Spine Approaches Flashcards by Franz Biehl

position for posterior approach to the lumbar spine

prone

shoulders forward flexed and abducted to unload brachial plexus

abdomen free to allow venous plexus drainage

pad ulner nerves at elbows

pad median nerves at wrists

head and neck neutral

no eye pressure

hips slightly flexed if decompressing, extended if fusing

knees flexed

pad peroneal nerves at knees

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incision for posterior approach to the lumbar spine

ID appropriate spinous process with fluoro

midline incision from level above to level below

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internervous plane for posterior approach to the lumbar spine

midline between erector spinae - so between the dorsal rami

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superficial dissection for posterior approach to the lumbar spine

incise lumbodorsal fascia

detach paraspinal muscles subperiosteally as one unit

dissect down along lamina to facet joints

continue lateral to strip facet capsule medial (descending part) to lateral (ascending part) of facet joint

can go up and over the lateral part (ascending) facet joint to the TP

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deep dissection for posterior approach to the lumbar spine

incise ligamentum flavum along superior edge of lamina

blunt dissection down lateral to dura to floor of spinal canal while retracting cord and nerve root medially

remove inferior aspect of lamina with rongeur

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danger for posterior approach to the lumbar spine

1) segmental arteries between TPs near facet joints
2) dorsal rami between TPs near facet joints
3) ID nerve roots individually
4) venous plexi around nerves and on floor of canal
5) iliac vessels anterior to vertebral body if you puncture annulus fibrosis

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how is the minimal access posterior approach to the lumbar spine different? i.e. what are the technical difficulties?

first of all, the approach is the same regarding superficial and deep dissection. However:

1) meticulous positioning key - too medial and spinous processes are in the way; too angled and you can’t target the microscope
2) need fluoro to be exact positioning
3) hemostasis very important

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which muscles might you encounter during posterior approach to the lumbar spine?

superficial = lat. dorsi.

deep = sacrospinalis, multifidus and rotatores

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position for transperitoneal approach to the lumbar spine

supine

abdomen and iliac crest exposed

catheterize to keep bladder empty

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incision for transperitoneal approach to the lumbar spine

just below umbilicus to just above symphysis vertically. extend superiorly by curving L around umbilicus

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internervous plane for transperitoneal approach to the lumbar spine

between abdominal muscles midline

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superficial dissection for transperitoneal approach to the lumbar spine

fibrous rectus sheath

between abdominal muscles

incise parietal peritoneum

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deep dissection for transperitoneal approach to the lumbar spine

trendelenberg the table

retract uterus with 0 silk tie

ID presacral nerve plexi (parasympathetic)

incise peritoneum over midline sacral promontory

ligate sacral artery

access L5-S1 disc for discectomy and fusion

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danger for transperitoneal approach to the lumbar spine

1) presacral nerve plexi - can use retroperitoneal saline injection to assist
2) midline sacral artery
3) lumbar vessels carefully dissectedand ligated to access great vessels
4) ureters must be mobilized laterally

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position for retroperitoneal approach to lumbar spine

supine

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incision for retroperitoneal approach to lumbar spine

midline as with transperitoneal, without splitting the parietal peritoneum

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internervous plane for retroperitoneal approach to lumbar spine

midline between rectus abdominus muscles

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superficial dissection for retroperitoneal approach to lumbar spine

rectus fascia

rectus abdominus

blunt dissection inferiorly

fascia of arcuate line divided

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deep dissection for retroperitoneal approach to lumbar spine

blunt dissection toward LLQ - you will encounter retroperitoneal fat, then psoas.

ID genitofemoral nerve

ID ureter on the underside of peritoneum and mobilize medially with peritoneum

ligate sacral veins

dissect proximal to iliac vessels

plane is between iliac vessels and psoas

ligate ascending iliolumbar vein

retract iliac veins

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dangers for retroperitoneal approach to lumbar spine

1) presacral nerve plexus should mobilize medial with peritoneum
2) ureters should mobilize medial with peritoneum
3) sympathetic chain on lateral vertebral body
4) segmental arteries and veins if you go above L5

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position for anterolateral approach to lumbar spine

semi-lateral on preferred side (aortic approach or caval approach)

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incision for anterolateral approach to lumbar spine

oblique from posterior half of 12th rib toward rectus abdominus stopping at its lateral border midway between umbilicus and symphysis

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internervous plane for anterolateral approach to lumbar spine

none, however, because external oblique, internal oblique and transverse abdominus are all innervated segmentally, little denervation occurs

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superficial dissection for anterolateral approach to lumbar spine

aponeurosis of external oblique parallel to fibres

muscle fibres of internal oblique perpendicularly

divide transverse abdominus in line with incision

ID peritoneum and retroperitoneal fat

blunt dissection of plane between retroperitoneal fat and psoas

retract peritoneum medially

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deep dissection for anterolateral approach to lumbar spine

follow psoas medially to reach anerior vertebral body ligate segmental arteries and veins as needed ID correct disc with needle and fluoro

dangers for anterolateral approach to lumbar spine

1) sympathetic chain on lateral vertebral body wall 2) genitofemoral nerve on anteromedial surface of psoas 3) segmental arteries and veins (must tie off) 4) vena cava if approaching from R side 5) ureter - retract with peritoneum

position for posterior approach to the cervical spine

prone neck in slight flexion apply tongs and fixed brace

incision for posterior approach to the cervical spine

midline, marked at the level of interest with fluoro

internervous plane for posterior approach to the cervical spine

midline between paracervical muscles

superficial dissection for posterior approach to the cervical spine

cauterize venous plexi incise nuchal ligament remove paraspinal muscles subperiosteally move lateral to expose lamina and facets

deep dissection for posterior approach to the cervical spine

remove ligamentum flavum from superior edge of lamina laminectomy Id dura, vertebral body, disc control epidural venous bleeding

danger for posterior approach to the cervical spine

1) don't traction cord 2) venous plexus bleeding around cord 3) do not enter transverse foramen 4) 3rd occipital nerve lateral to skin incision

which muscles might you encounter during posterior approach to the cervical spine?

superficial = trapezius intermediate = splenius capitis deep = semispinalis capitis, semispinalis cervicis, multifidus, short rotators, long rotators

position for posterior approach to C1/C2 specifically

prone neck flexed

incision for posterior approach to C1/C2 specifically

midline from EOP inferiorly for 6-8 cm

internervous plane for posterior approach to C1/C2 specifically

midline

superficial dissection for posterior approach to C1/C2 specifically

fascia nuchal ligament strip subperiosteally from spinous processes of C2/3 and tubercle of C1 and EOP

deep dissection for posterior approach to C1/C2 specifically

remove ligamentum flavum between C1/C2 remove posterior atlanto-occipital ligament

danger for posterior approach to C1/C2 specifically

1) do not retract cord near C1/2! 2) C2 and C3 occipital nerves are lateral to this field 3) vertebral artery crosses the field superior to C1

position for anterior approach to the cervical spine

supine roll between shoulder blades extend neck turn head away traction if distraction needed later 30° head elevation arm at side

which vertebrae can you access with anterior approach to C-spine?

C3-T1

incision for anterior approach to the cervical spine

oblique from midline at the level of interest to the lateral edge of SCM

anatomical landmark for C2-3

jaw line

anatomical landmark for C4-5

thyroid cartilage

anatomical landmark for C6

cricoid cartilage

internervous plane for anterior approach to the cervical spine

none superficial, however, between SCM and neck strap muscles intermediate and between R and L longus colli muscles deep

superficial dissection for anterior approach to the cervical spine

fascia platysma split longitudinally with fingers fascia immediately anterior to SCM retract SCM laterally retract sternohyoid, sternothyroid and trachea medially develop plane beteen medial edge of carotid sheath and midline structures incise pretracheal fascia retract sheath laterally ligate inferior and superior thyroid arteries if going above C3/4 develop plane posterior to esophagus

deep dissection for anterior approach to the cervical spine

split the longus collin midline and retract with ALL laterally confirm location with needle and fluoro

danger for anterior approach to the cervical spine

1) protect recurrent laryngeal nerve by placing retractors medial to longus colli 2) avoid sympathetic chain by subperiosteal midline dissection 3) avoid dissecting out to TP 4) avoid self-retainers near carotid sheath 5) take care not to lose the inferior thyroid artery behind the carotid sheath 6) do not extend this approach

position for Wiltse approach to the spine

prone on wilson or jackson table

indications for Wiltse approach to the spine

far lateral disc herniation pars defect

internervous plane for Wiltse approach to the spine

none. however, intermuscular plane between multifidus and longissimus

incision for Wiltse approach to the spine

3 cm from midline

superficial dissection for Wiltse approach to the spine

find the plane between multifidus and longissimus and develop with blunt dissection

deep dissection for Wiltse approach to the spine

manually palpate TP place clamp on TP and confirm level with fluoro dissect TP above and below ID pars medially

position for posterolateral approach to the thoracic spine

prone bolsters on each side of chest

incision for posterolateral approach to the thoracic spine

curved linear 8 cm lateral to and centered over the level of pathology, 10-13 cm long

internervous plane for posterolateral approach to the thoracic spine

non. split trapezius (innervated superiorly) and paraspinal muscles (innervated segmentally)

superficial dissection for posterolateral approach to the thoracic spine

fascial incision incise trapezius parallel to fibres and close to TPs cut down to posterior aspect of rib

deep dissection for posterolateral approach to the thoracic spine

remove all muscle attachments from rib subperiosteally dissect laterally on superior border dissect medially on inferior border divide rib 6-8 cm from midline lift and cut costo-transverse ligament remove rib remove muscle from TP remove TP with rongeur carefully enter retroperitoneal space with blunt dissection to expose vertebral body and disc

danger for posterolateral approach to the thoracic spine

1) intercostal arteries often damaged - this is okay, but bleeding must be controlled with ties 2) if dissection is too intensive you can enter the central canal 3) pleural tears require chest tubes

position for anterior approach to thoracic spine

lateral arms above head R sided approach is usually easier (no aorta)

incisionfor anterior approach to thoracic spine

2 cm below tip of scapula curving forward toward inframammary crease. complete the posterior part by curving rostral to a point half-way up scapula and midway between scapula and SPs

superficial dissection for anterior approach to thoracic spine

divide lat dorsi along skin incision divide serratus anterior use 5th intercostal space for T2-9 use 6th intercostal space for T10-12 cut down to periosteum then dissect subperiosteally resect posterior 3/4 of rib insert rib spreader and give time for paraspinal muscles to relax

deep dissection for anterior approach to thoracic spine

deflate lung and retract anteriorly incise pleura over esophagus and retract may ligate 1 intercostal artery if needed approach from R side

danger for anterior approach to thoracic spine

1) intercostal arteries are vulnerable at 2 points: during rib resetion and vertebral body approach 2) expand the lungs every 30 min

position for posterior approach in scoliosis

prone on knees bolsters for chest abdomen clear

incision for posterior approach in scoliosis

use C7/T1 and gluteal cleft as a midline guide

internervous plane for posterior approach in scoliosis

midline

superficial dissection for posterior approach in scoliosis

fascia split transverse processes dissect muscle subperiosteally

deep dissection for posterior approach in scoliosis

continue muscle dissection along lamina remove short rotators with cobb remove muscle to TPs

dangers for posterior approach in scoliosis

1) posterior rami emerge between TPs 2) segmental arteries emerge between TPs