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Anterior-o-lateral approach to thoraco lumbar region
- 1. Anterior -o- lateral approach to thoraco lumbar region Dr Zeeshan
- 2. Key points Health status, surgeon comfort, Anatomical knowledge And surgical goals • Approach Usually depend upon laterally of lesion but left side usually used • Lateral recess can be approached Rostral or caudal To diaphragm 1. Retro-Pleural 2. Trans-Pleural 3. Retro- peritoneal 4. Combined
- 3. Indication • Exposure: Wide antero lateral Exposure of vertebral column • Pathologies: trauma, DDD, Primary spinal tumor, Infection & deformity • Procedures: Diskectomies & Fusion, Disk arthroplasties, corpectomies and lateral plating
- 4. Surgical technique • Pre operative neuroimaging is key to guide for the side that can be used but left sided is usually approached. ( To protect inferior vena cava and liver retraction )
- 8. Incision was given obliquely along the superior margin of D10 or D12 rib Medially UpTo several centimeters onto abdomen
- 10. The dissection will be done to expose the upper border or margin of rib And the rib is dissected off from it’s muscle attachment and care should be taken to protect neurovascular bundle
- 11. It’s attachment is to 11th rib, it’s dissection will give access to plural cavity and retro peritoneal space. If 11th rib is dissected, the reconstruction of diaphragm will be difficult
- 12. If 10th rib is dissected, the dissection should be performed along the length of dissection. Removal of rib enhanced exposure and decrease post operative thoracotomy pain. Debakey rib retractor
- 13. Plural dissection • It’s usually opened but retro plural dissection should be attempted • Advantages: Avoid placement of chest tube, Can help to keep lung out of field • Disadvantage: Markly decreases the exposure • Lung retracted anteriorly
- 14. If 12th rib Is chosen • The dissection should be placed as described above • Internal and external oblique muscle dissected • The peritoneum is dissected bluntly off from the inferior surface of diaphragm and Retro- peritoneum space is opened • The diaphragm is incised with cuff • Greater risk of lung injury • Table mounted Self retaining retracted is placed
- 15. The dissection of psoas muscle should be done from medial to lateral direction, it will allow the lumbar plexus to rotate posteriorly With psoas muscle and protect muscle
- 16. For Anterior access to disk space or vertebral reconstruction. Segmental vessels course From anteromedial to posterolateral direction Cauterized the vessel from safe distance from arota. Because they may retract after being cut, would cause inaccessible bleeding.
- 17. Artery of Ademkiewicz • Can lead to post operative paraplegia • Pre operative spinal angiography to confirm it’s location • No issue in conventional spinal surgery due to collateral blood supply
- 18. Injury to cisterna chyli • Can lead to lymphocele or chylothorax • Suspected injury, give cream through NG and wait for 30 minutes • Chyl will be milky in color, identify the leak and close with non absorbable suture
- 19. In the end • After achieving The goal of surgery, chest tube can be placed if plural cavity had been opened. • Closure was performed layer by layer with absorbable or permanent suture
- 20. Complications • Pneumothorax, lymphocele, Pseudomeningocele, injury to Lung, Bowel vasculature, Neural elements, retro peritoneal hematoma and pseudohernia.