Surgical approaches to the spine

ABDULMONEM ALSIDDIKY, MD,SSCOAssistant professor ,consultant

Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA

Objectives

•Anterior (Transthoracic) Approach to the Thoracic Spine

•Anterolateral (Retroperitoneal) Approach to the Lumbar Spine

•Anterior (Transperitoneal) Approach to the Lumbar and Lumbosaccral Spine

•Posterior Approach to the Lumbar Spine

Anterior (Transthoracic) Approach to the Thoracic Spine

Anterior (Transthoracic) Approach to the Thoracic Spine

• Offers exposure of the anterior portions of the vertebral bodies, from T2 to T12

• A surgeon might need a thoracic surgeon who can deal with the hazards of the area

• Indications– Treatment of infections– Fusion of the vertebral bodies – Resection of the vertebral bodies for tumor and reconstruction with bone grafting – Correction of scoliosis – Correction of kyphosis – Osteotomy of the spine – Anterior spinal cord decompression – Biopsy

Position of the Patient• Place the patient on his or her side• stabilizing the patient with a kidney

rest or sandbags• Move the hand and arm on the side to

be approached above the patient's head or onto an airplane splint

• Place a small pad in the axilla of the dependent side to avoid compression of the axillary artery and vein

• Feel for a radial pulse after positioning; make sure that there is no venous obstruction in the arm

• The surgeon should be positioned behind the patient

Landmarks

• tip of the scapula • spines of the thoracic

vertebrae• Observe the

inframammary crease on the anterior chest wall

Incision

• Begin the incision two fingerbreadths below the tip of the scapula and curve it forward toward the inframammary crease

• Complete the incision by extending it backward and upward toward the thoracic spine

• ending at a point halfway up the medial border of the scapula and halfway between the spine and the scapula

Superficial Surgical Dissection

• Divide the latissimus dorsi muscle posteriorly in line with the skin incision

• Then, divide the serratus anterior muscle along the same line, down to the ribs

• This allows the scapula to be elevated and muscles to be cut proximally to expose the underlying ribs

• Because the operation is not performed in an intermuscular plane, bleeding is a problem; cutting cautery (diathermy) can be used to control it

• The thoracic cavity can be reached through – intercostal space – resection of one or more ribs

• Rib resection – creates a better exposure– The cut ribs can be used for bone grafting

• Which level – Depends on the location of the pathology– Apex of deformity– Two levels less (eg.T9 go through rib 7)

• Which side– Rt. Safer (away from aortic arch)

• strip all muscular attachments from the rib

• using a periosteal elevator or cautery

• resect the posterior three fourths of the rib as far posterior as necessary

Deep Surgical Dissection

• deflate the lung• retract it anteriorly• using moist lap pads to

protect it• Identify the structures

– Oesophagus– Aorta– Azygous vein – Ant. Longitudenal lig. – Segmintal vessels

Anterolateral (Retroperitoneal) Approach to

the Lumbar Spine

Anterolateral (Retroperitoneal) Approach to the Lumbar Spine

• provides access to all vertebrae from L1 to the sacrum

• allows drainage of an infection, such as a psoas abscess

• Lower the risk of a postoperative ileius

• slightly more difficult to reach the L5-S1 disc space

uses of this approach

Spinal fusion

Drainage of psoas

abscess of all or part of

a vertebral body

Instrumentation

Biopsy of a vertebral

body

Position of the Patient

• semilateral position

• about a 45° angle to the horizontal

• facing away from the surgeon

• Stabilize the patient

• left side up, so that the “aortic” rather than the “caval” side is approached.

Landmarks

• Palpate the 12th rib

• pubic symphysis

• lateral border of the rectus abdominis

Incision

• oblique flank incision

• from the posterior half of the 12th rib toward the rectus abdominis muscle

• stopping at its lateral border

• about midway between the umbilicus and the pubic symphysis

• Place a needle into the involved lumbar vertebra and take a radiograph to identify the exact location

Anterior (Transperitoneal) Approach to the Lumbar Spine

Anterior (Transperitoneal) Approach to the Lumbar Spine

• reserved for fusing L5 to S1

• fusing L4 to L5

• mobilization of the great vessels

• general surgeon help is appreciated

Position of the Patient

• Supine• two areas for incision

– Abdominal – iliac crest bone graft

• Insert – urinary catheter to keep

the bladder empty– nasogastric tube, ?

ileus

Landmarks

• Umbilicus – (? opposite the L3-4 disc

space)

• pubic symphysis

Incision

• midline longitudinal

• arches around the umbilicus

Posterior Approach to the Lumbar Spine

Posterior Approach to the Lumbar Spine

• the most common approach to the lumbar spine

• providing access to the cauda equina and the intervertebral discs

• expose the posterior elements of the spine

• Uses– Excision of herniated discs– Exploration of nerve roots– Spinal fusion– Removal of tumors

• Position of the Patient

• prone position

• On side– Flex the patient's hips and

knees to flex the lumbar spine and open up the interspinous spaces

• Landmarks

• Spinou sprocesses

• Line drawn between the highest points on the iliac crest is in the L4-5 interspace

• To determine the exact level is use a radiograph

• Incision

• midline longitudinal incision

• length of the incision depends on the number of levels to be explored

Thank you