Transcript Anterior (Transperitoneal) Approach to the Lumbar Spine

Surgical approaches to
the spine
ABDULMONEM ALSIDDIKY, MD,SSCO
Assistant professor ,consultant
Pediatric ortho. &ped. spine
RIYADH,SAUDI ARABIA
Objectives
•Anterior (Transthoracic) Approach to the Thoracic Spine
•Anterolateral (Retroperitoneal) Approach to the Lumbar
Spine
•Anterior (Transperitoneal) Approach to the Lumbar and
Lumbosaccral Spine
•Posterior Approach to the Lumbar Spine
Anterior (Transthoracic) Approach
to the Thoracic Spine
Anterior (Transthoracic) Approach to
the Thoracic Spine
• Offers exposure of the anterior portions of the vertebral bodies, from T2
to T12
• A surgeon might need a thoracic surgeon who can deal with the hazards
of the area
• Indications
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Treatment of infections
Fusion of the vertebral bodies
Resection of the vertebral bodies for tumor and reconstruction with bone grafting
Correction of scoliosis
Correction of kyphosis
Osteotomy of the spine
Anterior spinal cord decompression
Biopsy
Position of the Patient
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Place the patient on his or her
side
stabilizing the patient with a
kidney rest or sandbags
Move the hand and arm on the
side to be approached above the
patient's head or onto an airplane
splint
Place a small pad in the axilla of
the dependent side to avoid
compression of the axillary artery
and vein
Feel for a radial pulse after
positioning; make sure that there
is no venous obstruction in the
arm
The surgeon should be positioned
behind the patient
Landmarks
• tip of the scapula
• spines of the
thoracic vertebrae
• Observe the
inframammary
crease on the
anterior chest wall
Incision
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Begin the incision two
fingerbreadths below the
tip of the scapula and
curve it forward toward the
inframammary crease
Complete the incision by
extending it backward and
upward toward the thoracic
spine
ending at a point halfway
up the medial border of the
scapula and halfway
between the spine and the
scapula
Superficial Surgical
Dissection
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Divide the latissimus dorsi
muscle posteriorly in line
with the skin incision
• Then, divide the serratus
anterior muscle along
the same line, down to
the ribs
• This allows the scapula
to be elevated and
muscles to be cut
proximally to expose the
underlying ribs
• Because the operation is
not performed in an
intermuscular plane,
bleeding is a problem;
cutting cautery
(diathermy) can be used
to control it
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The thoracic cavity can be reached through
– intercostal space
– resection of one or more ribs
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Rib resection
– creates a better exposure
– The cut ribs can be used for bone grafting
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Which level
– Depends on the location of the pathology
– Apex of deformity
– Two levels less ( eg.T9 go through rib 7)
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Which side
– Rt. Safer (away from aortic arch)
• strip all muscular
attachments from the rib
• using a periosteal
elevator or cautery
• resect the posterior
three fourths of the rib
as far posterior as
necessary
Deep Surgical Dissection
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deflate the lung
retract it anteriorly
using moist lap pads to
protect it
Identify the structures
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Oesophagus
Aorta
Azygous vein
Ant. Longitudenal lig.
Segmintal vessels
Anterolateral
(Retroperitoneal) Approach
to the Lumbar Spine
Anterolateral (Retroperitoneal) Approach
to the Lumbar Spine
• provides access to all
vertebrae from L1 to the
sacrum
• allows drainage of an
infection, such as a
psoas abscess
• Lower the risk of a
postoperative ileius
• slightly more difficult to
reach the L5-S1 disc
space
uses of this approach
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Spinal fusion
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Drainage of psoas
abscess of all or part of
a vertebral body
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Instrumentation
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Biopsy of a vertebral
body
Position of the
Patient
• semilateral position
• about a 45° angle to the
horizontal
• facing away from the
surgeon
• Stabilize the patient
• left side up, so that the
“aortic” rather than the
“caval” side is approached.
Landmarks
• Palpate the 12th rib
• pubic symphysis
• lateral border of the
rectus abdominis
Incision
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oblique flank incision
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from the posterior half of
the 12th rib toward the
rectus abdominis muscle
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stopping at its lateral
border
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about midway between the
umbilicus and the pubic
symphysis
• Place a needle into the involved lumbar
vertebra and take a radiograph to identify
the exact location
Anterior (Transperitoneal)
Approach to the Lumbar
Spine
Anterior (Transperitoneal) Approach
to the Lumbar Spine
• reserved for fusing L5 to S1
• fusing L4 to L5
• mobilization of the great vessels
• general surgeon help is appreciated
Position of the Patient
• Supine
• two areas for incision
– Abdominal
– iliac crest bone graft
• Insert
– urinary catheter to
keep the bladder empty
– nasogastric tube,
? ileus
Landmarks
• Umbilicus
– (? opposite the L3-4
disc space)
• pubic symphysis
Incision
• midline longitudinal
• arches around the
umbilicus
Posterior Approach to the
Lumbar Spine
Posterior Approach to the
Lumbar Spine
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the most common approach to the lumbar spine
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providing access to the cauda equina and the
intervertebral discs
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expose the posterior elements of the spine
• Uses
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Excision of herniated discs
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Exploration of nerve roots
Spinal fusion
Removal of tumors
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• Position of the
Patient
• prone position
• On side
– Flex the patient's hips
and knees to flex the
lumbar spine and open
up the interspinous
spaces
• Landmarks
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Spinou sprocesses
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Line drawn between the
highest points on the iliac
crest is in the L4-5
interspace
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To determine the exact
level is use a radiograph
• Incision
• midline longitudinal
incision
• length of the incision
depends on the number
of levels to be explored
Thank you