Download Surgical Exposures of the Thoracic and Lumbar Spine

Surgical Exposures of the
Thoracic and Lumbar Spine
Cleveland Spine Review
Hands-On 2013
Marc E. Eichler, MD, FACS
Exposures of the Thoraco-Lumbar Spine
• Exposure of Cervico-thoracic spine (C7 – T2)
– 3rd rib thoracotomy
– Lateral parascapular
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Supraclavicular
Transaxillary
Transmanubrial
Transsternal
• Exposure of thoracic and thoraco-lumbar spine
(T1 – L5)
1
Lateral Parascapular Approach
(Extrapleural)
• Indications :
– Ventrolateral exposure of T1-5
• Instrument / fuse across the C-T jxn
– Variation of lateral Extracavitary
approach
– Anterior and posterior fixation
• Positioning :
– Prone on jackson table (or chest rolls
with ipsilateral roll medial)
• Incision :
– Midline incision beginning 3 segments
above pathology and ending 3
segments below
– Curve caudal incision to side of
approach (beneath scapula)
Lateral Parascapular Approach
(Extrapleural)
• Exposure :
– Incision is carried caudally through
trapezius and rhomboid muscles (loose
areolar plane between rhomboids and
erector spinae muscles)
– Myocutaneous flap is reflected laterally
along with the medial border of the scapula
(lateral incision of cuadal trapezius fibers
required but leave a cuff)
– Dissect deep thoracic fascia covering the
paraspinal muscles (erector spinae and
splenius muscles)
2
Lateral Parascapular Approach
(Extrapleural)
• Exposure :
– Dissect paraspinal muscles from spinous processes
and dorsal elements and retract the muscle mass
medially exposing dorsal rib cage, T-piece, facets,
laminae
– Subperiosteal rib dissection (Cobb, Doyen, Alexander)
– Protect neurovascular bundle beneath each rib
– Cut rib just distal to costovertebral tip and at posterior
axillary line
– Incise costotransverse and costovertebral ligament
(scalpel) and remove rib head
– Follow intercostal nerve back to foramen
– Mobilize sympathetic chain ventrally
– Do not sacrifice 1st thoracic intercostal (need to sacrifice
intercostals for corpectomy)
Lateral Parascapular Approach
(Extrapleural)
• Exposure :
– Can remove laminae / pedicle / T-piece first
to identify cord
– Preserve PLL till end if possible
– Place graft / instrumentation
3
Lateral Parascapular Approach
(Extrapleural)
• Exposure :
– Before closure check for an air leak
– Reapproximate transverse cut through trapezius /
rhomboid
• Complications :
– Neural injury
– Pleural air leak / Shoulder pain and dysfunction
• Disadvantages :
– Poor visualization across midline
– Difficult to place ventrolateral hardware
Thoracic and Thoracolumbar Spine Exposures
( T1 – L5 )
• Ventral
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Proximal Thoracotomy ( T1 – T4 ) - 3rd rib thoracotomy
Transthoracic Approach ( T5 – T10 )
Retropleural Thoracotomy (T5-10)
Thoracoabdominal approach ( T10 – L4 )
Retroperitoneal approach ( T12 – L4 )
Trans-peritoneal approach ( L5 – S1 )
• Dorsolateral
– Lateral Parascapular ( T1 – T5 )
– Lateral Extracavitary ( T5 – L5 )
– Costotravsversectomy ( T5 – L5 )
• Dorsal
– Dorsal Midline ( T1 – L5 )
– Transpedicular ( T1 – L5 )
– Transfacet Pedicle Sparing ( T1 – L5 )
4
Proximal Thoracotomy Approach
(Transthoracic Third Rib)
• Indications :
– Ventral pathology from T1-4
• Reach contralateral ventral path > lat parascap (but no post
instrumentation)
• Lower exposure and less “real-estate” than transaxillary / “see
cord 1st” unlike transsternal
• Positioning :
– Left lateral decubitus / Axillary roll
– Right arm in lateral arm rest (more extended than lower
thoracotomy)
• Incision :
– Incision from the right lateral paraspinous muscle area
at T4-5 along the medial caudal border of the scapula and
anterior to the costal cartillage of the fourth or fifth rib
Proximal Thoracotomy Approach
(Transthoracic Third Rib)
• Exposure :
– Incise trapezius and latissimus
dorsi muscles in line with the
incision
– Rib cage can be palpated and
retract the scapula by
sectioning parts of the
rhomboid major and serratus
anterior (do not completely
transect the serratus anterior
muscle)
– Palpate third rib (by counting
down)
• First rib often under second rib
5
Proximal Thoracotomy Approach
(Transthoracic Third Rib)
• Exposure :
– Dissect periosteum off of third rib
from posterior angle to the costal
margin – inferior rib go ant to post
(Doyen, Alexander, Cobb)
– Section rib (protect intercostal
artery / vein / nerve) (ant to post)
– Deflate lung / open rib bed
(periosteum, EF, PP)
– Rib spreader placed after
protecting the lung (Fin. / Tuf.)
– Identify disc space
Proximal Thoracotomy Approach
(Transthoracic Third Rib)
• Exposure :
– Incise parietal pleura (over disc space) and
identify segmentals over valley of vertebrae
– Ligate segmentals mid-body
– Perform corpectomy / fusion and instrument
Closure
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Close parital pleura if possible
Place CT (8-9th intercostal space) – 28F – 32F
Use rib approximator and #1 prolene
Close rib bed with prolene
Expand lung last (protect with malleable)
6
Proximal Thoracotomy Approach
(Transthoracic Third Rib)
• Complications :
– Lung injury (air leak)
– Esophageal / trachea / thoracic duct / subclavian
artery injury (arch caudal to T4)
– Tear of highest intercostal vein
– Other vessel injury (brachiocephalic vein)
– Scapula dysfunction 2o to rhomboid dissection
• Disadvantages
– Unfamiliar anatomy otherwise great exposure of
T1-4
•
Thoracic and Thoracolumbar Spine
Exposures ( T5 – L5 )
Ventral
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Transthoracic Approach ( T5-10 )
Retropleural Thoracotomy (T5-10)
Thoracoabdominal approach ( T10 – L4 )
Retroperitoneal approach ( T12 – L4 )
Perirectus retroperitoneal (mini-ALIF) approach (L2-3 – L5-S1)
Trans-peritoneal approach (L5 – S1)
• Dorsolateral
– Lateral Extracavitary ( T5 – L5 )
– Costotravsversectomy (T5 – L5)
• Dorsal
– Dorsal Midline ( T1 – L5 )
– Transpedicular ( T1 – L5 )
– Transfacet ( T1 – L5 )
7
Transthoracic Approach ( T5-10 )
• Indications :
– Ventral pathology from T5-10
– No posterior instrumentation
• Positioning :
– Lateral decubitus position ( bean bag
/ axillary roll / lateral arm board) with
approach from side of pathology/
convexity of scoliosis / or left if =
– Full 90o for orientation
– Does Adamkiewicz matter ?
(minimize consecutive segmentals
sacrificed / maintain anastomotic
arcade at foramen)
Transthoracic Approach ( T5-10 )
• Incision :
– For midthoracic vertebrae incise 1-2 rib levels
above the vertebral level of pathology (can use
AP film midaxillary but if deformity use
flouro)
– Discectomy can just remove rib that leads to
that level (T8-9 level remove 9th rib)
– Easier for exposure if too cranial not caudal
– Linear incision (count and confirm with flouro)
along rib extending from costochondral
junction to rib angle (post axillary line)
8
Transthoracic Approach ( T5-10 )
• Exposure :
– Dissect through trapezius, latissimus dorsi,
serratus anterior and posterior (lower Tspine only transect latissimus dorsi and
serratus posterior)
– Confirm correct rib and score the
periosteum with the bovie
– Elevate periosteum with Cobb / Alexander
/ Doyen (inferior rib go ant to post)
– Disarticulate the rib from the costochondral
jxn and cut the rib at its dorsal angle
Transthoracic Approach ( T5-10 )
• Exposure :
– Deflate the lung and open the rib bed
(periosteum and underlying endothoracic
fascia and parietal pleura)
– Use blunt dissection (sponge stick) for any
pleural adhesions
– Pack off the lung with lap sponge and place
rib spreader (Finochetto)
– Place self retaining retractor (ThompsonFarley / Synframe etc..)
9
Transthoracic Approach ( T5-10 )
• Exposure :
– Identify disc spaces first (convex)
and midvertebrae (concave)
– Confirm level
– Blade between ALL and aorta / vena
cava during corpectomy
– Open the parietal pleura (near disc
space)
– Ligate segmentals
– Identify pedicle
– Perform discectomy / corpectomy
Transthoracic Approach ( T5-10 )
• Exposure :
– Close parietal pleura if possible (cover ventral
instrumentation ?)
– Place two chest tubes 2-3 costal levels below
incision (apical and lung base)
• Ant. at midaxillary (avoid post. axillary)
– Reapproximate ribs (prolene) and close rib bed
– Before rib bed closure inflate lung
10
Transthoracic Approach ( T5-10 )
• Complications :
– Vessel injury
– Pulmonary compromise (pnuemonia
/ effusions etc..)
– Post thoracotomy pain syndrome
Disadvantages :
– Unable to instrument posteriorly
– Debilitating in elderly patients
Thoraco-abdominal Approach
(T10 – L1)
• Indications :
– Ventral pathology T10 – L1 requiring
decompression / fusion / stabilization
• Tumors
• Trauma
• Infections
– Position :
• Lateral decubitus (retroperitoneal)
– Right side vena cava / liver
– Left only spleen
– Scoliosis (convexity)
11
Thoraco-abdominal Approach
(T10 – L1)
• Incision :
– Start at lateral border of paraspinous
muscle over tenth rib
– Incise skin anteriorly over tenth rib
to junction of tenth rib and costal
cartillage
– Then curve incision from the tip of
the tenth rib to the lateral rectus
sheath and as far distally as needed
Thoraco-abdominal Approach
(T10 – L1)
• Exposure :
Extend incision deep through muscle layers to periosteum of 10th rib
Remove rib from ventral angle to costal cartillage
Split the costal cartillage of 10th rib (using knife)
Retract tips and identify diaphragm insertion onto cephalad cartillage and
abdominal musculature onto the caudal cartillage tip
– Bluntly dissect beneath caudal tip and identify retroperitoneal fat
– Bluntly dissect peritoneum off of the undersurface of the diaphragm
– Retract the peritoneum and open the musculature as you would for a
standard retroperitoneal approach (ext / int oblique and transversalis
fascia in line with the skin incision)
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12
Thoraco-abdominal Approach
Thoraco-abdominal Approach
13
Thoraco-abdominal Approach
(T10 – L1)
• Exposure :
– You can see the retroperitoneal space and the intrapleural cavity with the
intervening diaphragm
– Incise the diaphragm from inside the chest visualizing under the
diaphragm in the retroperitoneal space
– Incise the diaphragm around its periphery (approx. 1 inch from its periph.
attachment to the chest wall - avoid innervation) but leave a cuff around
its peripheral attachment to the chest wall for re-approximation (you
must remove the insertion of the diaphragm on the spine – the crus at T12
– L1)
– Mark the diaphragm with alternating sutures
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THORACOABDOMINAL
THORACOABDOMINAL
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THORACOABDOMINAL
THORACOABDOMINAL
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THORACOABDOMINAL
THORACOABDOMINAL
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THORACOABDOMINAL
THORACOABDOMINAL
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THORACOABDOMINAL
THORACOABDOMINAL
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Thoraco-abdominal Approach
(T10 – L1)
• Exposure :
– Close the diaphragm with running prolene and re-approximate the
costal cartillage (cranial tip has the insertion of the diaphragm and
caudal piece has the insertion of the transversalis fascia)
– Place a drain in the retroperitoneal space and chest tubes x 2
(apical and base via 7th or 8th intercostal space)
– Close the rib bed after re-approximating the ribs
– Close the abdominal and chest wall fascial / muscular layers in
standard fashion
THORACOABDOMINAL
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THORACOABDOMINAL
Man that Rich Schlenk
sure is a sexy guy
Retropleural Thoracotomy ( T5-10 )
(Can extend across diaphragm T5-L5)
• Indications :
– Ventral pathology over only 1-2 levels
(HNP / 1 - 2 level corpectomy)
• Incision and Exposure
– Initially similar to thoracotomy (if use
smaller incision difficult to instrument)
• After rib removal (not head) open
only the rib bed periosteum and
endothoracic fascia
21
Retropleural Thoracotomy ( T5-10 )
• Exposure :
– Blunt pleural dissection ( kitner / “peanut”)
– Complete removal of rib head after lung retraction
– Can follow intercostal nerve to foramen
Retropleural Thoracotomy ( T5-10 )
• Exposure :
– Identify segmentals and
ligate if necessary
– Perform discectomy /
corpectomy
– Evaluate for air leak before
closure
– Close rib bed
(endothoracic fascia)
22
Retropleural Thoracotomy
• Can be combined with retroperitoneal approach to
spare diaphragm
• Costodiaphragmatic recess cleared of pleura
• Sharp dissection of diaphragm from 11th and 12th
ribs allows communication of retropleural and
retroperitoneal spaces
• Diaphragm detached from underlying muscles
• Cuff of attachment L1 transverse process preserved
for closure of crus
Retropleural Thoracotomy
• Division of crus completes communication
• Iliopsoas and segmentals dissected
• Closure requires suturing diaphragm to psoas,
transverse processes, quadratus lumborum, and
costal cuff
23
Retropleural Thoracotomy ( T5-10 )
• Complications :
– Reduced pulmonary morbidity compared to thoracotomy
approach
– Similar neurologic risks
– Post thoracotomy pain syndrome similar to standard
thoracotomy
• Disadvantages :
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Levels exposed limited
More difficult to place ventrolateral fixation
No posterior instrumentation
Difficult “reapproximation”
Flank Retroperitoneal Approach
(L1 – L5)
• Indications :
– Ventrolateral pathology and/or deformity from L1 – L5
(? instrumentation L5)
• Scoliosis, fractures, tumors, infection
– Easy anterior instrumentation
– Less morbid than trans-peritoneal approach (less vessel
mobilization / previous intra-peritoneal surgery)
24
Flank Retroperitoneal Approach
• Positioning :
– Lateral decubitus position (left versus right)
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•
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Pathology
Vessels
Scoliosis - convexity
Left preferable
Radio-opaque bean bag (short bag)
Position over table break (12th rib and crest)
Axillary pad / Peroneal nerve
Flex ipsilateral hip
Surgeon anterior to patient
Flank Retroperitoneal Approach
• Incision :
– Equidistant between lowest rib and
superior iliac crest in oblique manner
starting at midaxillary line and extend
it proximally to edge of rectus sheath
(1-2 finger breadths below last rib)
• Incision varies according to level
(smaller incisions possible)
• Incision over T12 (T12 exposure for
L1)
25
Flank Retroperitoneal Approach
• Exposure :
– Incise fascia of external oblique
– External oblique opened in line of incision (fibers run posterior
to anterior)
– Internal oblique (perpendicular fibers)
– Transversus abdominis (often thin or absent) is opened in line
with incision (fibers in line with ext oblique)
– Transversalis fascia (open posterior to anterior)
– Retroperitoneal space (identify peritoneum and retroperitoneal
fat)
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
Flank Retroperitoneal Approach
Open transversalis
fascia from posterior to
anterior
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Flank Retroperitoneal Approach
• Exposure :
– After opening transversalis fascia posteriorly
dissect rest of peritoneum from under surface of
transversalis fascia to edge of rectus sheath
(kittner / sponge). Then open rest of transversalis
fascia
– Retract peritoneum ventrally (hand with lap
sponge)
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
• Exposure :
– Identify psoas muscle (avoid retropsoas
space)
– Genitofemoral nerve
– Palpate “the big four” (psoas, intervertebral
disc, vertebral body, aorta)
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
• Exposure :
– Sympathetic chain
– Ureter (usually reflected medially with peritoneum)
– Malleable or Deaver with moistened lap. for padding
(Thompson-Farley and Tuffier)
– Tilt OR table
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
Flank Retroperitoneal Approach
• Exposure :
– Mobilize psoas from ventral edge and at level of disc
space (kittner)
– Do not split psoas (iliohypogastric, ilioingiunal,
genitofemoral, lateral femoral cutaneous)
– Retract psoas posteriorly (identify pedicle)
– “Hills” (discs) versus “Valleys” (body)
• Vessels in valleys
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Flank Retroperitoneal Approach
• Exposure :
– Early identification of iliolumbar vein if
exposing L4-5 to the left of the left common
iliac and vena cava (crosses L5 and is a
horizontal tether)
– Work from L4-5 disc space down to L5 to
identify
– Ligate as far distal to vena cava as possible
– Left to right “sweeping” of aorta and vena cava
(kittner)
– Identify segmentals (if possible)
– Minimum of electrocautery
Flank Retroperitoneal Approach
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Flank Retroperitoneal Approach
Flank Retroperitoneal Approach
• Exposure :
– Retract aorta and vena cava to the right (narrow Deaver)
– Perform resection
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•
•
Partial dissectomies
Oscillating saw / osteotome
Long rongeurs
Down biting curettes / Karlin
– Closure
• Place drain / check peritoneum before closing
• Close transversalis fascia with prolene
• Close each fascial / muscle layer (int and ext oblique muscle / fascia)
34
Flank Retroperitoneal Approach
Flank Retroperitoneal Approach
• Complications :
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Bowel injury (viscera)
Renal, ureteral, great vessel injury
DVT
Prolonged Ileus
35
Flank Retroperitoneal Approach
• Disadvantages :
– Less familiar approach
– Posterior decompression (instrumentation) requires a
second “procedure”
– Beware of abnormal anatomy (tumors)
– Can be difficult to instrument L1 and L5
– May provide limited access to L5 and L5-S1 disc space
(lateral crossing of iliac vessels)
– Difficult to deal with bilateral pathology
Perirectus Retroperitoneal Approach
(Mini-ALIF L2-3 – L5-S1)
• Indications :
– Degenerative disc disease (lumbar)
• One or two levels (? three)
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–
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Selected cases of spondylolisthesis
Spinal infections
Correction of deformity (anterior release)
Some vertebral fractures (much easier via flank
retroperitoneal approach except at L5)
36
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Position :
– Supine
– Kidney rest at level of iliac crest
– Pre-op flouroscopy (AP)
Perirectus Retroperitoneal Approach
37
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Incision :
– Rule of thirds
– Intra-op flouroscopy
– Transverse incision
(one or two levels)
• Midline to just beyond lateral border
of rectus muscle
– Oblique incision
(two or three levels or obese patient)
• the “Wisconsin” incision
• Start 2-3 cm from midline
Rectus sheath composed of:
•Aponeurosis of ext. obl. / int.
oblique / transversus abdominus
•Below umbilicus all three
aponeuroses lie superficial to
the rectus muscle
Above Umbilicus
Below Umbilicus
38
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Exposure :
– Dissect to rectus sheath
– Divide rectus sheath transversely
– Separate rectus abdominis muscle from sheath
(kittner)
– Retract rectus abdominis medially (laterally)
– Identify and incise the transversalis fascia
– Joins peritoneum at arcuate line
Perirectus Retroperitoneal Approach
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Perirectus Retroperitoneal Approach
Perirectus Retroperitoneal Approach
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Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Exposure :
– Dissect peritoneum off undersurface of transversalis
fascia laterally (kittner)
– Primarily repair any peritoneal tears (beware of
bowel)
– Open rest of transversalis fascia
– Retract peritoneum medially (left ureter usually with
peritoneum)
Perirectus Retroperitoneal Approach
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Perirectus Retroperitoneal Approach
Perirectus Retroperitoneal Approach
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Perirectus Retroperitoneal Approach
Exposure
• Identify iliopsoas muscle as continue lateral dissection
(genitofemoral nerve)
• Palpate disc space / Vertebral body
• Confirm level (flouroscopy)
• L4-L5 use kittner to develop plane lateral to iliac vessels (northsouth)
• Identify iliolumbar vein (usually off left common iliac but may
arise from vena cava)
• Once iliolumbar vein ligated (distal) retract vessels to right (vena
cava / aorta)
• ? Need to ligate segmentals for retraction
Perirectus Retroperitoneal Approach
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ANTERIOR LUMBOSACRAL EXPOSURE
EXPOSURE L4 AND L5
Perirectus Retroperitoneal Approach
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Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Exposure :
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At L5-S1 work between iliacs
Retract right iliac vessel to the right (narrow Deever)
Seldom need left retraction
Ligate middle sacral vessels
Gently dissect soft tissue off disc (kittner not
electrocautery)
superior hypogastric plexus
ANTERIOR LUMBOSACRAL EXPOSURE
EXPOSURE L5 AND S1
45
Perirectus Retroperitoneal Approach
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Discectomy :
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–
–
–
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Perform annulotomy with #15 blade (“sawing motion)
Move scalpel away from vessels at L5-S1
Endplate elevators
Rongeurs
Graft placement
46
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Exposure :
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–
–
–
–
Place drain in retroperitoneal space
Inspect peritoneum on closure
Close transversalis fascia with prolene
If rectus sheath was incised close with prolene
Close other layers (int and ext oblique muscle / fascia)
Perirectus Retroperitoneal Approach
• Complications :
(Mini-ALIF)
– Gastrointestinal
•
•
•
•
Ileus
Bowel perforation
Adhesions
Hernia
– Vascular injury (remove retractors slowly)
•
•
•
•
•
Aorta
Vena cava
Iliac vessels
Iliolumbar vein
Plaque embolization
47
Perirectus Retroperitoneal Approach
(Mini-ALIF)
• Complications :
– Neural injury (beware of tumors)
•
•
•
•
Superior hypogastric plexus
Lumbosacral plexus
Root
Cauda equina / conus (disc space height / flouroscopy)
– Ureteral injury
– Fusion failure / hardware failure
– Graft dislodgement
Mini - ALIF
48
Trans-peritoneal Approach
(L4 – S1)
• Indications :
– Ventral mass at L5 – S1 (? L4) requiring decompression
and fusion / fixation
• Tumor
• Infection
• Trauma
– Position :
• Supine (with kidney roll for extension)
Trans-peritoneal Approach
(L4 – S1)
• Incision :
– Pfannenstiel incision (transverse smile incision)
• Exposure :
– Incise anterior rectus sheath, rectus muscle, and posterior
rectus sheath / abdominal fascia
– Open peritoneum (after insuring no bowel is adhered) the
length of the incision
– Pack off the bowel with lap sponges (sigmoid colon caudally
and small bowel superiorly – trendelenberg)
– Retract with deavers
– Identify posterior peritoneum over the sacral promontory
– Palpate aorta and both iliac vessels and feel the L5 – S1 disc
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Trans-peritoneal Approach
(L4 – S1)
• Exposure :
– Inject retroperitoneum with saline – the presacral peritoneum
(separates peritoneum from vessels) between bifurcation of iliacs
– Open the posterior peritoneum (ureter !!!)
– Avoid left common iliac vein which is often crossing over the L5 – S1
space
– Blunt dissection across the disc space
– Free up the bifurcation (vein / artery) and bluntly extend dissection
superiorly to expose L5
– Ligate the middle sacral vessels
– Avoid cautery (hypogastric plexus)
50
Trans-peritoneal Approach
(L4 – S1)
• Exposure :
– Close peritoneum and all fascial layers (posterior and anterior rectus sheath)
• Complications :
– Bowel / Ureter / Vessel injury
– Superior hypogastric plexus injury (males)
– Neurologic injury
• Disadvantages
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Rarely used approach
Very difficult if previous surgery
Better approaches available if above L5
Prolonged ileus
51
Conclusions
• Excellent dorsal and ventral exposures for pathology from C7
to S1
• Choose approach “according to patients pathology”
– Do not let your lack of “armamentarium” determine approach
– Anterior pathology is often handled best anteriorly
• Utilize chest, vascular, and general surgeons as needed but be
familiar with each approach so as to prevent “poor exposure”
by other surgeons
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