Approaches to spine

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Information about Approaches to spine
Health & Medicine

Published on January 11, 2014

Author: sunnysmartraj



approach to spine for surgery with indications

Seminar on “Approaches to Spine” 01 – 12 - 2010 Moderator: Presenter: Dr. Muralidhar N Dr. Somnath Machani Professor and HOD VIMS & RC. Post Graduate VIMS & RC .

Anatomy of the vertebral column ● 33 vertebrae ● 7 cervical ● 12 thoracic ● 5 lumbar ● 5 sacral ● 4 coccygeal

Parts ● Anterior body ● Posterior arch ● Neural arch ● Spinous process ● Transverse process ● Inferior and superior articular joints

Cross section of the Spinal Cord

Pedicle anatomy

Pedicle screw insertion

Posterior approach to the Lumbar spine Indications ● • Excision of herniated discs • Exploration of nerve roots • Spinal fusion • Removal of tumours • Provides access to • Cauda equina • Intervertebral disc • Spinous process • Laminae • Facet joints • pedicles

position ● Prone The position of the patient for the posterior approach to the lumbar spine. Alternatively, place the patient in the lateral position with the affected side up.

Incision Longitudinal incision over the spinous process Iliac crest for L4 - L5 interspace

Superfical surgical dissection ● Deepen fat and fascia

● Remove paraspinal muscles as one unit from spine

● ● Continue laterally Cauterize the nerves and arteries

● Remove the lig. Flavum from the superior attachment.

● Deep dissection

Beneath the ligament Flavum ● Identify the blue white dura

● ● Retract the dura and Nerve root medially View the disc space

● Iliac vessels can be damaged if instruments pass thro the annulus fibrosus

Enlarging measures ● For Dura and Nerve root ● For posterior spine ● skin

Applied anatomy of the posterior approach ● Superfical muscles ● Deep paraspinal muscles

Landmarks ● Spinous process ● Young patient ● PSIS ● L4 L5 ● Midline incision

● Deep dissection ● Dura protection

Transperitoneal Approach to Lumbar Spine ● Indication ● L 4 L5 Fusion ● L5 S1 fusion ● Position- supine ● Catheterize ● NG tube ● Bare Area- Abd incision and Iliac crest bone graft

incision ● ● Umblicus to pubic symphysis Curve to the left of umblicus

● Deepen the incision

● Separate the rectus abdominis to expose the peritoneum

● Pick peritoneum with forceps and incise it

protect the viscera, carefully deepen the upper half of the incision

● ● Retract abdominis, bladder Retract bowels

● Identify aorta ● Left common iliac artery ● Left ureter ● ● Danger of presacral parasympathetic plexus Extension- pack bowels and superioly incise upto the xiphisternum

Applied anatomy ● Umblicus ● Linea alba ● Pubic symphysis ● Rectus Abdominis

● Aorta ● Common iliac ● Ureter ● Presacral plexus ●

Video assisted lumbar surgery ● ● ● Transperitoneal laproscopic approaches Supine position Complication- vascular and peritoneal injury

Retroperitoneal Approach ● Advantages of transperitoneal ● Access from L1 to S ● Drainage of abscess ● Disadavantage ● Difficult to reach L5 S1

Indications ● ● Spinal fusion Drainage of psoas abscess and curetting the infected body ● Resection of all or part of vertebral body ● Biopsy of vertebral body and bone graft ● Sympathetic chain exposure

Position ● Semilateral 45º ● Sand bagsl ● Left side up ● Land mark- 12th rib ●

● ● Route of surgery

● Incision ● Oblique flank incision ● Internervous plane- none ●

Superficial dissection ● Transverse abdominis in line with the skin

● ● Identify peritoneum anteriorly Retroperitoneal fat posteriorly

● Blunt finger dissection

● Retract the peritoneal contents medially

Deep dissection ● ● Identify psoas Ligate and segmental arteries and mobilize the aorta and cava

Dangers ● Sympathetic chain ● Genitofemoral nerve ● IVC ● Ureters ● Extension● Posterioly ● Upper lumbar vertebrae rib may need to be excised

Costotransversectomy approch to the Thoracic Spine ● Indication ● ● Vertebral body biopsy ● Partial verterbral body resection ● Limited anterior spinal fusion ● ● Abscess drainage Ant. Lateral decompression of the spinal cord Advantage ● Need not enter the thoracic cavity originally used to draining tubercular abscess

Position ● Prone ● Bolsters ● Drape widely

Incision ● ● Curvilinear lateral to spinous process Center over the involved rib

Internervous Plane ● ● No true internervous plane Trapezius is cut and paraspinal muscles

● ● Cut onto the posterior aspect of the rib to be resected Incise the periosteum over the rib

● Separate muscles from the rib using subperiosteal resection

● ● Divide rib 8 cm from the midline Cut muscle attachment and costotransverse ligaments

● ● Enter the retropleural space by blunt dissection and digital palpation Safe in disease only

Dangers ● Nerves- Dura ● IC vessels ● Lungs- pneumo thorax ● Extension- only resect the adjacent ribs

Transthoracic Approach to the Thoracic Spine ● Indication • Treatment of infections, such as tuberculosis of the thoracic vertebral bodies20 • Fusion of the vertebral bodies • Resection of the vertebral bodies for tumor and reconstruction with bone grafting • Correction of scoliosis (Dwyer instrumentation technique and rods) • Correction of kyphosis • Osteotomy of the spine • Anterior spinal cord decompression • Biopsy

Position ● On the side ● Move arm above his head ● Approach from right side

Landmarks ● Inferior angle of the scapula ● Spinous process ● Inframammary crease ● Incision

Deep incision ● ● ● Latismus Dorsi division Serratus anterior- elevate scapula Rhomboids? ● Bleeding ● Resect ribs

● ● Retract scapula superiorly

Elevate the scapula with the cut attached muscles proximally to expose the underlying ribs. Cut the periosteum on the upper border of the rib.

● ● Enter the pleura from the rib above Strip muscle attachement s from the cephalad rib

Deep Dissection ● Deflate lungs ● Retract anteriorly ● Identify oesophagus ● Incise pleura

● ● ● Retract the oesophagus IC vessels that cross the field need to be ligated Cord ishemia

Dangers ● Vessels – IC vessels ● Lung care ● Enlarge ● ● ● Local- resect rib below Extensile measure- not possible Diaphram resected- Arcuate ligament

VATS ● Complication ● Intercostal neuralgia ● Atelectasis ● ● ● Excessive epidural blood loss 2500ml Temporary paraparesis in a scoliosis patient By Made et al

Posterior Approach to the Thoracic and Lumbar spine for Scoliosis ● Indications ● Scoliosis ● Posterior spine fusion ● Removal of tumour of the posterior aspect of the vertebra ● Open biopsy ● Stabilization of fractures vertebrae

Position ● Prone ● Bolsters ● Landmarks – gluteal cleft, C7 T1

● Incision ● Midline straight ● Internervous planemidline paraspinal muscles

Superficial Dissection ● Rotation in scoliosis ● Midline incision only Deep dissection ● Paraspinal muscles from spinous process ● Keep dissection open

Dangers ● Post primary rami ● Segmental Vessels ● Enlarge● ● Local- widen exposure using self retaining retractor Extensile- from cervical spine to coccyx

Applied anatomy ● ● Superficial mooring muscle Intermediate- accessory muscles of respiration ● Deep- paraspinal muscle ● Landmarks

● Superficial dissection dangers ● Thoracic spine- more bleeding ● Vertebral body rotation – convex side of curve ● Intermediate surgical dissection ● Deep portion● lumbar facet joints are larger ● Traumatic arthritis

Approach to the Posterio- lateral thorax for excision of Ribs ● After scoliosis surgery- removal of parts of ribs ● Position- prone with bolsters ● Land mark- prominent ribs ● Incision- same like scoliosis surgery ● Internervous plane- between Trapezius and Latismus dorsi

Superficial surgical dissection ● ● ● Lift the skin and subcutaneous tissue Centre the dissection over the most prominent rib Intermediate dissectionidentify the trapezius by the rolled border

● Free latismus dorsi from under the trapezius

Deep surgical dissection ● ● Split longitudinally over the deformed ribs Push the split periosteum to upper and lower border ● Stop lung expansion ● Resect the pleura from rib

Danger ● Neurovascular bundle ● Pneumothorox ● Prevent puckering ● Enlarge● ● ● Local continue subcutaneous dissection laterally Extensile- not possible Removal of ribs

Posterior Approach to cervical spine • Posterior cervical spine fusion • Excision of herniated discs • Treatment of tumors • Treatment of facet joint dislocations • Nerve root exploration

Position ● Prone ● Few degrees of flexion ● Upright- less venous bleeding but air emboli

● ● Landmark- C2 and C7 Incision- midline over the pathology

● ● Incise fascia Note the third occipital nerve

● Continue up to tthe spinous process

● Remove paraspinal muscles posteriorlyunilaterally or bilaterally

● ● Perform a laminectomy and dissect as much is needed Retract nerve root and spinal cord medially

● Deep dissection ● Note the spinous process

Dangers ● Spinal cord and its nerve root ● Posterior primary rami ● Venous plexus bleeding ● Enlarging ● Local ● extensile

Applied surgical anatomy ● Superficial dissection ● Trapezius ● Sternocleido mastoid ● Splenius capitis

● Deeper ● Longissmus capitis ● Semispinalis capitis ● Ligamentum flavum

Posterior approach to C1 C2 ● Indication ● ● ● ● ● Spinal fusion Decompression lamiectomy Treatment of tumours Position – same as posterior approach Incision from inion

● Deepen in the midline

Superficial dissection Incise the nuchal ligament down onto the large spinous processes of C2. Lateral view (inset). Note that the ring of C1 is further anterior than the spinous process of C2.

Remove the paracervical muscles from the posterior elements of C1 and C2. Carry the dissection up to the base of the occiput

Deep dissection ● Remove the posterior atlanto occipital membrane between C1 and occiput

Dangers ● Retraction of cord ● Nerves- C2 and C3 ● Vertebral artery ● Enlarge ● Local ● extensile

Anterior approach to the Cervical Spine ● Indication • Excision of herniated discs • Interbody fusion • Removal of osteophytes from the uncinate processes and from either the anterior or the posterior lip of the vertebral bodies • Excision of tumors and associated bone grafting • Treatment of osteomyelitis • Biopsy of vertebral bodies and disc spaces • Drainage of abscesses

Position Place the patient supine on the operating table with a small sandbag between the shoulder blades to ensure an extended position of the neck. Turn the patient's head away from the planned incision

Landmarks • Hard palate-arch of the atlas • Lower border of the mandible-C2-3 • Hyoid bone-C3 • Thyroid cartilage-C4-5 • Cricoid cartilage-C6 • Carotid tubercle-C6

Incision Incise the fascial sheath over the platysma in line with the skin incision. Split the platysma longitudinally, parallel to its long fibers

● Identify platysma and incise fascia medial to it Skin and platysma are very vascular. Use epinephrine

Retract the sternocleidomastoid laterally, and the strap muscles and thyroid structures medially. Cut through the exposed pretracheal fascia on the medial side of the carotid sheath. The cervical spine C3 through C5 (cross section). Retract the sternocleidomastoid laterally and the strap muscles medially, and incise the pretracheal fascia immediately medial to the carotid sheath

Deep dissection Dissect the longus colli muscle subperiosteally from the anterior portion of the vertebral body and retract each portion laterally to expose the anterior surface of the vertebral body. The longus colli muscles are retracted to the left and right of the midline to expose the anterior surface of the vertebral body

Dangers ● ● ● Recurrent laryngeal nerve Symathetic nerve and Stellate Ganglion Carotid sheath and contents ● Vertebral artery ● Inferior thyroid artery

Anterior Approaches ● Necessity ● ● ● Anterior spinal for cord decompression Failed laminectomy Relative indications ● Traumatic ● Infection ● Degenerative ● Neoplastic ● deformity

Anterior Transoral Approach ● Indications ● ● Odointecomy ● ● TB abscess Skull base surgery Complication ● infection

Anterior Retropharyngeal Approach ● Upper cerivcal spine and graft ● Extramucosal- less chance of infection ● Extended sub total maxillectomy ● Alternate to transoral ● For exposure and removal of tumour from the base of skull

Low Anterior cervical approach ● Same as Anterior cervical approach ● From left side 1 finger breath above the clavicle ● Extending across the midline ●

High transthoracic Approach ● ● ● Uses C6 to T4 Kyphosis forces the cervical spine in to the chest Incision- Periscapular

Modified Anterior Thoracic Approach ● Supine ● Stable neck ● ● Ligate and divide thyroid vessels Dont damage RLN or Superior laryngeal nerve


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