• Patient positioning that prevents abdominal tension greatly reduces blood loss during spi­nal surgery.

• The use of intraoperative fluoroscopy should be routinely used to confirm the spinal level before decompression and instrumentation.

• Careful preoperative measurement of the ped­icle width and length should be performed prior to each posterior spinal fusion to help prevent nerve root, thecal sac, and aortic injury.

• Placement of pedicle screws before laminec­tomy utilizes the lamina as a safe guard for the possibility of pedicle screw instrumentation slippage.

• Understanding the biomechanics of the spine will help build solid fusion constructs that counteract destabilizing forces acting on the spine.

• Smoking cessation prior to spinal instrumen­tation improves arthrodesis rates.

• 1–2 grams of vancomycin powder applied before closure is helpful in reducing surgical site infection.

0.2% [51]. The most common cause of postop­erative visual deficit is ischemic optic neuropathy (ION). The major risk factors include prolonged intraoperative hypotension, postoperative anemia, and facial swelling. Avoiding or immediately correcting these risk factors greatly reduces the incidence of ION [52]. Visual deficit can also result from central retinal artery occlusion, isolated stroke, or embolic phenomenon. While ocular complica­tions are rare, prevention of such complications in high-risk patients (e.g., patients with diabe­tes, hypertension, history of prior stroke or cases with long operative time) is achieved by reducing the central venous pressure [53, 54].

The most common complication after spine surgery is postoperative wound infection. The incidence reported in the literature is quite vari­able and ranges from 0.5% to 15% [

59–61].

This is likely due to variation in case complex­ity across the different studies examining spine infection rates. Infection can be prevented by use of prophylactic antibiotics [62]. The most effective prophylactic antibiotic agents are those that have action against the most common bacteria present in tissues adjacent to the surgi­cal site. Cefazolin is commonly used at our institution. It is currently recommended that perioperative antibiotics be administered 30 min to 1 h preoperatively to ensure adequate levels at the surgical site at the time of skin incision [63, 64]. In addition to preoperative antibiotics, irrigation solutions are commonly used intraop­eratively. Common irrigants include bacitracin, iodine, chlorhexidine, neomycin, and poly­myxin. There is no clinical evidence that these irrigants reduce infection rates in spine surgery, but in vitro studies show a significant reduction in bacterial counts [65]. More recently, vanco­mycin powder has gained popularity for reduc­ing surgical site infections. Typically 1–2 g is added generously to the wound upon closure. This is the typical practice at our institution. There is no class 1 evidence proving vancomy­cin powder effectiveness, but there are many retrospective and prospective studies that vali­date its everyday use in spinal instrumentation surgery [66–72].

planted previous techniques because of its advan­tageous biomechanical properties and greater reduction power. Familiarity with the instrumen­tation techniques discussed in this chapter will help the surgeon minimize complications while enabling the treatment of a wide variety of spinal pathologies.

61. Fernandez-Sousa JM, Gavilanes JG, Municio AM, Paredes JA, Perez-Aranda A, Rodriguez R. Primary structure of cytochrome c from the insect Ceratitis capitata. Biochim Biophys Acta. 1975;393(2):358–67.

68. Martin JR, Adogwa O, Brown CR, Bagley CA, Richardson WJ, Lad SP, et al. Experience with intra­wound vancomycin powder for spinal deformity sur­gery. Spine (Phila Pa 1976). 2014;39(2):177–84.

69. O'Neill KR, Smith JG, Abtahi AM, Archer KR, Spengler DM, McGirt MJ, et al. Reduced surgical site infections in patients undergoing posterior spinal stabilization of traumatic injuries using vancomycin powder. Spine J. 2011;11(7):641–6.

71. Strom RG, Pacione D, Kalhorn SP, Frempong­Boadu AK. Decreased risk of wound infection after posterior cervical fusion with routine local applica­tion of vancomycin powder. Spine (Phila Pa 1976). 2013;38(12):991–4.