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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 – – – – 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 – – – – – – 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 – – – – – 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 – – – – – – 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) – – – – 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 14 THORACOABDOMINAL THORACOABDOMINAL 15 THORACOABDOMINAL THORACOABDOMINAL 16 THORACOABDOMINAL THORACOABDOMINAL 17 THORACOABDOMINAL THORACOABDOMINAL 18 THORACOABDOMINAL THORACOABDOMINAL 19 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 20 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 : – – – – 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) • • • • – – – – – 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 26 Flank Retroperitoneal Approach Flank Retroperitoneal Approach Open transversalis fascia from posterior to anterior 27 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 28 Flank Retroperitoneal Approach Flank Retroperitoneal Approach 29 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 30 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 31 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 32 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 33 Flank Retroperitoneal Approach Flank Retroperitoneal Approach • Exposure : – Retract aorta and vena cava to the right (narrow Deaver) – Perform resection • • • • 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 : – – – – 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) – – – – 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 39 Perirectus Retroperitoneal Approach Perirectus Retroperitoneal Approach 40 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 41 Perirectus Retroperitoneal Approach Perirectus Retroperitoneal Approach 42 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 43 ANTERIOR LUMBOSACRAL EXPOSURE EXPOSURE L4 AND L5 Perirectus Retroperitoneal Approach 44 Perirectus Retroperitoneal Approach (Mini-ALIF) • Exposure : – – – – – 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 : – – – – – 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 : – – – – – 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 49 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 – – – – 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 52