Spine Surgery Set-Up

A detailed understanding of surgical anatomy is essential in anterior cervical spine surgery to prevent unintentional damage to critical structures such as the esophagus, vertebral artery, spinal cord, and nerve roots, which are closely located to the surgical site.

While knowledge of anatomy remains paramount, the emerging method of stereotactic intraoperative imaging can support surgeons during cervical spine procedures.

Stereotactic intraoperative imaging is especially beneficial in situations where typical anatomical reference points are absent or modified due to factors such as deformities, trauma, revision surgery, morbid obesity, or ossification of the posterior longitudinal ligament.

This technique provides real-time imaging throughout the surgical procedure, assisting the surgeon in navigating intricate anatomical structures, achieving accurate instrument placement, and reducing the likelihood of complications.

However, it is crucial to emphasize that although stereotactic intraoperative imaging is advantageous, it cannot replace the need for a thorough comprehension of surgical anatomy. Surgeons must have extensive knowledge to ensure the safety and success of anterior cervical spine surgeries.

Stereotactic operations have been used for intracranial surgery since the early 20th century. In spine surgery, computer-assisted navigation emerged in the 1990s. Initially, it relied on frame-based stereotaxis, but advancements now allow for intraoperative imaging and frameless registration. These improvements have made computer-assisted navigation standard in complex anterior cervical spine cases, enhancing accuracy and reducing operative time.

Utilizing intraoperative O-arm navigation facilitates successful and secure performance of minimally invasive anterior transcorporeal foraminotomies and decompressions. It enables the precise extraction of diseased tissue while safeguarding vital anatomical structures. Moreover, this advanced technology enhances the accuracy of screw placement and minimizes radiation exposure for surgeons, surpassing the capabilities of conventional methods

Navigation technology is a useful tool in complex spinal surgeries, but it should not replace the surgeon’s knowledge of anatomy. It should be used as a supportive guide, and confirmation from anatomical landmarks is essential to ensure patient safety.

Approach Stereotactic Navigation

Room Setup

The preferred method for setting up the operating room with stereotactic navigation involves a spacious environment, utilizing a large operative theater to accommodate the O-arm. After patient sedation and intubation, baseline motor functions are established, and the patient is positioned in a supine position with their head secured in a Mayfield 360 head holder. Care is taken to maintain a neutral neck position.

The C-Arm is brought into the room for confirmation of corpectomy location, while the passive reference frame and StealthStation are positioned at the head of the bed. To save space, the O-Arm and Navigation station remain outside the room during C-Arm usage. If the surgeries are scheduled at different times, multiple surgeons can share a single O-arm.

Instruments Equipped With Tracking Technology And The Reference Frame

Reflective spheres are attached to instruments used during the navigated part of the procedure, allowing for optical tracking. The standard instrument set includes a navigated drill and ball-tip probe, with the option to incorporate additional instruments if required. Accurate tracking relies on ensuring the spheres are properly seated, while any interference such as blood or tools can disrupt the tracking process.

To ensure accurate alignment, it is recommended to register the instruments and frame to the StealthStation before attaching the frame. This registration process establishes the spatial relationship between the instruments and frame. It is preferable to perform this registration prior to making the incision to avoid any potential inaccuracies caused by accidental movement when the frame is already attached to the Mayfield head holder.

For optimal use of space during anterior spine exposure, it is suggested to firmly attach the reference array to the Mayfield within a range of 6 to 8 inches from the operative field. This ensures a stable reference position while keeping it away from the surgical area.

To maintain sterility, the non-sterile post is covered with transparent plastic draping, and a small opening is created using scissors to allow for frame insertion. The scissors are subsequently removed from the sterile field.

Method And In-Surgery Spin

Once the frame is attached, the surgical team proceeds with the Smith-Robinson surgical approach. The location of the pathology is confirmed visually and through fluoroscopy. Caspar pins are carefully placed, and distraction is applied. Subsequently, an imaging scan is performed following the approach and Caspar pin distraction.

To prevent tissue desiccation and enhance image quality, the wound is irrigated and left undisturbed. Retracting the soft tissues is essential for accurate imaging. The frame is shielded with surgical drapes, and a sterile towel safeguards it during O-arm closure. Positioning the O-Arm correctly, the green towel is removed before image acquisition commences.

Direct Referencing and Localization

To maintain accuracy, precautions must be taken when removing the protective drape due to the frame’s vulnerability to unintended movement. It is recommended to verify instrument positioning by aligning it with referenced images using a probe on a bony landmark.

If accuracy declines, alternatives include re-registering the system, employing fluoroscopy, or opting for a free-hand technique. Once the imaging scan is completed, the microscope is introduced into the field and remains present throughout the case. Discectomy is performed at both the cranial and caudal levels to aid in subsequent corpectomy.

Screens display images of instruments and the targeted area for the surgeon’s monitoring, while the StealthStation monitor offers supplementary views and trajectory projections managed by the O-arm operator. The corpectomy commences at a designated point, typically the mid-portion of the vertebral body, using a burr. The remaining course of the procedure is determined based on the surgeon’s preference.


Although intraoperative stereotactic navigation may not be indispensable or cost-effective for routine procedures, it can offer significant value and dependability for patients with intricate anatomy, severe pathology, or worrisome characteristics.

It is essential to avoid excessive confidence or complacency when utilizing navigation assistance, and regular accuracy checks should be conducted throughout the case. The cervical spine’s flexibility makes it vulnerable to even minor movements that can result in accuracy loss, highlighting the need for verification through anatomical landmarks or fluoroscopy.

The potential drawbacks of this technique, including increased operative time, a learning curve, and disruptions to workflow, should be taken into consideration. However, with an increase in the number of cases and adaptability, these disadvantages can be overcome, as is typical with the introduction of any new technology.

The use of navigation-assisted spine surgery is a developing technology that provides valuable support in a range of spine procedures. This guide is designed to enhance the precision and efficiency of complex anterior cervical spinal surgery. The described technique has been demonstrated to be trustworthy and successful, empowering cervical spine surgeons to undertake more intricate or minimally invasive procedures with heightened levels of safety and accuracy.

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Based on 107 reviews
Dr. Nakul Karkare is awesome! And patriotic! Thank you, Dr. Karkare for displaying the American Flag in your waiting room, honoring and mourning our military personnel, this Memorial Day, who died while serving in the United States Armed Forces.
00:52 30 May 23
Excellent and skilled orthopedic practice specializing in joint replacements. Dr Karkare was trained at the Hospital for Special Surgery and has excellent results, as do his associates!! Would gladly refer family members to the practice!!
00:24 30 May 23
I had such a wonderful experience with Complete Orthopedics in Stony Brook. Not only did Dr. Kuo fix my broken wrist with such kindness and care, but the office staff, including Billing, Reception and the X-Ray Technician, was always so helpful, going out of their way to ensure that each patient felt welcome, answering any questions with a smile, and ensuring any issues with insurance/billing were handled with the utmost professionalism. I highly recommend their practice!
Victoria DeMatteo
19:49 10 May 23
I'm very happy St. Catherine's sent me to this office for treatment after I broke my collar bone! Unfortunately the break was too severe to repair on its own and I had to have it rebuilt a week after the injury. Dr. Vaksha did a great job fixing it. I'm three months out, and I have full use of the arm and shoulder. The whole office staff is very professional, accommodating, and welcoming. I hope to not need orthopedic services again, but Dr. Vaksha will be my number one choice if I or anyone in family suffers such am injury.
Tina Rivera
20:42 08 May 23
No one likes going to the doctor. But these people make it painless. I go for knees, hips and shoulders. At almost 70 Complete Orthopedics keeps my active life style running smoothly. Whether chasing my Grandson and even surfing again, I highly recommend them!!
Thomas Slavin
15:02 02 Mar 23
Dr. Kuo knowledgeable and competent surgeon- very good experience and more importantly great result.
Joseph McCoy
21:23 25 Feb 23
Dr Vaksha was so kind and helpful. He took extra time with us and explained things so thoroughly. Highly recommend. Office very clean.
Susan Bosinius
20:20 19 Feb 23
Dr Vaksha, is a great doctor very professional knows what he talking about. Treat patient with upmost respect. Thank You
Troy Spencer
16:46 19 Jan 23
Dr. Karkare is an amazing doctor, very caring and attentive, the girl at the front desk is very kind and helpful. .elizabeth .thank you so much .
blanca ventura
21:32 26 Oct 22
Been going to this place before my accident and after I had my knee surgery. So happy how I been treated and how well I am getting. Thank you all and specially Dr. VAKSHA for everything and getting back on track.
Ita Opico
19:01 25 Oct 22
Love this place From the minute I called I was treated kindly. When I arrived The Dr saw me right away he was compassionate and ordered the appropriate tests for me. I came back in for my follow up and had the same great experience.
Christine Rostock
21:28 23 May 22
Dr Vaksha and Dr karkare are 2 of the best orthopedic doctors around my wife Susan had a very serious broken ankle in March of 2019 she didn't think she was going to walk again Dr vaksha did an excellent surgery on her ankle he said it was his toughest he ever did he put a lot of hardware in her ankle and told her she would be alright she made remarkable recovery thanks to his surgery as of now she regained 100 percent use of her ankle she would highly recommend him to anyone. My own experience with Dr karkare has been wonderful he takes his time with you listens to what you have to say and prescribes various treatments and is very caring I would highly recommend him to anyone I would give both doctors a 10 plus rating we are very happy with them the best.
Harry Jones
23:31 19 May 22
Complete orthopedics is a wonderful place to go when you hurt or injured a great staff and wonderful doctors very knowledgeable and helpful I would recommend this place to all of my family and friends that is in me of orthopedic care I give them 10 thumbs up
Wayne Pemberton
17:39 18 May 22
The staff is very professional and helpful. Dr. Vaksha is excellent. He takes time to listen and offer suggestions to help you get better. I’m very thankful and happy to be a patient here at Complete Orthopedics.
Phoenix Rising
19:54 16 May 22
Dr.Karkare is the best. He listens to everything and explains everything I recommend him to everyone. I am so happy he is my doctor.
Myrna James
00:48 13 May 22
Dr.Kuo is amazing very attentive,caring,and passionate and staff is awsome too.Thank you for everything Dr.kuo.
Erick Murillo
23:17 12 May 22
I was in a car accident November 1 I was referred to Dr. Vaksha For shoulder surgery . I he was amazing he made me feel very comfortable and explained everything that was going to happen from surgery all the way through my physical therapy highly recommend Dr. Vaksha
Yolanda Ojeda
19:37 09 May 22
My appointment with Dr. Vaksha was amazing. Dr. Vaksha was very thorough and kind. I would refer this office to anyone who needs a great orthopedic doctor.
John Senechal
19:54 05 May 22
Scheduling my appointment was quick and easy. The staff was super friendly and down to earth. I was seen on time. The appropriate test, “x-rays” were taken before the conversation with doctor, something I really liked, test for analysis and conversation was done upfront. Dr. V had a great personality and was no BS, straight forward diagnosis and a play on next steps. I am happy I found them and would refer them to friends and family.
00:46 03 May 22
I have seen Dr. Kuo two times already and he's awesome along with his staff. Very friendly office and I'm glad to be a patient here.
Camaris A
20:01 28 Apr 22
Amazing team!! Very caring, profesional, and friendly!! Dr. Kevin Kuo, you are the best, very passionate, caring, and helping thank you for getting me better and being so kind to me! Elizabeth you the best thank you for you help always and you big smile and positive actitud❤️🙏🏼
breidy valerio
19:01 22 Apr 22
The staff is truly exceptional, they make you feel comfortable and welcomed. The doctors are amazing,always professional, compassionate and great listeners.
Elizabeth Collado
03:25 09 Apr 22
What a great place! The place is clean and organized.The staff is wonderful. Setting up physical therapy is right there as well.I'm so glad I found this place.
Donna Anne
22:45 05 Apr 22
This was my 1st time breaking something in my 27 years on this planet. I was recommended here by a friend Dr. Vashka helped me from day 1 and still continues to check in on me and my healing ankle. Would highly recommend
tyron davis
16:06 01 Apr 22
Brand new office, same great doctors! Rooms are clean, plenty of parking, physical therapy attached, Dr. Karkare and his staff are awesome. Thank you!
Emily B
02:49 24 Mar 22
Dr.VAksha is the best, I love the way he treats me as his patient, he is caring,understanding and very attentive to my needs
Mirna Caballero
14:53 03 Mar 22
Great staff. Dr. Vaksha is awesome and takes the time to listen to his patients. He is very compassionate. I would highly recommend this office.
Bebe Doyle
01:24 23 Feb 22
After suffering from a severe ankle injury Dr. V was able to help me heal and return back to work completely to a job where I stand for 12 hours a day. The office is very clean and I appreciated the reminders of my appointments via phone call and through text. The patient portal made it easy for me to access all my documents including work notes. The office staff is wonderful and Rebecca was able to schedule me with a busy schedule and awesome at answering all of my questions including referring me to a great physical therapy office. I highly recommend this office to anyone who’s looking for knowledgeable and kind orthopedic office.
Elizabeth Birchwell
21:31 28 Jan 21
The staff here are great, I was seen at the time of my appointment and was well taken care of!
Shaun Berry
18:14 07 Jan 21
They are an excellent practice. The front and back office people are amazing and so helpful. Rebecca is such a kind and understanding person. I had an issue with paperwork and she cleared it right up. Dr. Karkare is very knowledgeable, helpful, and caring.
Matt S.
19:31 18 Nov 20
Rebecca K. - What a true burst of sunshine. Very friendly and definitely an asset to the practice!
Laura Aston
18:17 17 Nov 20
Great experience, the Doctor is nice but the staff is incredible. I worked with Linda, who was profession and assisted me beyond what any person has done at other practices. Complete Ortho should be complimented for having such a person on their staff.I highly recommend this place!!!
Joe Allen
17:26 17 Nov 20
Linda and Becca they are so good ever time I come they are very nice I would tell everyone I no to come to this office..
Barbara Victor
16:45 17 Nov 20
I was rear ended in an auto accident , Dr Vashka was recommended by a friend of mine .I was experiencing Back , neck , and shoulder pain . After a thorough examination and given exercises to do at home , I am feeling much better , and I ended up avoiding surgery . The staff at Complete Ortho is extremely attentive and show great care when making an appointment and are very friendly and i never waited more than 5 minutes for my appointment . So I would strongly recommend Complete Orthopedics for any aches and pains that one might be experiencing.....
Bill Becht
04:44 17 Nov 20
It was the afternoon of Friday Sept. 24. We were in Pt. Jefferson and my wife, Mary Ann, broke her hip. We went to Mather Hospital and it was determined that she would have to have an operation to have it repaired. This would be her third time under the knife in the past year. It just so happened that we were very fortunate enough to have Dr. Karkare, who was on standby, perform the surgery. He put in a rod and two screws in her hip. She spent a few days in the hospital and then went to Gurwin rehabilitee for another few weeks.It has now been almost six weeks and we both worked the election the other day. If it wasn’t for Dr. Karkare’s expertise she never would have been able to work. She is able to walk with a walker and is doing physical therapy three times a week.We can not thank the doctor enough for the compassion and dedication that he puts into his work. It allows Mary Ann do the things that she likes to do, even on a limited basis for a while. I know that with her will, perseverance and the great work that the surgeon performed she will be back on her feet in no time.Sincerely:John V. PlumpEast Northport, NY 11731
Jack Harris
14:36 06 Nov 20
In the year of 2018 I was referred to Dr. Karkare because I was experiencing severe knee joint pain. After exhausting physical therapy and trying to labor through the pain, I had to make a quality of life decision. Total knee replacement was the only viable option. Dr. Karkare made my decision easy as he walked me through the whole process from surgery to recovery.On 12/13/19 ( Friday the 13th) I enter Lenox Hill Hospital in great hands. From the time I entered Dr. Karkare’s office for the first time until now, his staff has been amazing. Andrea the medical coordinator walked me through all the paper work and necessary preparations for the surgery. Courtesy and kind would be an understatement. Dr. Karkare went over and beyond from the wellness checks and phone calls all to assure me that I was important to him. This was the right decision no pain and no limp. Complete Orthopedics should be your choice!
Kenneth Randolph
22:18 25 Sep 20
Dr. Vadshka has a great bedside manner. He really takes his time and explains treatment options.
T Lee
12:33 09 Sep 20
I suffered with pain in both knees for years. My orthopedic doctor kept recommending knee replacement . I fought it for years, as I was just afraid. When I had no choice and could barely walk , it was recommended I see Dr. Karkare. We set up a consultation and my wife and I left his office feeling totally confident and comfortable with moving ahead with the surgery. He explained everything to us, and the office staff set everything up for us and made the process easy. So about one month after our initial meeting I had the first knee done. I was up walking mere hours after the surgery, and on the workout machines the next morning. I went home two days after the surgery, and yes walked my daughter down the aisle at her wedding only one week after the surgery without even a cane! Three months later I had the other knee done and went home the very next day. Dr. Karkare put my fears to rest . I would highly recommend him. His expertise gave me my life back. Thank you Dr. Karkare.SincerelyVito Congro
Ethel Congo
23:58 12 Aug 20
Dr Rhodin really cares for his patients. When I see him he makes sure to review my progress in detail.
Micki Cahill
15:03 08 Feb 20
My mom had a total hip replacement by dr karkare. He is the BEST orthopedic doctor.Her incision is almost invisable.She is going back for her other hip next week. The office staff is the best, love Andrea.You wont find a better doctor.
Ryan Brigandi
21:06 13 Jul 18
There is no better Orthopedic doctor you will find. Broke my ankle three places on a Saturday. Called Dr. Karkare. He had is team ready at the hospital and operated on me within 6 hours after my injury. Now After 3 months of great care by him and his staff, I am walking to normalcy.
Spacecom Tel
04:13 23 Mar 18

I am Vedant Vaksha, Fellowship trained Spine, Sports and Arthroscopic Surgeon at Complete Orthopedics. I take care of patients with ailments of the neck, back, shoulder, knee, elbow and ankle. I personally approve this content and have written most of it myself.

Please take a look at my profile page and don't hesitate to come in and talk.