Dr Ajay Shah IOM Nepal

1. Surgical Approaches for Thoracic and Lumbosacral Spine
Moderator : Prof Dr BL Shrestha
Presenter : Dr Ajay Shah (Resident)
Department of Orthopedics and Trauma Surgery
TUTH, IOM

2. Factors deciding specific surgical approach
• Location of bony lesion
• Presence of medical comorbidities
• Degree of kyphosis
• Region of spine involved
• Experience and preference of surgeon

3. Approach to Thoracic Spine
Posterior Approach
• Midline Posterior approach
• Costotransversectomy
• Lateral extracavitary
Anterior Approach
• Transthoracic approach
• Thoracotomy
• Endoscopic approach

4. Posterior Midline Approach
Indications
• Posterior spine fusion
• Stabilization of fractured vertebra
• Correction of scoliosis
• Removal of tumors of posterior aspects of vertebra
• Open biopsy

5. Advantages
• Familiarity
• Ability to achieve circumferential decompression
• Stronger three column fixation with pedicle screws
• Safe performance of anterior debridement by extended approaches
• Avoids entry to thoracic cavity

6. Position
• Prone position, alternatively lateral position
• Bolsters under patient side
• Shoulders less than 90 degree of abduction
and slightly flexed forward
• Head and neck in relaxed position
• Padding at elbow ,wrist , knee and feet
• Flex patients hips and knee

10. Costotransversectomy Approach
• Classically developed for drainage of tuberculous abscess
• Allows access to posterior vertebral body, intervertebral disc and foramen
• Offers limited view of anterior spinal canal
• It does not involve major encroachment to thoracic cavity

11. Indications
• Abscess drainage
• Partial vertebral body biopsy
• Treatment of traumatic spine injuries
• Biopsy and decompression of neoplasms
• Anterolateral decompression of cord

12. Position
• Prone position
• Bolsters on each side of rib cage
Landmark
• Palpate the spinous process
• If the patient has gibbus deformity, use it as
landmark
Incision
• Curved linear incision 8cm lateral to
appropriate spinous process
• Center the incision over rib involved

13. Incise subcutaneous fat and fascia in line of incision
Incise trapezius muscle parallel with its fibers Cut down into the posterior aspect of rib to be resected

14. Strip muscles laterally and medially
Incise the periosteum over rib
Separate all muscles attachment using periosteal
dissection
Divide rib about 6-8cm from midline
Lift it and cut any remaining muscle attachments and
costotransverse ligament

15. • Twist the rib’s medial end to complete
the resection and remove it
• Abscess cavity is now exposed
• Resect the transverse process for greater
exposure

16. Lateral Extracavitary Approach
• Simultaneous exposure of posterior elements of spine and anterior vertebral body
• Better access to ventral thecal sac
• Avoids thoracotomy and laparotomy
Indications
• Circumferential decompression and stabilization of spine
• Address midline ventral pathology
• Neural decompression

17. Limitations
• Significant muscle dissection
• Longer recovery time
• May need to sacrifice intercostal nerve

19. Anterior Approach to Thoracolumbar Junction
• Expose simultaneously lower thoracic and upper lumbar vertebra
• More difficult exposure
• Thoracic lesions exposed through chest and lumbar lesions through anterior
retroperitoneal incision
Indications
• Deformity correction including kyphosis and/or scoliosis
• Vertebral tumors , fractures and infections such as osteomyelitis

20. • Position : Right lateral decubitus
• Incision : Curvilinear ( posteriorly
midline of back along 10th rib then
obliquely downward on abdomen

21. Transthoracic Approach
Indications
Anterior exposure of vertebral bodies T1-4 anterolateral region
• Infections
• Fusion of vertebral bodies
• Resection of vertebral bodies for tumor and reconstruction with bone grafting
• Correction of scoliosis, kyphosis
• Anterior spinal cord decompression
• Biopsy
Disadvantages
• Mobilization of scapula and violation of chest wall muscles
• Violation of pleural space and need for chest tube placement

22. Position Incision
Patient should be placed on his/her side
Patients hand and arm should be placed above
head
Two finger breadth below tip of scapula
Curve the incision forward toward inframammary crease
Extend it backward and upward towards the thoracic spine

23. Latissimus dorsi divided posteriorly in line
with skin incision
Serratus anterior divided along the line of skin
incision down to the ribs

24. Elevate scapula with the cut attached muscles
proximally to expose underlying ribs
Cut periosteum on the upper border of rib
Enter the pleura from above the rob
Insert rib spreader to hold the ribs apart

25. • Deflate the lung
• Identify the esophagus over the
vertebral bodies
• Incise the pleura over lateral side
of esophagus
Fig A View from surgeon standing
dorsal to spine
Fig B Axial view of exposure with
patient in the decubitus position

26. • Mobilize esophagus with finger dissection
• Retract it from anterior surface of spine
• Intercostal vessels that cross the operative
field are ligated

27. Endoscopic Approach to Anterior Thoracic Spine
Indications
• Decompression
• Treatment of fractures
• Neoplastic lesions
• Correction of deformity
Contraindication
• Cardiopulmonary insufficiency.
• Acute Post traumatic respiratory failure
• Coagulopathy

28. Advantages of VATS
• Small incision into intercostal space without need for rib resection
• High resolution video allows surgeon to see pathology in great detail
• Postoperative pain and morbidity are reduced
• Decreased recovery time
• Less postoperative pulmonary dysfunction

29. • Position : Lateral decubitus
• Table flexed maximally to widen intercostal spaces
• Collapse of ipsilateral lung allows clear visualization of operative field
• Mark the portal position

30. • Typically 2-3 working portals are used
and 2 others are used for
instrumentation
• 1 portal is placed directly over the
pathology posterior to midaxillary line
• Another placed two levels superior to
midaxillary line
• One is placed at the level of pathology or
more distal
• Fourth portal placed anterior to
midaxillary line

31. Approach to Lumbar Spine
Posterior Approach
• Midline Posterior Approach
• Paraspinal Approach
• Minimally invasive Lateral Approach
Anterior Approach
• Transperitoneal Approach
• Retroperitoneal Approach

32. Midline Posterior approach
Indications
• Excision of herniated discs
• Exploration of nerve roots
• Spinal fusion
• Removal of tumors
• Correction of congenital spine deformities( scoliosis, kyphosis and lordosis )

33. Advantages
• Easy and well known technique
• Good access and exposure of posterior elements
• Low risk of spinal cord injury
• Ease of localization of appropriate spinal level
Disadvantages
• Deep soft tissue and muscular dissection
• Risk of iatrogenic spinal instability
• Restricted access to ventral pathology

34. Position
• Prone position, alternatively lateral
position
• Bolsters under patient side
• Shoulders less than 90 degree of
abduction and slightly flexed
forward
• Head and neck in relaxed position
• Padding at elbow ,wrist , knee and
feet
• Flex patients hips and knee

35. Deepen the incision through the fat and fascia in
line with the skin incision until spinous process
itself is reached
Detach the paraspinal muscles subperiosteally
Longitudinal incision over the spinous process,
extending from spinous process above to spinous
process below level of pathology

36. • Dissect paraspinal muscles from spinous
process and lamina to facet joint
• Remove paraspinal muscles subperiosteally
• Continue dissecting laterally, stripping joint
capsule from descending and ascending facets
• Close to facet joints, are branches of lumbar
vessels supplying paraspinal muscles,
frequently bleed as dissection is carried out
laterally

37. • Remove ligamentum flavum by cutting its
attachment to superior or leading edge of
inferior lamina
• Immediately beneath ligamentum flavum
and epidural fat is blue-white dura
• Identify the nerve root

38. • Insert blunt dissector under cut edge of
liagmentum flavum
• Use kerrison rongeur to remove distal
end of lamina
• Remaining portion of ligamentum
flavum at its attachment to
undersurface of lamina is removed

39. Fig A
• Using blunt dissection , continue down to
floor of spinal canal, retracting dura and its
nerve root medially
• Reveal posterior aspect of disc
Fig B
• Cross-section revealing retraction of dural
tube and a herniated nucleus pulposus
impinging nerve root

40. Paraspinal Approach
• Provide direct access to transverse processes and mammillary process
• Provide excellent bed for posterolateral lumbosacral fusion
• Basis for minimally invasive transforaminal lumbar interbody fusions
• Useful in
removing far-lateral disc herniation,
decompressing a ‘far out’ syndrome
Inserting pedicle screws
Position : Prone position
Incision: Longitudinal paramedian lateral to the border of erector spinae muscles

42. Minimally Invasive Lateral Approach
Indications
• Used for multilevel interbody fusions to correct kyphoscoliosis
• For interbody support when treating adjacent segment degeneration
• To drain psoas abscess
Advantages
• Smaller incision
• Less tissue dissection and muscle damage
• Potential for less blood loss
• Decreased postoperative pain
• Shorter hospital stay
• Quicker return to activities

43. Disadvantages
• Prolonged operative period
• Not appropriate for every case
• Less surface area of bone exposed
• Steep Learning curve for surgeons
• Increased radiation exposure

44. Patient placed in lateral decubitus position with table
flexed to increase distance between patient’s ribs and
iliac crest
Fluroscopic image showing center positioning over
disc space
A mark is made on skin corresponding to this mark

45. • Two incision technique shown with
lateral and posterolateral marks
• Posterolateral mark is made posterior
to 1st mark, at border between erector
spinae and abdominal oblique muscles
• Posterolateral incision is made about
the length of surgeon’s index finger

46. Finger dissection is used down to lumbodorsal fascia
Surgeon uses digital palpation to sweep abdominal contents
anteriorly and create cavity in retroperitoneal space
Index finger guides intial dilator down to psoas
When initial dilator is secured with k-wire,large
dilators are used to spread psoas and retractor is
placed over dilators

47. When retractor is deployed , soft tissue over disc space
must be cleared away
Probe is used to detect any nerves that may cross the field
Cobb elevator to release contralateral annulus which
aids in coronal correction of deformity

48. Anterior approach to lumbar spine
• Transperitoneal Approach
• Retroperitoneal(Anterolateral)
approach

49. Transperitoneal approach
Longitudinal midline incision from just below
umbilicus to just above pubic symphysis
Extend it superiorly, to left of umbilicus
Incise subcutaneous fat in line of skin incision
Incise rectus sheath longitudinally

50. With fingers, separate rectus abdominis muscles in
midline to expose peritoneum Pick up peritoneum with 2 pairs of forcep and incise it
distally

51. With one hand inside abdominal cavity to protect
viscera,carefully deepen upper half of the incision

52. Retract posterior peritoneum
Ligate middle sacral artery
Identify presacral parasympathetic plexus overlying
aorta and sacral promontory
Mobilize great vessels as needed for additional exposure
Expose L5-S1 disc space subperiosteally

53. Retroperitoneal ( Anterolateral ) Approach
Indications
• Spinal fusion
• Drainage of psoas abscess and curettage of infected
vertebral body
• Resection of all or part of vertebral body and/or
intervertebral disc
• Biopsy of a vertebral body

54. Advantages over transperitoneal
approach
• Provides access from L1 to sacrum
• No risk of postoperative ileitis
Position
• Semilateral position
• Body should be at about 45-90 degree to
horizontal,facing away

55. Oblique flank incision, from posterior half of 12th rib
toward rectus abdominis muscle
Incise external oblique muscle and aponeurosis in
line with its fibers and in line with skin incision

56. Divide internal oblique in line with skin incision and
perpendicular to line of its muscular fibers
Incise underlying transversus abdominis in line with
skin incision

57. Identify peritoneum and its content in anterior part of wound
Posteriorly the retroperitoneal fat Using blunt finger dissection: plane between
retroperitoneal fat and psoas muscle fascia

58. Mobilize the peritoneal cavity and its content, and
retract them medially
Ligate the lumbar vessels ( segmental branches of aorta
Mobilize aorta and vena cava to reach anterior part of
vertebral body

59. Posterior Approach to Sacrum and Sacroiliac Joint
Indications
• Trauma
• Infection
• Degenerative disease
• Inflammatory process

62. References
• Rothman-Simeone The Spine 6th Edition
• Surgical exposures in orthopedics, Stanley Hoppenfeld 4th Edition
• Chapman’s comprehensive orthopedics surgery, 4th Edition
• Campbell’s operative orthopedics, 14th Edition