into the disk space

Take a lateral shot and advance the K wire to the mid-point of the space

Ask for the stimulator, clip onto the black dilator, turn on, and ask the Neurophys rep to turn the sound on. Stimulate in each of the 4 compass directions. The direction in which you are stimulating is demarcated by a white band at the top of the black dilator. If there is a response you will need to reposition the dilator, sweeping muscle or soft tissue in front of the dilator, then try again. 

Push serial dilators over the black dilator, make sure you hold down the smaller dilators before pushing down the bigger dilator

Once all 3 dilators are in place ask for the retractor. Make sure the blades are closed before pushing into place. 

Take a shot to verify the retractor trajectory is in line with the disk space

Open the retractor 2 clicks up and 2 clicks sideways

Manually stimulate with the probe, including the spot where the shim will be placed

Place the shim, use a Cobb to tap it into place a couple times, then take a shot to verify trajectory before seating it all the way down

Remove the shim placer

Use the knife to perform the annulotomy

Use the 6 shaver then the 8 shaver to shave the disk space

Pituitary to remove disk fragments then Kerrison

Always orient tools with your hand away from you and the tip of the instrument towards you. You may bring this trajectory back to normal once you are in the disk space but maintain it religiously before. 

Ask for the trial, hammer it into place, then use the slap hammer to take it out

Put the graft in place, hammer it in

Use the awl to make the screw holes then place the screws, usually 5 mm shorter than the plate 

Close the retractor then come out

Close the muscle with O poly, then dermal with 2-0 poly, and finish with running sub-q monocryl, steri-strips

Miele likes standing films,