1. Surgical approaches to the spine
ABDULMONEM ALSIDDIKY, MD,SSCO
Assistant professor ,consultant
Pediatric ortho. &ped. spine
RIYADH,SAUDI ARABIA

2. 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

3. Anterior (Transthoracic) Approach to the Thoracic Spine

4. 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
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

5. Position of the Patient
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

6. Landmarks
tip of the scapula
spines of the thoracic vertebrae
Observe the inframammary crease on the anterior chest wall

7. Incision
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

8. Superficial Surgical Dissection
Divide the latissimus dorsi muscle posteriorly in line with the skin incision

9. 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

10. Because the operation is not performed in an intermuscular plane, bleeding is a problem; cutting cautery (diathermy) can be used to control it

11. The thoracic cavity can be reached through
intercostal space
resection of one or more ribs
Rib resection
creates a better exposure
The cut ribs can be used for bone grafting
Which level
Depends on the location of the pathology
Apex of deformity
Two levels less (eg.T9 go through rib 7)
Which side
Rt. Safer (away from aortic arch)

12. 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

14. Deep Surgical Dissection
deflate the lung
retract it anteriorly
using moist lap pads to protect it
Identify the structures
Oesophagus
Aorta
Azygous vein
Ant. Longitudenal lig.
Segmintal vessels

17. Anterolateral (Retroperitoneal) Approach to the Lumbar Spine

18. 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

19. uses of this approach
Spinal fusion
Drainage of psoas abscess of all or part of a vertebral body
Instrumentation
Biopsy of a vertebral body

20. 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.

21. Landmarks Palpate the 12th rib pubic symphysis
lateral border of the rectus abdominis

22. Incision oblique flank incision
from the posterior half of the 12th rib toward the rectus abdominis muscle
stopping at its lateral border
about midway between the umbilicus and the pubic symphysis

26. Place a needle into the involved lumbar vertebra and take a radiograph to identify the exact location

27. Anterior (Transperitoneal) Approach to the Lumbar Spine

28. 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

29. 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

30. Landmarks
Umbilicus
(? opposite the L3-4 disc space)
pubic symphysis

31. Incision
midline longitudinal
arches around the umbilicus

37. Posterior Approach to the Lumbar Spine

38. Posterior Approach to the Lumbar Spine
the most common approach to the lumbar spine
providing access to the cauda equina and the intervertebral discs
expose the posterior elements of the spine
Uses
Excision of herniated discs
Exploration of nerve roots
Spinal fusion
Removal of tumors

39. 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

40. Landmarks Spinou sprocesses
Line drawn between the highest points on the iliac crest is in the L4-5 interspace
To determine the exact level is use a radiograph

41. Incision midline longitudinal incision
length of the incision depends on the number of levels to be explored

46. Thank you