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Orthopaedic Anatomy > Spine Approaches > Flashcards

Spine Approaches Flashcards

1
Q

position for posterior approach to the lumbar spine

A

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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2
Q

incision for posterior approach to the lumbar spine

A

ID appropriate spinous process with fluoro

midline incision from level above to level below

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3
Q

internervous plane for posterior approach to the lumbar spine

A

midline between erector spinae - so between the dorsal rami

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4
Q

superficial dissection for posterior approach to the lumbar spine

A

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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5
Q

deep dissection for posterior approach to the lumbar spine

A

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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6
Q

danger for posterior approach to the lumbar spine

A

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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7
Q

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

A

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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8
Q

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

A

superficial = lat. dorsi.

deep = sacrospinalis, multifidus and rotatores

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9
Q

position for transperitoneal approach to the lumbar spine

A

supine

abdomen and iliac crest exposed

catheterize to keep bladder empty

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10
Q

incision for transperitoneal approach to the lumbar spine

A

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

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11
Q

internervous plane for transperitoneal approach to the lumbar spine

A

between abdominal muscles midline

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12
Q

superficial dissection for transperitoneal approach to the lumbar spine

A

fibrous rectus sheath

between abdominal muscles

incise parietal peritoneum

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13
Q

deep dissection for transperitoneal approach to the lumbar spine

A

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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14
Q

danger for transperitoneal approach to the lumbar spine

A

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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15
Q

position for retroperitoneal approach to lumbar spine

A

supine

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16
Q

incision for retroperitoneal approach to lumbar spine

A

midline as with transperitoneal, without splitting the parietal peritoneum

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17
Q

internervous plane for retroperitoneal approach to lumbar spine

A

midline between rectus abdominus muscles

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18
Q

superficial dissection for retroperitoneal approach to lumbar spine

A

rectus fascia

rectus abdominus

blunt dissection inferiorly

fascia of arcuate line divided

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19
Q

deep dissection for retroperitoneal approach to lumbar spine

A

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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20
Q

dangers for retroperitoneal approach to lumbar spine

A

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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21
Q

position for anterolateral approach to lumbar spine

A

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

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22
Q

incision for anterolateral approach to lumbar spine

A

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

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23
Q

internervous plane for anterolateral approach to lumbar spine

A

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

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24
Q

superficial dissection for anterolateral approach to lumbar spine

A

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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25
Q

deep dissection for anterolateral approach to lumbar spine

A

follow psoas medially to reach anerior vertebral body

ligate segmental arteries and veins as needed

ID correct disc with needle and fluoro

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26
Q

dangers for anterolateral approach to lumbar spine

A

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

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27
Q

position for posterior approach to the cervical spine

A

prone

neck in slight flexion

apply tongs and fixed brace

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28
Q

incision for posterior approach to the cervical spine

A

midline, marked at the level of interest with fluoro

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29
Q

internervous plane for posterior approach to the cervical spine

A

midline between paracervical muscles

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30
Q

superficial dissection for posterior approach to the cervical spine

A

cauterize venous plexi

incise nuchal ligament

remove paraspinal muscles subperiosteally

move lateral to expose lamina and facets

31
Q

deep dissection for posterior approach to the cervical spine

A

remove ligamentum flavum from superior edge of lamina

laminectomy

Id dura, vertebral body, disc

control epidural venous bleeding

32
Q

danger for posterior approach to the cervical spine

A

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

33
Q

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

A

superficial = trapezius

intermediate = splenius capitis

deep = semispinalis capitis, semispinalis cervicis, multifidus, short rotators, long rotators

34
Q

position for posterior approach to C1/C2 specifically

A

prone

neck flexed

35
Q

incision for posterior approach to C1/C2 specifically

A

midline from EOP inferiorly for 6-8 cm

36
Q

internervous plane for posterior approach to C1/C2 specifically

A

midline

37
Q

superficial dissection for posterior approach to C1/C2 specifically

A

fascia

nuchal ligament

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

38
Q

deep dissection for posterior approach to C1/C2 specifically

A

remove ligamentum flavum between C1/C2

remove posterior atlanto-occipital ligament

39
Q

danger for posterior approach to C1/C2 specifically

A

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

40
Q

position for anterior approach to the cervical spine

A

supine

roll between shoulder blades

extend neck

turn head away

traction if distraction needed later

30° head elevation

arm at side

41
Q

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

A

C3-T1

42
Q

incision for anterior approach to the cervical spine

A

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

43
Q

anatomical landmark for C2-3

A

jaw line

44
Q

anatomical landmark for C4-5

A

thyroid cartilage

45
Q

anatomical landmark for C6

A

cricoid cartilage

46
Q

internervous plane for anterior approach to the cervical spine

A

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

47
Q

superficial dissection for anterior approach to the cervical spine

A

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

48
Q

deep dissection for anterior approach to the cervical spine

A

split the longus collin midline and retract with ALL laterally

confirm location with needle and fluoro

49
Q

danger for anterior approach to the cervical spine

A

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

50
Q

position for Wiltse approach to the spine

A

prone on wilson or jackson table

51
Q

indications for Wiltse approach to the spine

A

far lateral disc herniation

pars defect

52
Q

internervous plane for Wiltse approach to the spine

A

none. however, intermuscular plane between multifidus and longissimus

53
Q

incision for Wiltse approach to the spine

A

3 cm from midline

54
Q

superficial dissection for Wiltse approach to the spine

A

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

55
Q

deep dissection for Wiltse approach to the spine

A

manually palpate TP

place clamp on TP and confirm level with fluoro

dissect TP above and below

ID pars medially

56
Q

position for posterolateral approach to the thoracic spine

A

prone

bolsters on each side of chest

57
Q

incision for posterolateral approach to the thoracic spine

A

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

58
Q

internervous plane for posterolateral approach to the thoracic spine

A

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

59
Q

superficial dissection for posterolateral approach to the thoracic spine

A

fascial incision

incise trapezius parallel to fibres and close to TPs

cut down to posterior aspect of rib

60
Q

deep dissection for posterolateral approach to the thoracic spine

A

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

61
Q

danger for posterolateral approach to the thoracic spine

A

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

62
Q

position for anterior approach to thoracic spine

A

lateral

arms above head

R sided approach is usually easier (no aorta)

63
Q

incisionfor anterior approach to thoracic spine

A

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

64
Q

superficial dissection for anterior approach to thoracic spine

A

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

65
Q

deep dissection for anterior approach to thoracic spine

A

deflate lung and retract anteriorly

incise pleura over esophagus and retract

may ligate 1 intercostal artery if needed

approach from R side

66
Q

danger for anterior approach to thoracic spine

A

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

67
Q

position for posterior approach in scoliosis

A

prone

on knees

bolsters for chest

abdomen clear

68
Q

incision for posterior approach in scoliosis

A

use C7/T1 and gluteal cleft as a midline guide

69
Q

internervous plane for posterior approach in scoliosis

A

midline

70
Q

superficial dissection for posterior approach in scoliosis

A

fascia

split transverse processes

dissect muscle subperiosteally

71
Q

deep dissection for posterior approach in scoliosis

A

continue muscle dissection along lamina

remove short rotators with cobb

remove muscle to TPs

72
Q

dangers for posterior approach in scoliosis

A

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

73
Q
A

Orthopaedic Anatomy (15 decks)

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