This document summarizes a seminar on approaches to the spine. It describes the anatomy of the vertebral column and parts of individual vertebrae. It then discusses several surgical approaches to different regions of the spine including the posterior, anterior, and lateral approaches to the lumbar spine, costotransversectomy and transthoracic approaches to the thoracic spine, and posterior approaches to the cervical and thoracic/lumbar spine for scoliosis correction. For each approach, it provides the indications, patient position, incision details, and dangers to watch out for. Applied surgical anatomy is also discussed.

1. Seminar
on
“Approaches to Spine”
01 – 12 - 2010
Moderator:
Presenter:
Dr. Muralidhar N
Dr. Somnath Machani
Professor and HOD
VIMS & RC.
Post Graduate
VIMS & RC
.

2. Anatomy of the vertebral column
●
33 vertebrae
●
7 cervical
●
12 thoracic
●
5 lumbar
●
5 sacral
●
4 coccygeal

3. Parts
●
Anterior body
●
Posterior arch
●
Neural arch
●
Spinous process
●
Transverse process
●
Inferior and superior
articular joints

5. Cross section of the Spinal Cord

6. Pedicle anatomy

7. Pedicle screw insertion

8. Posterior approach to the Lumbar spine
Indications
●
•
Excision of herniated discs
•
Exploration of nerve roots
•
Spinal fusion
•
Removal of tumours
•
Provides access to
•
Cauda equina
•
Intervertebral disc
•
Spinous process
•
Laminae
•
Facet joints
•
pedicles

9. 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.

10. Incision
Longitudinal incision over
the spinous process
Iliac crest for L4 - L5
interspace

11. Superfical surgical dissection
●
Deepen fat and fascia

12. ●
Remove paraspinal
muscles as one unit from
spine

13. ●
●
Continue laterally
Cauterize the nerves and
arteries

14. ●
Remove the lig. Flavum
from the superior
attachment.

15. ●
Deep dissection

16. Beneath the ligament Flavum
●
Identify the blue white
dura

17. ●
●
Retract the dura and
Nerve root medially
View the disc space

18. ●
Iliac vessels can be
damaged if instruments
pass thro the annulus
fibrosus

19. Enlarging measures
●
For Dura and Nerve root
●
For posterior spine
●
skin

20. Applied anatomy of the posterior approach
●
Superfical muscles
●
Deep paraspinal muscles

21. Landmarks
●
Spinous process
●
Young patient
●
PSIS
●
L4 L5
●
Midline incision

22. ●
Deep dissection
●
Dura protection

23. 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

24. incision
●
●
Umblicus to pubic
symphysis
Curve to the left of
umblicus

25. ●
Deepen the incision

26. ●
Separate the rectus
abdominis to expose the
peritoneum

27. ●
Pick peritoneum with
forceps and incise it

28. protect the viscera, carefully deepen
the upper half of the incision

29. ●
●
Retract abdominis,
bladder
Retract bowels

30. ●
Identify aorta
●
Left common iliac artery
●
Left ureter
●
●
Danger of presacral
parasympathetic plexus
Extension- pack bowels
and superioly incise upto
the xiphisternum

31. Applied anatomy
●
Umblicus
●
Linea alba
●
Pubic symphysis
●
Rectus Abdominis

33. ●
Aorta
●
Common iliac
●
Ureter
●
Presacral plexus
●

34. Video assisted lumbar surgery
●
●
●
Transperitoneal
laproscopic approaches
Supine position
Complication- vascular
and peritoneal injury

35. Retroperitoneal Approach
●
Advantages of transperitoneal
●
Access from L1 to S
●
Drainage of abscess
●
Disadavantage
●
Difficult to reach L5 S1

36. 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

37. Position
●
Semilateral 45º
●
Sand bagsl
●
Left side up
●
Land mark- 12th rib
●

38. ●
●
Route of surgery

39. ●
Incision
●
Oblique flank incision
●
Internervous plane- none
●

41. Superficial dissection
●
Transverse abdominis in
line with the skin

42. ●
●
Identify peritoneum
anteriorly
Retroperitoneal fat
posteriorly

43. ●
Blunt finger dissection

44. ●
Retract the peritoneal
contents medially

45. Deep dissection
●
●
Identify psoas
Ligate and segmental
arteries and mobilize the
aorta and cava

46. Dangers
●
Sympathetic chain
●
Genitofemoral nerve
●
IVC
●
Ureters
●
Extension●
Posterioly
●
Upper lumbar vertebrae rib may need to be excised

47. Costotransversectomy approch to the
Thoracic Spine
●
Indication
●
●
Vertebral body biopsy
●
Partial verterbral body resection
●
Limited anterior spinal fusion
●
●
Abscess drainage
Ant. Lateral decompression of the spinal cord
Advantage
●
Need not enter the thoracic cavity
originally used to draining tubercular abscess

48. Position
●
Prone
●
Bolsters
●
Drape widely

49. Incision
●
●
Curvilinear lateral to
spinous process
Center over the involved
rib

50. Internervous Plane
●
●
No true internervous
plane
Trapezius is cut and
paraspinal muscles

51. ●
●
Cut onto the posterior
aspect of the rib to be
resected
Incise the periosteum over
the rib

52. ●
Separate muscles from
the rib using subperiosteal
resection

53. ●
●
Divide rib 8 cm from the
midline
Cut muscle attachment
and costotransverse
ligaments

54. ●
●
Enter the retropleural
space by blunt dissection
and digital palpation
Safe in disease only

55. Dangers
●
Nerves- Dura
●
IC vessels
●
Lungs- pneumo thorax
●
Extension- only resect the
adjacent ribs

56. 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

57. Position
●
On the side
●
Move arm above his head
●
Approach from right side

58. Landmarks
●
Inferior angle of the
scapula
●
Spinous process
●
Inframammary crease
●
Incision

59. Deep incision
●
●
●
Latismus Dorsi division
Serratus anterior- elevate
scapula
Rhomboids?
●
Bleeding
●
Resect ribs

60. ●
●
Retract scapula superiorly

61. Elevate the scapula with the
cut attached muscles
proximally to expose the
underlying ribs.
Cut the periosteum on the
upper border of the rib.

62. ●
●
Enter the pleura from the
rib above
Strip muscle attachement
s from the cephalad rib

63. Deep Dissection
●
Deflate lungs
●
Retract anteriorly
●
Identify oesophagus
●
Incise pleura

64. ●
●
●
Retract the oesophagus
IC vessels that cross the
field need to be ligated
Cord ishemia

65. Dangers
●
Vessels – IC vessels
●
Lung care
●
Enlarge
●
●
●
Local- resect rib below
Extensile measure- not possible
Diaphram resected- Arcuate ligament

66. VATS
●
Complication
●
Intercostal neuralgia
●
Atelectasis
●
●
●
Excessive epidural blood
loss 2500ml
Temporary paraparesis in a
scoliosis patient
By Made et al

67. Posterior Approach to the Thoracic and
Lumbar spine for Scoliosis
●
Indications
●
Scoliosis
●
Posterior spine fusion
●
Removal of tumour of the posterior aspect of the vertebra
●
Open biopsy
●
Stabilization of fractures vertebrae

68. Position
●
Prone
●
Bolsters
●
Landmarks – gluteal cleft,
C7 T1

69. ●
Incision
●
Midline straight
●
Internervous planemidline paraspinal
muscles

70. Superficial Dissection
●
Rotation in scoliosis
●
Midline incision only
Deep dissection
●
Paraspinal muscles from spinous process
●
Keep dissection open

72. Dangers
●
Post primary rami
●
Segmental Vessels
●
Enlarge●
●
Local- widen exposure
using self retaining
retractor
Extensile- from cervical
spine to coccyx

73. Applied anatomy
●
●
Superficial mooring
muscle
Intermediate- accessory
muscles of respiration
●
Deep- paraspinal muscle
●
Landmarks

74. ●
Superficial dissection dangers
●
Thoracic spine- more bleeding
●
Vertebral body rotation – convex side of curve
●
Intermediate surgical dissection
●
Deep portion●
lumbar facet joints are larger
●
Traumatic arthritis

75. 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

76. Superficial surgical dissection
●
●
●
Lift the skin and
subcutaneous tissue
Centre the dissection over
the most prominent rib
Intermediate dissectionidentify the trapezius by
the rolled border

77. ●
Free latismus dorsi from
under the trapezius

78. 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

79. Danger
●
Neurovascular bundle
●
Pneumothorox
●
Prevent puckering
●
Enlarge●
●
●
Local continue
subcutaneous dissection
laterally
Extensile- not possible
Removal of ribs

80. Posterior Approach to cervical spine
•
Posterior cervical spine fusion
•
Excision of herniated discs
•
Treatment of tumors
•
Treatment of facet joint dislocations
•
Nerve root exploration

81. Position
●
Prone
●
Few degrees of flexion
●
Upright- less venous
bleeding but air emboli

82. ●
●
Landmark- C2 and C7
Incision- midline over the
pathology

83. ●
●
Incise fascia
Note the third occipital
nerve

84. ●
Continue up to tthe
spinous process

85. ●
Remove paraspinal
muscles posteriorlyunilaterally or bilaterally

86. ●
●
Perform a laminectomy
and dissect as much is
needed
Retract nerve root and
spinal cord medially

87. ●
Deep dissection
●
Note the spinous process

88. Dangers
●
Spinal cord and its nerve
root
●
Posterior primary rami
●
Venous plexus bleeding
●
Enlarging
●
Local
●
extensile

89. Applied surgical anatomy
●
Superficial dissection
●
Trapezius
●
Sternocleido mastoid
●
Splenius capitis

90. ●
Deeper
●
Longissmus capitis
●
Semispinalis capitis
●
Ligamentum flavum

91. Posterior approach to C1 C2
●
Indication
●
●
●
●
●
Spinal fusion
Decompression
lamiectomy
Treatment of tumours
Position – same as
posterior approach
Incision from inion

92. ●
Deepen in the midline

93. 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.

94. Remove the paracervical muscles
from the posterior elements of C1 and
C2. Carry the dissection up to the
base of the occiput

95. Deep dissection
●
Remove the posterior
atlanto occipital
membrane between C1
and occiput

96. Dangers
●
Retraction of cord
●
Nerves- C2 and C3
●
Vertebral artery
●
Enlarge
●
Local
●
extensile

97. Anterior approach to the Cervical Spine
●
Indication
•
Excision of herniated discs
•
Interbody 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

98. 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

99. 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

100. Incision
Incise the fascial sheath over the platysma in
line with the skin incision. Split the platysma
longitudinally, parallel to its long fibers

101. ●
Identify platysma and
incise fascia medial to it
Skin and platysma are very vascular. Use
epinephrine

102. 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

103. 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

104. Dangers
●
●
●
Recurrent laryngeal
nerve
Symathetic nerve and
Stellate Ganglion
Carotid sheath and
contents
●
Vertebral artery
●
Inferior thyroid artery

105. Anterior Approaches
●
Necessity
●
●
●
Anterior spinal for cord decompression
Failed laminectomy
Relative indications
●
Traumatic
●
Infection
●
Degenerative
●
Neoplastic
●
deformity

106. Anterior Transoral Approach
●
Indications
●
●
Odointecomy
●
●
TB abscess
Skull base surgery
Complication
●
infection

107. Anterior Retropharyngeal Approach
●
Upper cerivcal spine and graft
●
Extramucosal- less chance of infection
●
Extended sub total maxillectomy
●
Alternate to transoral
●
For exposure and removal of tumour from the base of skull

108. Low Anterior cervical approach
●
Same as Anterior cervical approach
●
From left side 1 finger breath above the clavicle
●
Extending across the midline
●

109. High transthoracic Approach
●
●
●
Uses C6 to T4
Kyphosis forces the
cervical spine in to the
chest
Incision- Periscapular

110. Modified Anterior Thoracic Approach
●
Supine
●
Stable neck
●
●
Ligate and divide thyroid
vessels
Dont damage RLN or
Superior laryngeal nerve

111. Thankyou