*Title Page
INTRAOPEARTIVE USE OF CITOW CERVICAL VISUALIZER (CCV) TO IMPROVE
VISUALIZATION
OF THE CERVICAL SPINE – TECHNICAL CASE REPORT AND REVIEW OF 50-CASES Jonathan S.
Citow, M.D., Robert Erickson, M.D. Jill Pickett, RN, Igor Yalovetskiy, PA – C,
Mike Campagna, K.C. Hoos, BS, and Chacko Thomas, RT Section of Neurosurgery
Condell Medical Center, Libertyville, Illinois,
Lake Forest Hospital, Lake Forest, Illinois, University of Chicago Hospitals,
Chicago, Illinois, and Rosalind Franklin University Medical Center, North
Chicago, Illinois
For
correspondence contact Lake County Neurosurgery 712 S. Milwaukee Ave.
Libertyville, IL 60048 ph. 847-362-1848 fax 847-362-3351 customerservice@citowcv.com
*References
(cited in order of appearance)
References
American
Journal of Roentgenology Department of Radiology, Brigham and Women’s Hospital
75 Francis St. Boston, MA 02115
*Mini
Abstract (50 words)
The CCV was
developed by Neurosurgeon Jonathan Citow, MD after years of trying to find a
better way to ensure accuracy in counting the lower levels of the cervical spine
during surgery especially with larger patients.
*Key Points
(3-5 main points of the article)
Object
One of the challenging aspects of cervical spine surgery is visualizing and
counting the appropriate levels due to the difficulty of penetrating X-ray beams
through the shoulders. The authors describe a technique for transient
intraoperative caudal displacement of the shoulders to enable improved
visualization of the lower cervical and upper thoracic spine. The Citow Cervical
Visualizer (CCV) www.citowcv.com helps localize the correct surgical levels and
may also be used for guiding intraoperative placement of instrumentation when
combined with fluoroscopy. It may also be used in the emergency room or
radiology department to obtain a full cervical spine X-ray extending down to T1
in trauma cases.
Methods
A prospective study was conducted using 50 consecutive patients over a 4 month
period (March – July, 2008). The patient’s sex, height, weight and age were
documented along with each patient’s lowest spinal level identified, both with
and without the CCV on two consecutive shots. The force of the displacement was
also measured.
Results
The 50-patients included 26 males and 24 females. The weight ranged from 110
lbs. to 270 lbs. with a mean weight of 185 lbs. The height ranged from 4 ft. 11
in. to 6 ft. 2 in. with a mean of 5 ft 6 1/4 in. The age ranged from 37 years to
67 years with a mean age of 49 years. The force applied was 24-37 lbs. There was
an average improvement in visualized cervical levels of 2.84 vertebrae. There
were no complications noted with use of the device. There were no instances of
shoulder dislocation, brachial plexus injury or IV dislocation.
Conclusion
The CCV is a useful adjuvant to cervical spine surgery. It will help visualize
levels that may not be seen with traditional methods such as taping the
shoulders or tying bands around the wrists and pulling them during the X-ray.
This technique has been proven safe and effective.
*Structured
Abstract (300 words)
Introduction
One of the
challenging aspects of cervical spine surgery is correctly localizing the lower
levels during anterior and posterior procedures. Traditional methods such as
taping the shoulders throughout the entire case have been used as well as tying
straps around the wrists and pulling them caudally while shooting the X-rays.
These methods both cause problems such as brachial plexus injury, dislodging of
IVs, shoulder dislocations and peripheral nerve pressure injuries. The CCV (Fig.
1) was designed to help transiently displace the shoulders for a very short time
while shooting the X-ray and allowing the body to resume its normal position
immediately after.
Clinical materials and methods
50
consecutive patients were evaluated in this series between March – July, 2008.
The inclusion criteria was any patient having an anterior cervical diskectomy
and fusion. No candidates were excluded from this study. The study included 26
males and 24 females. The age range was 37-67 years with a mean age of 49. The
height range was 4ft. 11in. to 6ft. 2in. with a mean of 5ft. 6 1/4in. The weight
ranged from 110 lbs. to 270 lbs. with a mean of 185 pounds.
The top of
the lowest cervical level identified was recorded for each patient initially
without using the CCV and then with the CCV. (Table 1). Tests were performed by
CCV on individuals of various stature, gender, weight, and age using a standard
operating table. A spring force gauge was used to obtain the amount of force in
pounds required to migrate the shoulders far enough to expose two additional
cervical vertebrae. The results ranged from 24-37 lbs to achieve a 2 level
improvement in visualization. (Table 2).
The X-rays
used were done with a GE AMX Plus Portable Machine and Kodak CR Cassettes. An
average of 76 kVp at 32 Mas for a medium male and 74 kVp at 24 mAs for a medium
female.
Description of technique
The CCV (Fig.
2) arches were adjusted based on the shoulder width and rests on top of the
acromion processes. The user sits or stands at the head of the OR table during
the intraoperative X-ray and pushes the shoulders caudally towards the feet. The
shoulders are only displaced during the actual X-ray. No taping of the shoulders
was ever used. There was no pulling down of the wrists with straps. To decrease
the X-ray exposure of the person using the CCV, an X-ray gown and thyroid shield
was worn with another X-ray gown draped around their arms, shielding them from
radiation exposure. A disposable covering with padding (Fig. 2) was used on each
CCV arch to allow cushioning of the shoulders and also to prevent contamination
of the patients. No additional straps or taping was used with the device. No
muscle relaxants were used in any case. Patients were positioned normally. The
X-rays were read by an independent radiologist.
Results
All of the
patients were noted to have improved visualization with the use of the CCV.
*Manuscript Text (must include page numbers)
INTRAOPEARTIVE USE OF CITOW CERVICAL VISUALIZER (CCV) TO IMPROVE VISUALIZATION
OF THE CERVICAL SPINE – TECHNICAL CASE REPORT AND REVIEW OF 50-CASES
Jonathan S.
Citow, M.D., Robert Erickson, M.D. Jill Pickett, RN, Igor Yalovetskiy, PA – C,
Mike Campagna, K.C. Hoos, BS, and Chacko Thomas, RT
Section of
Neurosurgery Condell Medical Center, Libertyville, Illinois, Lake Forest
Hospital, Lake Forest, Illinois, University of Chicago Hospitals, Chicago,
Illinois, and Rosalind Franklin University Medical Center, North Chicago,
Illinois
Object
One of the challenging aspects of cervical spine surgery
is visualizing and counting the appropriate levels due to the difficulty of
penetrating X-ray beams through the shoulders. The authors describe a technique
for transient intraoperative caudal displacement of the shoulders to enable
improved visualization of the lower cervical and upper thoracic spine. The Citow
Cervical Visualizer (CCV) www.citowcv.com
helps localize the correct surgical levels and may also be used for guiding
intraoperative placement of instrumentation when combined with fluoroscopy. It
may also be used in the emergency room or radiology department to obtain a full
cervical spine X-ray extending down to T1 in trauma cases.
Methods
A prospective study was conducted using 50 consecutive patients over a 4 month
period (March – July, 2008). The patient’s sex, height, weight and age were
documented along with each patient’s lowest spinal level identified, both with
and without the CCV on two consecutive shots. The force of the displacement was
also measured.
Results
The 50-patients included 26 males and 24 females. The weight ranged from 110
lbs. to 270 lbs. with a mean weight of 185 lbs. The height ranged from 4 ft. 11
in. to 6 ft. 2 in. with a mean of 5 ft 6 1/4 in. The age ranged from 37 years to
67 years with a mean age of 49 years. The force applied was 24-37 lbs. There was
an average improvement in visualized cervical levels of 2.84 vertebrae. There
were no complications noted with use of the device. There were no instances of
shoulder dislocation, brachial plexus injury or IV dislocation.
Conclusion
The CCV is a useful adjuvant to cervical spine surgery. It will help visualize
levels that may not be seen with traditional methods such as taping the
shoulders or tying bands around the wrists and pulling them during the X-ray.
This technique has been proven safe and effective.
KEY WORDS CCV, Citow Cervical Visualizer, cervical spine surgery, localization,
X-ray, and fluoroscopy www.citowcv.com
Page Two
Introduction
One of the
challenging aspects of cervical spine surgery is correctly localizing the lower
levels during anterior and posterior procedures. Traditional methods such as
taping the shoulders throughout the entire case have been used as well as tying
straps around the wrists and pulling them caudally while shooting the X-rays.
These methods both cause problems such as brachial plexus injury, dislodging of
IVs, shoulder dislocations and peripheral nerve pressure injuries. The CCV (Fig.
1) was designed to help transiently displace the shoulders for a very short time
while shooting the X-ray and allowing the body to resume its normal position
immediately after.
Clinical materials and methods
50
consecutive patients were evaluated in this series between March – July, 2008.
The inclusion criteria was any patient having an anterior cervical diskectomy
and fusion. No candidates were excluded from this study. The study included 26
males and 24 females. The age range was 37-67 years with a mean age of 49. The
height range was 4ft. 11in. to 6ft. 2in. with a mean of 5ft. 6 1/4in. The weight
ranged from 110 lbs. to 270 lbs. with a mean of 185 pounds.
The top of
the lowest cervical level identified was recorded for each patient initially
without using the CCV and then with the CCV. (Table 1). Tests were performed by
CCV on individuals of various stature, gender, weight, and age using a standard
operating table. A spring force gauge was used to obtain the amount of force in
pounds required to migrate the shoulders far enough to expose two additional
cervical vertebrae. The results ranged from 24-37 lbs to achieve a 2 level
improvement in visualization. (Table 2).
The X-rays
used were done with a GE AMX Plus Portable Machine and Kodak CR Cassettes. An
average of 76 kVp at 32 Mas for a medium male and 74 kVp at 24 mAs for a medium
female.
Description of technique
The CCV (Fig.
2) arches were adjusted based on the shoulder width and rests on top of the
acromion processes. The user sits or stands at the head of the OR table during
the intraoperative X-ray and pushes the shoulders caudally towards the feet. The
shoulders are only displaced during the actual X-ray. No taping of the shoulders
was ever used. There was no pulling down of the wrists with straps. To decrease
the X-ray exposure of the person using the CCV, an X-ray gown and thyroid shield
was worn with another X-ray gown draped around their arms, shielding them from
radiation exposure. A disposable covering with padding (Fig. 2) was used on each
CCV arch to allow cushioning of the shoulders and also to prevent contamination
of the patients. No additional straps or taping was used with the device. No
muscle relaxants were used in any case. Patients were positioned normally. The
X-rays were read by an independent radiologist.
Results
All of the
patients were noted to have improved visualization with the use of the CCV.
Page Three
Discussion
The CCV was
very useful in improving the chance of identifying the correct level during
surgery. This is a radiolucent device made of carbon fiber. It is light weight
and easy to hold. The arms of the visualizer are adjustable for various shoulder
widths and rests on top of the shoulders at the level of the acromion processes.
In order to ameliorate radiation exposure to staff, a rail guided table Mount
for the CCV (Fig. 3) has been created. Usage of the table mount replicates the
bilateral distal motive pressure upon the patients’ shoulders which would
otherwise be provided by the CCV Operator; thereby eliminating the need for Hand
Operation of the CCV during intra-operative radiography.
Upon
completion of radiography the table mount relaxes pressure upon the shoulders
via a quick release trigger, yet remains positioned for additional “hands free”
usage of the CCV. The table mount is fully compatible with all patient operating
tables equipped with accessory side rails to include but not be limited to the
following manufacturers: Jackson/Shearer-Mayfield/Skytron/Amsco/Stryker/Mizuho/Maquet.
The “Hands
Free” operation of the CCV device also allows for usage under continuous
fluoroscopy.
Disposable
plastic covers with foam bases were used on each arch to prevent transmission of
bacteria between patients and also to pad the shoulders. No evidence of bruising
was noted on any of the 50 patients. The force applied was never high enough to
damage the patient’s bones or dislocate their shoulders. There were no
complications associated with the device. There was no dislodgement of the
endotracheal tube or patient changes in position during surgery. There were no
instances of impaired visualization from the device.
The risk of
radiation to the users’ hands are decreased by wearing lead gloves, draping a
lead apron around the arms and also wearing one around the body as well as a
thyroid shield. A saline bag can also be placed along the visualizer at the
upper cervical spine to allow stronger penetration with the X-ray beam to
visualize more challenging areas of the lower cervical spine while not burning
out the upper cervical spine levels. The saline will absorb some of the
radiation to allow a more clean appearing X-ray. This was not needed on these
specific 50 cases but we have used this on multiple occasions in the past.
Occupational
radiation monitoring devices are reported in rems. Effective dose is a term used
to describe the relative risk of biologic effect caused by radiation exposure.
Because some types of radiation cause more damage than others, the rem is used
to account for the differences in these biologic effects. The maximum allowable
occupational dose limit for radiation workers is 5000 mrems, or 50 mSv, per
year. All staff in the operating room should wear personal dosimeter monitors,
aprons, thyroid shields and eye protection.
The total
effect dose for a cervical spine series of five X-rays without protection is .27
mSv or Page Four
27 mrem. When
a member of the operating room staff uses the CCV with proper radiation
protection, they would receive a significantly lower dose, as proper shielding
reduces exposure Page Four
by
approximately 16 fold. The CCV usage involves minimal risk for the patient as
well as the staff and is well within the recommend guidelines. A baseline and a
final film were all that was needed.
In our cases,
the CCV has also been found to be useful for artificial cervical disk placement
and posterior procedures. Without the CCV, we would have had to fuse two
patients in which we were able to implant an artificial cervical disk. We were
able to use the CCV with the Mayfield head holder and Jackson spinal table
without problems. The improved visualization should decrease the number of X-ray
shots and hence operating room time and expense. The better imagery has the
benefit of easier confirmation of the operative level and increases the ability
to assess the graft and screw placement. This study compared levels obtained
versus not taping.
We have now
initiated a study of CCV versus taping. In our experience, we have noted at
least one level of additional exposure over taping.
Conclusion
The CCV is a
useful adjuvent to cervical spine surgery. It can help visualize levels that may
not be seen with traditional methods. It does not have the risks of the current
practices such as taping the shoulders throughout the entire case or tying bands
around the wrists and pulling them during the X-ray. This technique has been
proven safe and effective.
Disclaimer
Jonathan
Citow, M.D., is a coinventor of the Citow Cervical Visualizer and is a
coshareholder in its financial returns.
Page Five
Figure 1 -Citow
Cervical Visualizer (CCV) Figure 2 -Disposable boots. Figure 3 – Universal Table
mount Figure 4 – Usage Suggestions Figure 5 -X-rays of cervical spine with use
of CCV Figure 6 -X-rays of cervical spine without use of CCV
Table 1 –
Data/Details of the 50 patients included in this study Table 2 – Data/CCV Test
to migrate the shoulders to expose two additional cervical vertebrae
References
1. American Journal of Roentgenology Department of Radiology, Brigham and
Women’s Hospital 75 Francis St. Boston, MA 02115
Figure
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