Download - Approaches to spine
Seminar
onApproaches to Spine
Moderator: Presenter:Dr. Muralidhar N Dr. Somnath Machani Professor and HOD Post GraduateVIMS & RC. VIMS & RC
.
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
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