This step-by-step guide describes the surgical application of C-LOX for the treatment of Wobbler Syndrome.
Overview
IMPORTANT REMINDER: We strongly advise attending one of the Spinal Surgery workshops to acquire the necessary skills for performing Spinal Surgery with C-LOX independently. This article is designed to provide an overview of the technique and to merely offer guidance.
Pre-Operative Assessment and Planning
Radiographs
Pre-operative radiographs are used to make a preliminary selection of spacer and screw sizes. It is advisable, but not indispensable, to use fluoroscopy while performing the distraction-fusion technique with the C-LOX Cage. Fluoroscopy will provide an accurate intra-operative assessment of correct implant and screw size, and of the depth and location of spacer and screw placement.
Surgical Protocol
A step-by-step guide
The following describes the surgical application of C-LOX, an anchored intervertebral spacer, for the treatment of Canine Cervical Spondylomyelopathy (Wobbler Syndrome). This procedure is authored by Dr. Günter Schwarz and Prof. Dr. Franck Forterre.
1. Patient Positioning
Place the dog in dorsal recumbency with a fulcrum underneath to support the neck. Avoid overextension. Perform a standard ventral approach to the cervical spine.
2. Disc Space Exposure
Identify and expose the affected disc space. Use a beaver blade to create a window in the ventral annulus fibrosus, ensuring it is slightly larger than the selected spacer. The vertebral endplates delimit the cranial and caudal borders of the opening. Care must be taken not to penetrate the dorsal part of the annulus during disectomy.
3. Placement of C-LOX Distractor
Drill vertically oriented 2.5 mm holes exactly into each of the adjacent vertebrae. These
holes must be exactly on the midline and should be located in the caudal half of the cranial
and in the cranial half of the caudal vertebrae. Penetration depth should at least be 2/3 of
the vertebral body depth in order to avoid tilting when distracting the vertebrae. The crista ventralis marks the median plane of the vertebrae but makes it easy to slide off the midline. Pre-operative measurements and fluoroscopy will aid in taking care not to enter the spinal canal. Insert the C-LOX Distractor into the pre-drilled holes and open its jaws to widen the intervertebral disc space.
holes must be exactly on the midline and should be located in the caudal half of the cranial
and in the cranial half of the caudal vertebrae. Penetration depth should at least be 2/3 of
the vertebral body depth in order to avoid tilting when distracting the vertebrae. The crista ventralis marks the median plane of the vertebrae but makes it easy to slide off the midline. Pre-operative measurements and fluoroscopy will aid in taking care not to enter the spinal canal. Insert the C-LOX Distractor into the pre-drilled holes and open its jaws to widen the intervertebral disc space.
4. Nucleus Pulposus Removal
Use the C-LOX Spinal Disc Broaching Curette to carefully remove remnants of the nucleus pulposus. The dorsal part of the annulus fibrosus can be felt as a more dense structure and
should be preserved. The exposed end plates are freed from as much connective tissue as possible, but subchondral bone must be fully preserved.
should be preserved. The exposed end plates are freed from as much connective tissue as possible, but subchondral bone must be fully preserved.
If a considerable amount of nucleus pulposus material is found within the spinal canal, it can be carefully removed using fine curettes or delicate arthroscopic biopsy forceps.
5. Placement of the C-LOX Template
The appropriate size for the C-LOX implant can be determined pre-operatively using diagnostic imaging. Attach the C-LOX Implantation Placement Rod to the corresponding C-LOX Template and insert it into the intervertebral disc space to ensure a proper fit. Again, vertical beam fluoroscopy can be particularly helpful in this process. If inserting the template requires significant force or results in minimal distraction, consider using a thinner or thicker template for a better fit.
6. C-LOX Cage Insertion
After establishing optimal fit, the C-LOX Template is replaced by the corresponding C-LOX Cage. Spikes on the cranial and caudal side will ensure a secure seating of the implant, but can make insertion slightly more difficult compared to the C-LOX Template of the same
size. Press the cage firmly down into place.
size. Press the cage firmly down into place.
7. Removal of Distractor and Rod
Remove the C-LOX Distractor and Implantation Placement Rod after confirming proper seating of the C-LOX Cage. Secure the cage with locking screws.
8. Locking Cortical Screw Placement
Select the appropriate drill guide based on the intended screw length. Attach the drill guide to the implant and use the dedicated 2.0mm drill bit to create a hole for the Locking Cortical Screw. This drill bit is integrated with the drill guide and facilitates precise placement of the screw within the vertebral body. Screw lengths are determined pre-operatively from measurements on lateral radiographs. Insert the four locking cortical screws using the Star-Drive Screwdriver, ensuring they are securely anchored within the vertebral body without penetrating the endplates or spinal canal. Again, fluoroscopy can be very helpful in achieving optimal screw placement.
9. Closure and use of bone substitutes
Cancellous bone or bone substitutes can be apposed to the ventral surface of the treated disc space.
Close the soft tissues in a routine manner.
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