Seminar
onApproaches to Spine

Moderator: Presenter:Dr. Muralidhar N Dr. Somnath Machani Professor and HOD Post GraduateVIMS & RC. VIMS & RC

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01 12 - 2010

In 1989, Siliski, Mahring, and Hofer evaluated 52 intercondylar femoral fractures (AO type C) treated predominantly with blade plates. Three quarters of the fractures were caused by high-energy mechanisms, and 39% were open fractures. Overall, good or excellent results were obtained in 81% of fractures, and range of motion averaged 107 degrees. Results were better in type C1 fractures (92% good or excellent results) than in type C2 and type C3 fractures (77% good or excellent results). Only three (5.8%) fractures had malalignment in the sagittal plane; however, shortening of 1 to 3 cm occurred in 15 patients. Shortening was intentional to improve stability in 11 older patients (average age 60 years), but it was unintentional in four younger patients (average age 30 years). Infection occurred in four patients (7.7%) and accounted for three of the four poor results. Two fractures complicated by infection required amputation, and one required arthrodesis to treat the infection. Perioperative antibiotics were not used in closed and type I open fractures.

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 fusionRemoval of tumoursProvides access toCauda 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

DisadavantageDifficult 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 45

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

IndicationAbscess drainage

Vertebral body biopsy

Partial verterbral body resection

Limited anterior spinal fusion

Ant. Lateral decompression of the spinal cord

AdvantageNeed not enter the thoracic cavityoriginally 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

EnlargeLocal- resect rib below

Extensile measure- not possible

Diaphram resected- Arcuate ligament

VATS

ComplicationIntercostal 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

IndicationsScoliosis

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 plane- midline paraspinal muscles

Superficial DissectionRotation in scoliosis

Midline incision onlyDeep 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 dangersThoracic 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 dissection- identify 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 posteriorly- unilaterally 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

EnlargingLocal

extensile

Applied surgical anatomy

Superficial dissection

Trapezius

Sternocleido mastoid

Splenius capitis

DeeperLongissmus capitis

Semispinalis capitis

Ligamentum flavum

Posterior approach to C1 C2

IndicationSpinal 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

EnlargeLocal

extensile

Anterior approach to the Cervical Spine

Indication

Excision of herniated discsInterbody 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

NecessityAnterior spinal for cord decompression

Failed laminectomy

Relative indicationsTraumatic

Infection

Degenerative

Neoplastic

deformity

Anterior Transoral Approach

IndicationsTB abscess

Odointecomy

Skull base surgery

Complicationinfection

Anterior Retropharyngeal Approach

Upper cerivcal spine and graft

Extramucosal- less chance of infection

Extended sub total maxillectomyAlternate 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

Thankyou