surgical approaches of spine

1. Dr.Y.Sai Pramod

2. SURGICAL MANAGEMENT
 Effectiveness of chemotherapy has obviated the need for surgical
therapy in many cases
 Operative management includes -
- Excision and debridement of diseased parts of verterbrae
- Evacuation of tubercular abscess
- Arthrodesis of unstable and painful spine and to prevent severe
kyphosis
- Mechanical decompression of the cord for neurological
complications

3. VARIOUS SURGICAL PROCEDURES
 Radical debridement ,Drainage of cold abscess
 Anterior decompression& spinal fusion by grafting and
instrumentation.
 Rachitomy /Racheactomy.
 Costotransversectomy
 Anterolateral decompression
 Posterior fusion
 Laminectomy

4. INDICATIONS FOR OPERATIVE DECOMPRESSION
ARE –
 Doubtful diagnosis
 Failure of response after 3-6 months of non operative
treatment – debridement with or without fusion
 Failure of neurological complications to respond to
conservative therapy or in case of advanced stage –
decompression with or without fusion
 Fusion of mechanical instability after healing

5.  In case of recurrence of disease or of neurological
complications – debridement with or without
decompression with or without fusion
 To prevent severe kyphosis by debridement with
fusion by panvertebral surgery in children with
extensive dorsal lesions
 In case of neurological complications due to severe
kyphosis anterior transposition of the cord through
extrapleural anterolateral approach

6. SURGICAL APPROACHES
 Any surgery on the vertebral column must ensure
least disruption of intact healthy columns
 In classical spondylodiscitis where the
destruction is in the anterior columns, anterior
approach is rational thus preserving the only
biological stability the patient has i.e the
posterior arch and ligament complex

7. Approaches for dorsal spine –
 Anterolateral extrapleural approach (D2-L1)-
Developed by Griffith,Seddon, Roaf
 Transpleural anterior approach(D1-L1) –
Developed by Hodgson and Stock
 Posterolateral approach- Developed by Martin
 Dura is exposed by hemilaminectomy first and
then extended laterally to remove posterior ends
of 2-4 ribs corresponding transverse process and
pedicles

8. ANTEROLATERAL DECOMPRESSION OR LATERAL RACHOTOMY
 Anterolateral extrapleural approach (D2-L1)-
Developed by Griffith,Seddon, Roaf
 Prone position/ right lateral position.
Begin the incision in the midline at a point 10 cm
proximal to the lesion, gently curve it laterally a
distance of 7.5 cm, and return to the midline at a point
10 cm distal to the lesion
 Incise the skin retract paraspinal muscles,carefully
seperate intercostal vessels and nerves

9.  After exposing the rib remove the medial end of 2-4
ribs ,tranverse process and pedicle of the vertebra
 Remove the offending material, such as a caseous mass,
granulation tissue, a necrotic disc, or a nest of
sequestra

10. Transpleural anterior approach(D1-L1) –
Developed by Hodgson and Stock
STEPS-
- An incision is made along the rib which in mid axillary
line lies opposite the center of the leision
- ribs are resection from costochondral junction,
- lung is freed by blunt dissection b/w parietal and
visceral pleura,
- plane is developed between aorta and vertebral
bodies after retraction of the lungs
- paravertebral abscess is opened by T- shaped incision
- then debridement ,decompression with or without
bone grafting

11. APPROACHES TO CERVICAL SPINE –
 For radical debridement and arthrodesis
 ANTERIOR APPROACH – Most commonly used
 Between SCM and carotid sheath laterally and oesophgus and trachea
medially
 Hodgson approach through posterior triangle – by retracting
SCM,Carotid sheath , trachea,oesophagus anteriorly and to the opposite
side
 Transoral approach for atlantoaxial region
 Retropharyngeal approach for clivus to c3
 Transthyroid approach

12. Anterior approach to cervical spine (C2-D1)
 Incision: along the medial
border of the SCM / short
transverse at the appropriate
level.
 Pt. in supine
 Approach from left due to
recurrent laryngeal N. on Rt
 Gap b/w laterally SCM &
Carotid sheath and medially
Esophagus & trachea is made
 A longitudinal incision over the
ant. Longitudinal ligament is
made to expose the vertebra.
 then abscess is drained and
vertebra is dealt.

13. •Patient in supine with head in 5-10
deg. Hyper extension
• a preliminary tracheostomy is
done after anaesthesia.
•Uvula and soft palate is bisected
for exposure.
•A long. Incision is made on the
pharygeal wall
•This exposes the vertebrae
TRANS ORAL APPROACH FOR ATLANTO-OCCIPITAL REGIONS

14. TRANS THYROID APPROACH
Make a collar incision along the uppermost crease of the neck between
the hyoid bone and the thyroid cartilage extending as far laterally as
the carotid sheaths

15. Anterior retropharyngeal approach for upper cervical vertebra
–Mc Afee et al. JOHN HOPKINS inst.
• Done on right side for Rt. Handed
patients. With neck in extension.
•Incision is just upward extension of the
anterior approach i.e along medial border
of SCM.
•A transverse submandibular incision is
made from symphysis mentii to tip of
mastoid process .a vertical limb is made
from the center point of the transverse
incision distally as wanted.
•Then dissection proceeds to
retropharyngeal space between the
contents of carotid sheath laterally and
larynx & pharynx antero medially.

16. APPROACHES TO LUMBAR SPINE-
Anterolateral approach /lumbar vertebrotomy
 Pt. in Rt lateral position so approach
is from left side to avoid damage to
inferior vena cava.
 A semicircular incision is given with
center of incision opposite to the
vertebral body to be exposed.
 Retract para spinal muscles
proximally and distally and resect
the transverse process from their
bases.
 Retract the psoas muscle gently
anteriorly and laterally exposing the
body of the required vertebrae.

17. Extraperitoneal anterior approach
 Position is 45 deg. Right lateral position
 Incision extending from renal angle
posteriorly to the lower part of lateral
margin of rectus abdominis anteriorly.
 Abdominal muscles are split in the line
of incision.
 The periosteum is gently stripped off
the posterior abdominal wall
 Push the peritoneum and its contents to
right side.
 If psoas abscess is present it is drained
by longitudinal incision.
 The aorta , inferior venacava ,
sympatheticchain are reflected laterally
along with psoas muscle exposing the
desired vertebrae.

18.  Posterior spinal decompression and arthrodesis
 To control mechanical instability in other wise healed disease
 To stabilize craniovertebral operation
 Or as a part of panvertebral operation
 Based on Albee and Hibbs technique
 Albee technique –
 Fusion of spinous process into one continuous bony ridge by
tibial graft inserted across the diseased site
 Hibbs technique-
 Fusion induced by overlapping numerous small osseous flaps from
contiguous laminae,spinous process and articular facets

19. COMPLICATIONS
1. Cold abscess
2. Paraplegia
3. Chronic discharging Sinuses
4. Secondary infection
5. Amyloidosis
6. Fatality

20. COLD ABSCESS
 Commonest complication of Potts disease.
 The abscess consists of a central mass of caseous
debris,serum,lecocytes, bone sand, and TBbacilli, with a
limiting wall of granulation tissue. In the absence of
secondary infection the fluid is sterile.

21. ABSCESS IN CERVICAL
SPINE –
The abscess may be present
 Retropharyngeally in the
posterior triangle of the
neck or
 Supraclavicular area or in
the axilla
 The tuberculous detritus
may gravitate downward
under the prevertebral
fascia to form a
mediastinal abscess.

22. ABSCESS IN THE THORACIC REGION –
 May press the spinal cord posteriorly causing paraplegia
 May spread laterally towards extrapleural space causing effusion
 May may penetrate the ALL and lie in the mediastinum
 May enter anterior abdominal wall through lateral aortic ligament
and quadratus lumborum
 May enter psoas sheath or may form lumbar abscess through
medial aortic ligament

23. ABSCESS IN LUMBAR REGION –
 The abscess may present in
 Psoas sheath,
 Femoral triangle ,
 Gluteal region,
 Petits triangle
 and very rarely to iliac crest.

24. Potts paraplegia
 Neurological complication is the most dreaded and
crippling complication of spinal tuberculosis.
 It occurs in 10-30% cases of spinal tuberculosis.
 More common in first 3 decades of life.
 Thoracic region is affected more commonly followed
by cervical and lumbar regions.
 Most common pathology of paraplegia in developing
countries still remains spinal tuberculosis

25. Classification – by Griffiths ,Sedon, Roaf in 1956 based on the
pathology
Group A –Early onset paraplegia/Paraplegia associated with
active disease
 During active stage of the disease usually within 2 years of the
onset
 Pathology – inflammatory oaedma,tuberculous granulation
tissue,tuberculous abscess, tuberculous caseous tissue or
ischaemic lesions of the cord

26. Group B –Late onset paraplegia/Paraplegia associated with
healed disease
 Many years after the disease persisted in the vertebral column
(after 2 years ) due to mechanical pressure or due to
recrudescence of the disease
 Pathology – tubercular debris ,sequestra from vertebral body or
disc,inernal gibbus,stenosis of the vertebral canal,severe
deformity.

27. EthioPathogenesis –
 Paraplegia occur due to the pressure on the tissues of cord due to
various causes
1.Inflammatory causes -
- Inflammatory oedema due to vascular stasis or due to toxins
- Tuberculous granulation tissue
- Tuberculous abscess
- Tuberculous caseous tissue
2.Mechanical causes -
- Tubercular debris
- Sequestra from vertebral body and disc
- Stenosis of vertebral canal
- Internal gibbus along the anterior wall of spinal canal

28. 3.Intrinsic causes –
- Prolonged stretching of the cord over a severe deformity
- Pathological dislocation of spine
- Infarction of spinal cord due to endarteritis or thrombosis of
spinal vessels
- Tuberculous meningo myelitis
- Myelomalacia and Syringomyelic changes
4.Spinal tumor syndrome –
Cord compression due to diffuse extradural granuloma or
tuberculoma or peridural fibrosis without any radiological
evidence of tuberculous involvement of vertebrae

29.  Signs and symptoms –
 Paraplegia occurs in association with vertebral lesion.
Paraplegia of slow onset –
 Spontaneous twitching of muscles of lower limb and clumsiness while
walking
 Extensor plantar response , exaggerated reflexes
 Sustained clonus of ankle and patella
 Spastic motor para-paresis
 Spastic paraplegia in extension
 Spastic paraplegia in flexion
 Bladder and anal sphincter invlovement with varying degree of
sensory deficit
 Flaccid paralysis/Areflexic paralysis with anaesthesia and loss of
sphincter control

30. Paraplegia of sudden onset –
Occur due to –
- Thromboembolic ischemia of cord
- Pathological dislocation
- Rapid acculmulation of infective material
Patient presents with sudden complete flaccid paralysis like
spinal shock which may gradually change into spasticity.
Vibration and joint position sense are the last to disappear.

31.  Staging of Progressive severity of neural deficit due to cord
compression based on degree of motor involvement-by Goel ,Tuli,
Kumar .
STAGE 1-
 Patient is not aware of any motor weakness and able to walk
normally. On clinical examination attending physician finds ankle
clonus and plantar extensor response ,but these signs may
disappear on re examination after rest in recumbent position.
STAGE 2 –
 Patient presents with complaints of incoordination or spasticity
of limbs while walking,but manages to walk with or with out
support.on clinical examination all signs of spastic paresis are
present.

32. STAGE 3 –
 Patient is bedridden and cannot walk due to severe weakness
.clinical examination reveals spastic paraplegia in
extension.sensory deficit is present but less than 50%
STAGE 4 -
 Patient with paraplegia with flexor spasms or paraplegia in
flexion
 Patient with paraplegia in extension who develops spontaneous
flexor spasms and or more than 50% sensory deficit(bed sores)
and or sphincter disturbances
 Flaccid paralysis due to very severe cord compression
 Flaccid paralysis due to sudden cord compression

33. Role of myelography
 Spinal tumor syndrome
 Multiple vertebral lesions
 When patient has not recovered after surgical decompression
- Presence of myelographic block indicate inadequate mechanical
decompression and need for second decompression
- Failure to recover in the absence of block indicate intrinsic damage to
the cord such as in ischaemic infarction,interstitial gliosis,atrophy of
the cord,tuberculous myelitis,myelomalacia
 To rule out other causes of paraplegia (Arachnoiditis)

34. TREATMENT
 Prevention of paraplegia is of paramount importance by early
diagnosis and prompt treatment
 Every case of tuberculosis spine needs immediate admission,
strict bed rest , ATT, and mechanical decompression in indicated
cases

35. Absolute indications :
1. When there is no progressive recovery after conservative
treatment(3-4 weeks).
2. When neurological complications develop during conservative
treatment
3. When the neurological complications become worse while
undergoing ATT and bed rest
4. Patients who have recurrence of neurological complication
5. Patients with cervical abscess with difficulty in deglutition
and respiration
6. Advanced cases with sphincter disturbances ,flaccid paralysis
, severe flexor spasms

36. Relative :
1. - Recurrent paraplegia
2. - Paraplegia with onset in old age
3. - Painful paraplegia
4. - Complications such as UTI and renal stones.
Rare :
1. - Post spinal disease
2. - Spinal tumour syndrome
3. - Severe paralysis secondary to cervical disease
4. - Severe cauda equina paralysis

37.  In paradiscal lesions , adequate decompression of the cord
anteriorly by anterior (or) anteroateral approach
(Laminectomy is contraindicated because it is inadequate for
decompression of the anterior part ,besides it removes healthy areas
thus making it unstable and pathological dislocation,deterioration of
neural satus and increase in kyphotic deformity has been noted)
 Costotranversectomy can be done to drain fluid abscess
 Internal gibbus is removed in cases of paraplegia with kyphosis
of more than 60 degrees or more

38.  Posterior spinal fusion is done for extensive
disease during childhood to minimize the severe
kyphotic deformity (>60 degrees) and thus
preventing delayed neural complications
 In long standing cases like atrophy with kyphosis
of 45 degrees or more patient is kept under close
observation as long as the patient is able to walk
,the moment when the patient is unable to walk
then decompression and transposition is done.

39. PROGNOSIS
GOOD PROGNOSIS
 Early onset disease
 Partial involvement of the cord
 When neural complications
develop slowly
 When complications are of
short duration
 Young and with good general
condition
 Active vertebral disease
 Kyphotic deformity <60
degrees
 On MRI cord is normal
 Wet lesion
POOR PROGNOSIS
 Late onset disease
 Complete involvement of the
cord
 Rapid development of neural
complications
 When complications are of
longer duration
 Old patient with poor general
condition (>12 months)
 Healed vertebral disease
 Kyphotic deformity > 60
degrees
 On MRI cord shows
myelomalacic or syrinx changes
 Dry lesion

40. RECOVERY
 Many patients even with advanced disease do recover to some
extent with satisfactory mechanical decompression and ATT.
 Order of recovery –
 Vibration and joint sense >Temperature, Touch, Pain > Voluntary
motor activity , sphincter function and wasting of muscles.

41. spinal braces for rehabilitation
 Patients with spinal tuberculous, bracing with a
conforming orthosis has been used in combination
with antituberculous drugs as initial treatment.
Bracing is continued 3 mo after the first
radiologic sign of bony fusion.
 The nature of the brace depends on the level of
the lesion

42.  For D4 –L2-Taylor brace is used
 For dorsal spine in growing age especially if vertebrae
involved are more than 2 ,Milwaukee brace or Jewett
brace is recommended .

43.  ASH brace (anterior
spinal hyperextension)
preferred in young girls
and women as it gets
accommodated in
contours of the body.
 For c1-c7 Four post collar
or SOMI (sterno-
occipital-mandibular
immobilizer) can be used.
 Goldthwaite brace for L3
and below vertebrae

44. THANK U