CIS Self-Study Lesson Plan

Lesson No. CIS 246 (Instrument Continuing Education - ICE) by Carol Petro, RN, BSN, CNOR, CRCST, CIS
O.R. Educator, Surgery & Sterile Processing
Sponsored by: Indiana University Health North Hospital
Indiana University Health Saxony Hospital

basics of
SPINAL INSTRUMENTS
O
LEARNING OBJECTIVES NE MUST FIRST UNDERSTAND THE ANATOMY OF THE SPINE AND
1. Provide a description of the anatomy know the common spinal procedures that are performed before detailed
of the spine information about spinal instruments can become most useful. These
2. Present an overview of the three instruments can be classified into five categories, and each has a very
approaches to the spine during a important and different role to play in successful surgical procedures. This lesson pro-
surgical procedure vides a foundation of general information and instrument identification that should be
3. Identify basic instruments used in understood by all Certified Instrument Specialist (CIS) technicians.
posterior spinal surgeries
s 2ETRACTORS
s %LEVATORS OBJECTIVE 1: PROVIDE AN
s 2ONGEURS OVERVIEW OF THE ANATOMY
s .ERVEHOOKS OF THE SPINE
s #URETTES The human spine extends from the skull
to the pelvis. It is comprised of individual
bones, called vertebra, that are grouped
together in four regions:
)NSTRUMENT#ONTINUING%DUCATION)#% LESSONS
provide members with ongoing education in s 4HE CERVICAL SPINE REFERS TO THE NECK
the complex and ever-changing area of surgical area that contains seven vertebrae.
instrument care and handling. These lessons are s 4HE THORACIC SPINE SPANS THE CHEST AREA
DESIGNEDFOR#)3TECHNICIANSBUTCANBEOFVALUE
TOANY#2#34TECHNICIANWHOWORKSWITHSURGICAL and contains 12 vertebrae.
instrumentation. s 4HE LUMBAR LOW BACK AREA CONTAINS
five vertebrae.
Earn Continuing Education Credits:
Online: You can use these lessons as an in-service s 4HE SACRUM AND COCCYX COMPLETE THE
WITHYOURSTAFFORVISITWWWIAHCSMMORGFORONLINE spine in the pelvis area, with fused $IAGRAM,ATERAL6IEWOF3PINAL#OLUMN
grading at a nominal fee. non-separated vertebrae.
By mail: &ORWRITTENGRADINGOFINDIVIDUALLESSONS The anterior approach to the thoracic
send completed 15-question quiz and $15 Diagram 1 shows a lateral (side) view and lumbar spine requires the assistance
TO0%#"USINESS/FlCE0URDUE5NIVERSITY3TEW- of each of the four spinal regions. of a vascular or general surgeon who can
ART#ENTER2OOM-EMORIAL-ALL7EST
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Scoring: %ACHQUESTIONONLINEQUIZWITHA
PASSINGSCOREOFORHIGHERISWORTHTWOPOINTS
CONTACTHOURS TOWARDYOUR#)3RE
CERTIlCATION APPROACHES TO THE SPINE
POINTS OR#2#34RE
CERTIlCATIONPOINTS  DURING A SURGICAL PROCEDURE
)!(#3--PROVIDESONLINEGRADINGSERVICEFOR
ANYOFTHE,ESSON0LANVARIETIES0URDUE5NIVERSITY
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#)3LESSONS
More information: Direct any questions about
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Questions about written grading are answered by
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manipulate vessels and organs out of the
OBJECTIVE 2: PRESENT AN way. Then the orthopedic or neurospinal
OVERVIEW OF THE THREE surgeon can operate on the spine itself.
Note: When operating from the posteri-
or or lateral approach, these vessels and
The surgeon’s approach to the spine organs are not in the path of the posterior
during surgery impacts the type of or lateral spine. The anterior approach
instruments that will be used for the also requires additional retractors and
procedure. The three possible approaches vascular clamps that are not needed for
are anterior (from the front of the spine), posterior or lateral spinal cases, and the
posterior (from the back of the spine), or lateral approach uses minimally inva-
lateral (on the side of the spine). sive instruments. Note: The instrument
 CIS Self-Study Lesson Plan

Photo 1: Derrico retractor 0HOTO!DSON#EREBELLARRETRACTOR 0HOTO4OP#ASPARNERVEROOTRETRACTOR

"OTTOM$ERRICONERVEROOTRETRACTOR

discussion in this lesson plan focuses instruments used differ according to the used to expose the bone of the spine. The
primarily on instruments used for the location of the surgery. Cobb elevator has various lengths of han-
posterior approach to the spine. dles and sizes of paddles, depending on
Common spinal procedures include: RETRACTORS the level of spine in which the procedure
s $ISCECTOMYANYLEVELOFSPINE nTO To expose the spine, the surgeon will require is performed. The surgeon uses the Cobb
remove herniated disc material press- an electro cautery pencil, knife handle, elevator and a surgical sponge to elevate
ing on a nerve root or the spinal cord elevator, and self-retaining retractor. The and push the muscle away from the bone
s ,AMINECTOMYnASPINALOPERATION type of retractor will depend on the depth to allow visualization of the spine. More
to remove the lamina: part of the of the incision. For all spine surgeries, dissection is required if spinal implants
vertebral bone Weitlaner retractors (not pictured) of and bone fusion are planned. When more
s !NTERIOR,UMBAR)NTERBODY&USION different lengths are initially used to es- delicate work is needed, the Penfield 4
!,)& nUSEOFFRONTAPPROACHTOFUSE tablish retraction of the skin and muscle. elevator (Photo 6) is used.
lumbar spinal bones together by As the wound deepens and lengthens,
removing a between-vertebrae disc and the Derrico retractor (Photo 1) or Adson RONGEURS
replacing it with a bone or metal spacer. Cerebellar retractor (Photo 2) may be Depending on the procedure, a large
This procedure can also be performed used. The body of the Derrico retractor is amount of bone removal is needed. The
with a Posterior Lumbar Interbody longer to accommodate a longer incision. Stille-Luer Horsley rongeur (Photo 7;
Fusion (PLIF) that approaches the The hand-held Meyerding retractor or left), Leksell rongeur (Photo 7; middle),
spine through the low back, or a Taylor retractor (not pictured) are com- and Duckbill rongeur (Photo 7; right) are
Thoracic Lumbar Interbody Fusion monly used when obtaining bone from used to remove the spinous process (the
(TLIF) that is performed at the higher the iliac crest for bone fusion in the spine. boney projections on each vertebra where
(thoracic) level of the spine. Delicate work near the disc can require the muscles and ligaments attach to the
s !NTERIOR#ERVICAL$ISCECTOMYAND the use of the Derrico nerve root retrac- spine). Note: the Stille-Luer Horsley and
&USIONnTHISPROCEDUREISPERFORMED tor (Photo 3; bottom) or Caspar nerve Leksell rongeurs point straight from the
to relieve neck and other pain caused root retractor (Photo 3; top), along handle, while the duckbill points to the
by spinal cord or nerve root pressure with the Micro Williams retractors side. The Stille-Luer Horsley rongeur pro-
from a cervical disc herniation (not pictured), which have deep and vides a 10 mm bite to remove bone while
s 3PINEREALIGNMENTOFSCOLIOSISSIDE
narrow blades. Note: nerve root retrac- the Leksell and Duckbill are available in a
ways curve of the spine) or kyphosis tors have a crooked design so they can variety of widths.
(humpback curve of the thoracic spine). be placed deep in the wound to retract a The Kerrison rongeur (Photo 8) is used
nerve root while angling out of the sur- to remove bone from smaller areas of the
OBJECTIVE 3: IDENTIFY BASIC geon’s visual path so he or she can see the spine. Its features include:
INSTRUMENTS USED IN
POSTERIOR SPINAL SURGERIES
Five basic instrument categories are
generally used for all spinal surgeries:
retractors, periosteal elevators, rongeurs,
nerve hooks, and curettes. Since the size
of individual vertebra bones increase in
size as they progress from the cervical
spine to the lumbar area, the size of bone
surgical site. The person’s hand holding
the retractor must be out of the midline
view of the spine, so the nerve can be
retracted to the side while the surgeon
works around it.
ELEVATORS
The Hoen Sedilot elevators (Photo 4) and
Cobb elevators (Photo 5) are commonly
s 6ARIABLEJAWWIDTHSINCLUDINGMM
2 mm, 3 mm, 4 mm, and 5 mm.
s 4WOJAWSLANTSOANDO
s #ANBEUSEDFORUPORDOWNBITING
(most commonly used is up biting)
s (ASALONGERSHAFTLENGTHFORSPINALCASES
than shorter shaft instruments used for
ear, nose, and throat (ENT) surgeries
 CIS SELF-STUDY LESSON PLAN

0HOTO(OEN3EDILOTELEVATOR 0HOTO#OBBELEVATOR 0HOTO0ENlELDELEVATOR

0HOTO,EFT3TILLE ,UER(ORSLEYRONGEUR 0HOTO+ERRISONRONGEURS 0HOTO0ITUITARYRONGEURS

-IDDLE,EKSELLRONGEUR2IGHT$UCKBILLRONGEUR

0HOTO#ASPERSERRATEDPITUITARYRONGEUR 0HOTO-ICROSTRAIGHTPITUITARYRONGEUR Photo 12: Peapod pituitary rongeur

0ITUITARYRONGEURS0HOTO AREUSED to remove disc tissue: the micro straight

to remove disc and tissue in small spaces. pituitary rongeur (Photo 11), the Peapod
Their features include: pituitary rongeur (Photo 12), and the Mi-
s #ANBEUSEDFORSTRAIGHTUPANDDOWN cro Williams pituitary rongeur, common-
biting ly called “snaggeletooth” (Photo 13).
s !VAILABLEINSEVERALJAWWIDTHS
including 2 mm, 3 mm, and 4 mm.
s 0ROPERLENGTHOFSHAFTTOACCOMMODATE
spinal procedures
Some rongeurs, such as the Casper
pituitary rongeur (Photo 10), have ser-
rated jaws to help remove disc and tissue.
Micro-disectomy procedures require the
use of a microscope, and three rongeurs
are commonly used in these procedures
NERVE HOOKS
Surgeons use nerve hooks to explore
areas around the delicate nerves located
in the spine, and three main nerve hooks
should be part of every basic set used in 0HOTO-ICRO7ILLIAMSPITUITARYRONGEUR
spinal surgeries. These include the Dandy
blunt nerve hook (Photo 14), which has
a short and blunt design, the Cushing
Gasserian blunt nerve hook (Photo 15),
which is longer in length, and the Weary
 CIS Self-Study Lesson Plan

0HOTO$ANDYBLUNTNERVEHOOK 0HOTO#USHING'ASSERIANNERVEHOOK 0HOTO7EARY"LACKNERVEHOOK

0HOTO-ALISMICRO NERVEHOOK 0HOTO2IGHT!NGLEDCURETTE,EFT3TRAIGHTCURETTE 0HOTO%PSTEINCURETTE

Black nerve hook (Photo 16), which has a
thinner and more pointed design. When
working under a microscope, the Malis
(micro) nerve hook (Photo 17), which is
smaller, may be required.
CURETTES
Curettes help to remove bone and are
available with various sizes of cups. Note:
Curette cups can be periodically sharp-
ened for better performance, but atten-
tion to maintaining the cup size specifica-
tions is very important, and they must be
verified. Also, after multiple sharpenings,
the depth of the cup will be compromised
and, if used, the instrument will not meet
the surgeon’s expectations.
Curettes can be straight (Photo 18;
bottom) or angled (Photo 18; top), and
system may involve different screws, hooks,
plates, and rods to stabilize the spine.
IN CONCLUSION
Spinal instrumentation and implants have
developed through the years. However,
the basic instruments required to gain
access to and expose the spine have
remained the same for several decades,
and this instrumentation is common to
CIS SELF-STUDY
LESSON PLANS
TECHNICAL EDITOR
CARLA MCDERMOTT, RN, CRCST
#LINICAL.URSE)))
3OUTH&LORIDA"APTIST(OSPITAL
spine sets throughout the surgical world.
Nurses, CIS technicians, and other sterile
processing professionals must become
very familiar with these basic spine
instruments. As they do so, proper care
and inspection will better ensure that
the surgeon will have the needed tools to
accomplish the spinal surgeries.
WANT TO BE AN AUTHOR?
)!(#3--ISSEEKINGVOLUNTEERSTOWRITE
ORCONTRIBUTEINFORMATIONFOROUR#)33ELF
3TUDY,ESSONS$OINGSOISAGREATWAYTO
surgeons will be very specific about their 0LANT#ITY&, contribute to your own professional devel-
requirements. The Epstein curette with a OPMENTTOYOUR!SSOCIATIONANDTOYOUR
REVERSE
ANGLEDCUTTINGCUP0HOTO IS SERIES WRITER/EDITOR #ENTRAL3ERVICEDEPARTMENTPEERS
typically requested for micro-discectomy JACK D. NINEMEIER, PH.D. )!(#3--WILLPROVIDEGUIDELINESAND
surgeries. -ICHIGAN3TATE5NIVERSITY help you with the lesson to assure it will be
The variety of spinal implants can %AST,ANSING-) ANENJOYABLEPROCESS&ORMOREINFORMATION
present a learning challenge for CIS tech- PLEASECONTACT%LIZABETH"ERRIOS
nicians because there are implant systems ELIZABETH IAHCSMMORG 
designed for each level of the spine. Each
 3PONSOREDBY

CIS Self-Study Lesson Plan Quiz -

Basics of Spinal Instruments
,ESSON.O#)3)NSTRUMENT#ONTINUING%DUCATION )#% s,ESSONEXPIRES.OVEMBER

1. 7HICHAREAOFTHESPINEREFERSTOTHE 6. 7HICHTYPEOFRETRACTOROFDIFFERENT 12.7HICHTYPEOFNERVEHOOKISTYPICALLY

NECKAREA lengths is initially used in all spinal USEDWHENWORKINGUNDERAMICROSCOPE
a. Thoracic surgeries to establish retraction of the a. Dandy
b. Lumbar SKINANDMUSCLE B#USHING'ASSERIAN
C#ERVICAL a. Derrico C-ALIS
D3ACRUM B!DSON#EREBELLAR D7EARY"LACK
C7EITLANDER
2. 7HICHAREAOFTHESPINEHASFUSEDNON D-EYERDING 13.7HICHTYPEOFCURETTEISTYPICALLY
SEPARATEDVERTEBRAE REQUESTEDFORMICRO DISSECTEDSURGERIES
a. Thoracic 7. 7HICHTYPEOFELEVATORISUSEDFORTHE a. Angled
b. Lumbar MOSTDELICATEWORK B3TRAIGHT
C3ACRUM A0ENlELD C%PSTEIN
D#OCCYX B(OEN3EDILOT D"ANDCABOVE
e. c and d above C#OBB
d. a and c above 14. The basic instruments required to gain
3. 7HICHAPPROACHTOSPINALSURGERY access to and expose the spine have
requires the assistance of a vascular or 8. 7HICHTYPEOFRONGEURPOINTSSTRAIGHT remained the same for several decades.
GENERALSURGEON FROMITSHANDLE a. True
a. Anterior A3TILLE ,UER(ORSLEY b. False
b. Posterior B$UCKBILL
c. Lateral C,EKSELL 15.7HICHTYPEOFRETRACTORISARE
d. All the above d. a and c above commonly used when obtaining bone
from the iliac crest for bone fusion in
4. 7HICHAPPROACHTOSPINALSURGERYISDONE 9. 7HICHTYPEOFRONGEURISUSEDTOREMOVE THESPINE
WITHMINIMALLYINVASIVEPROCEDURES BONEFROMSMALLERAREASOFTHESPINE a. Derrico
a. Anterior A$UCKBILL B-EYERDING
b. Posterior B+ERRISON c. Taylor
c. Lateral C,EKSELL d. b and c above
d. a and c above d. Pituitary

5. 7HICHSURGICALPROCEDUREFUSESSPINAL 10.7HICHTYPEOFPITUITARYRONGEURHAS

bones together by removing a between- SERRATEDJAWS
vertebrae disc and replacing it with a A-ICROSTRAIGHT
BONEORMETALSPACER B#ASPER
a. ALIF c. Peapod
b. TLIF D-ICRO7ILLIAMS
c. PLIF
d. All the above 11.-ICRO DISCECTOMYPROCEDURESREQUIRE
the use of a microscope.
a. True
b. False

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