SPINAL ANATOMY AND SURGICAL APPROACHES

George W. Wood II

CHAPTER

37

ANATOMY OF VERTEBRAL COLUMN ANATOMY OF SPINAL JOINTS ANATOMY OF SPINAL CORD AND NERVES ANATOMY OF CERVICAL, THORACIC, AND LUMBAR PEDICLES CIRCULATION OF SPINAL CORD SURGICAL APPROACHES
ANTERIOR APPROACHES

1524 1524 1525 1526 1528 1529 1529

Anterior Approach, Occiput to C3 1530 Extended Maxillotomy and Subtotal Maxillectomy 1531 Anterior Approach, C3 to C7 1535 Anterolateral Approach, C2 to C7 1536 Anterior Approach to Cervicothoracic Junction, C7 to T1 1537 Anterior Approach to the Thoracic Spine 1540 Video-Assisted Thoracic Surgery 1542

Anterior Approach to the Thoracolumbar Junction 1543 Anterior Retroperitoneal Approach, L1 to L5 1544 Percutaneous Lateral Approach to Lumbar Spine, L1 to L4-5 (DLIF or XLIF) 1546 Anterior Transperitoneal Approach to the Lumbosacral Junction, L5 to S1 1548 Video-Assisted Lumbar Surgery 1549 POSTERIOR APPROACHES 1551

ANATOMY OF VERTEBRAL COLUMN
The vertebral column comprises 33 vertebrae divided into five sections (seven cervical, 12 thoracic, five lumbar, five sacral, and four coccygeal) (Fig. 37-1). The sacral and coccygeal vertebrae are fused, which typically allows for 24 mobile segments. Congenital anomalies and variations in segmentation are common. The cervical and lumbar segments develop lordosis as an erect posture is acquired. The thoracic and sacral segments maintain kyphotic postures, which are found in utero, and serve as attachment points for the rib cage and pelvic girdle. In general, each mobile vertebral body increases in size when moving from cranial to caudal. A typical vertebra comprises an anterior body and a posterior arch that enclose the vertebral canal. The neural arch is composed of two pedicles laterally and two laminae posteriorly that are united to form the spinous process. To either side of the arch of the vertebral body is a transverse process and superior and inferior articular processes. The articular processes articulate with adjacent vertebrae to form synovial joints. The relative orientation of the articular processes accounts for the degree of flexion, extension, or rotation possible in each segment of the vertebral column. The spinous and transverse processes serve as levers for the numerous muscles attached to them. The length of the vertebral column averages 72 cm in men and 7 to 10 cm less in women. The vertebral canal extends throughout the length of the column and provides protection for the spinal cord, conus medullaris, and cauda equina.

ANATOMY OF SPINAL JOINTS
The individual vertebrae are connected by joints between the neural arches and between the bodies. The joints between the neural arches are the zygapophyseal joints or facet joints. They exist between the inferior articular process of one vertebra and the superior articular process of the vertebra immediately caudal. These are synovial joints with surfaces covered by articular cartilage, a synovial membrane bridging the margins of the articular cartilage, and a joint capsule enclosing them. The branches of the posterior primary rami innervate these joints. The interbody joints contain specialized structures called intervertebral discs. These discs are found throughout the vertebral column except between the first and second cervical vertebrae. The discs are designed to accommodate movement, weight bearing, and shock by being strong but deformable. Each disc contains a pair of vertebral end plates with a central nucleus pulposus and a peripheral ring of anulus fibrosus sandwiched between them. They form a secondary cartilaginous joint or symphysis at each vertebral level. The vertebral end plates are 1-mm-thick sheets of cartilage-fibrocartilage and hyaline cartilage with an increased ratio of fibrocartilage with increasing age. The nucleus pulposus is a semifluid mass of mucoid material, 70% to 90% water, with proteoglycan constituting 65% and collagen constituting 15% to 20% of the dry weight. The anulus fibrosus consists of 12 concentric lamellae, with alternating

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CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES

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Occipital – C2 C3 – C7
Trigeminal V1 nerve V2 V3

Anterior
Occipitals Superior clavicular Intercostals Posterior Lateral Medial Axillary Radial Post. cutan. Dorsal cutan. Musculocutan. Medial cutan. Radial Median Ulnar
Posterior

Posterior
C2 C3 C4 T3 T4 T6 T10 T12 S5 S3 C8 L4 S1 C7
T1 T2

C2 C3 C5 T2 C4 T3 T4 T6 T8
C6

C5

T8

T1

T1–T12

T10 T12
L1 S4

C6

C8 L2 L3 L4

C7

Ilioinguinal Lat. cutan. nerve of thigh

L1– L5

Sacrum and coccyx

Tibial Sural med. Plantars lat.

L4

L5

cutan. Femoral Anterior cutan. Saphenous Sciatic Common peroneal Lat. cutan. Sup. peroneal Deep peroneal

L3

L5

S1

S1

Dermatomes

Cutaneous nerves

Dermatomes

FIGURE 37-1 Vertebral column: upper cervical vertebrae (occiput to C2), lower cervical vertebrae (C3-7), thoracic vertebrae (T1-12), lumbar vertebrae (L1-5), sacrum, and coccyx.

FIGURE 37-2 Dermatomal and sensory distribution. (Redrawn from Patton HD, Sundsten JW, Crill WE, et al, editors: Introduction to basic neurology, Philadelphia, 1976, WB Saunders.)

orientation of collagen fibers in successive lamellae to withstand multidirectional strain. The anulus is 60% to 70% water, with collagen constituting 50% to 60% and proteoglycan about 20% of the dry weight. With age, the proportions of proteoglycan and water decrease. The anulus and nucleus merge in a junctional zone without a strict demarcation. The discs are the largest avascular structures in the body and depend on diffusion from a specialized network of end plate blood vessels for nutrition.

ANATOMY OF SPINAL CORD AND NERVES
The spinal cord is shorter than the vertebral column and terminates as the conus medullaris at the second lumbar vertebra in adults and the third lumbar vertebra in neonates. From the conus, a fibrous cord called the filum terminale extends to the dorsum of the first coccygeal segment. The spinal cord is enclosed in three protective membranes—the pia, arachnoid, and dura mater. The pia and arachnoid membranes are separated by the subarachnoid space, which contains the cerebrospinal fluid. The spinal cord has enlargements in the cervical and lumbar regions that correlate with the brachial plexus and lumbar plexus. Within the spinal cord

are tracts of ascending (sensory) and descending (motor) nerve fibers. These pathways typically are arranged with cervical tracts located centrally and thoracic, lumbar, and sacral tracts located progressively peripheral. This accounts for the clinical findings of central cord syndrome and syrinx. Understanding the location of these tracts aids in understanding different spinal cord syndromes (Figs. 37-2 and 37-3; Table 37-1). Spinal nerves exit the canal at each level. Spinal nerves C2-7 exit above the pedicle for which they are named (the C6 nerve root exits the foramen between the C5 and C6 pedicles). The C8 nerve root exits the foramen between the C7 and T1 pedicles. All spinal nerves caudal to C8 exit the foramen below the pedicle for which they are named (the L4 nerve root exits the foramen between the L4 and L5 pedicles). The final dermatomal and sensory nerve distributions are shown in Figure 37-2. Because the spinal cord is shorter than the vertebral column, the spinal nerves course more vertically as one moves caudally. Each level gives off a dorsal (sensory) root and a ventral (mostly motor) root, which combine to form the mixed spinal nerve. The dorsal root of each spinal nerve has a ganglion located near the exit zone of each foramen. This dorsal root ganglion is the synapse point for the ascending sensory cell bodies. This structure is sensitive to pressure and heat and can cause a dysesthetic pain response if manipulated.

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PART XII  THE SPINE

ANATOMY OF CERVICAL, THORACIC, AND LUMBAR PEDICLES
Numerous studies have documented the anatomical morphology of the cervical, thoracic, and lumbar vertebrae. Advanced internal fixation techniques, including pedicle screws, have been developed and used extensively in spine surgery, not only for traumatic injuries but also for degenerative conditions. As the role for anterior and posterior spinal instrumentation continues to evolve, understanding the morphological characteristics of the human vertebrae is crucial in avoiding complications during fixation. Placement of screws in the cervical pedicles is controversial and carries more risk than anterior plate or lateral

Motor (descending paths)

Bi-directional paths 4 5

S = sacral T = thoracic C = cervical

Sensory (ascending paths) 6 7

3 S T C

S T C

Intermediolateral grey nucleus (sympathetic)

8 C TS

2

Dentate ligament 9
cm

1

2.5-4

Anterior spinal artery

Anterior motor nerve root

FIGURE 37-3 Schematic cross section of cervical spinal cord. (Redrawn from Patton HD, Sundsten JW, Crill WE, et al, editors: Introduction to basic neurology, Philadelphia, 1976, WB Saunders.)

mass fixation. Although cervical pedicles can be suitable for screw fixation, uniformly sized cervical pedicle screws cannot be used at every level. Screw placement in the pedicles at C3, C4, and C5 requires smaller screws (<4.5 mm) and more care in placement than those of the other cervical vertebrae. CT measurements of cervical pedicle morphology found that C2 and C7 pedicles had larger mean interdiameters than all other cervical vertebrae, and that C3 had the smallest mean interdiameter. The outer pedicle width-to-height ratio increased from C2 to C7, indicating that pedicles in the upper cervical spine (C2-4) are elongated, whereas pedicles in the lower cervical spine (C6-7) are rounded. It also is crucial to know that cervical pedicles angle medially at all levels, with the most medial angulation at C5 and the least at C2 and C7. The pedicles slope upward at C2 and C3, are parallel at C4 and C5, and are angled downward at C6 and C7. The vertebral artery from C3 to C6 is at significant risk for iatrogenic injury during pedicle screw placement. The pedicle cortex is not uniformly thick. The thinnest portion of the cortex (the lateral cortex) protects the vertebral artery, and the medial cortex toward the spinal cord is almost twice as thick as the lateral cortex. Variations in the course of the vertebral artery also place it at risk during placement of pedicle screws. At the C2 and C7-T1 levels, the vertebral artery is less at risk during pedicle screw fixation. The vertebral artery follows a more posterior and lateral course at C2, whereas at C7-T1 it is outside the transverse foramen. Pedicle dimensions and angles change progressively from the upper thoracic spine distally. A thorough knowledge of these relationships is important when considering the use of the pedicle as a screw purchase site. A study of 2905 pedicle measurements made from T1 to L5 found that pedicles were widest at L5 and narrowest at T5 in the horizontal plane (Fig. 37-4). The widest pedicles in the sagittal plane were at T11, and the narrowest were at T1. Because of the oval shape of the pedicle, the sagittal plane width was generally larger than the horizontal plane width. The largest pedicle angle in the horizontal plane was at L5. In the sagittal plane, the pedicles angle caudad at L5 and cephalad at L3-T1. The depth to the anterior cortex was significantly longer along the pedicle axis than along a line parallel to the midline of the vertebral body at all levels except T12 and L1.

TABLE 37-1 

Ascending and Descending (Motor) Tracts
PATH Anterior corticospinal tract Vestibulospinal tract Lateral corticospinal (pyramidal tract) Dorsolateral fasciculus Fasciculus proprius Fasciculus gracilis Fasciculus cuneatus Lateral spinothalamic tract Anterior spinothalamic tract FUNCTION Skilled movement Facilitates extensor muscle tone Skilled movement Pain and temperature Short spinal connections Position/fine touch Position/fine touch Pain and temperature Light touch SIDE OF BODY Opposite Same Same Bidirectional Bidirectional Same Same Opposite Opposite

NUMBER (See Fig. 37-3) 1 2 3 4 5 6 7 8 9

Modified from Patton HD, Sundsten JW, Crill WE, Swanson PD, editors: Introduction to basic neurology, Philadelphia, 1976, WB Saunders.

B. Medial to the medial wall of the pedicle lies the dural sac. 37-5 and 37-6). This seemed to be true for all levels of thoracic vertebrae.6 cm with minimum of 0. More proximally. In the lumbar spine. The mammillary process technique is based on a small prominence of bone at the base of the transverse process. The pedicles of the thoracic and lumbar vertebrae are tubelike bony structures that connect the anterior and posterior columns of the spine. The lumbar roots usually are situated in the upper third of the foramen. It is important in preoperative planning to assess individual spinal anatomy with the use of high-quality anteroposterior and lateral radiographs of the lumbar and thoracic spine and axial CT at the level of the pedicle. Usually the mammillary process is more A B FIGURE 37-5 Pedicle entrance point in thoracic spine at intersection of lines drawn through middle of inferior articular facets and middle of insertion of transverse processes (1 mm below facet joint). (Redrawn from Roy-Camille R. Because the laminae and the pars interarticularis can be identified easily at surgery. they provide landmarks by which a pedicular drill starting point can be made.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES T3 T8 L4 1527 c c c d d d e e e A B C FIGURE 37-4 Pedicle dimensions of T3 (A). after which a self-tapping screw is passed through the pedicle into the vertebral body. thoracolumbar.) lateral than the intersection technique starting point. T2 = 34 degrees. (2) the pars interarticularis technique. The intersection technique is perhaps the most commonly used method of localizing the pedicle. (Redrawn from Roy-Camille R. A. T3 = 23 degrees. three-dimensional structure that is filled mostly with cancellous bone (62% to 79%).5 cm. it is more dangerous to penetrate the pedicle medially or inferiorly as opposed to laterally or superiorly. and L4 (C) vertebrae.7 to 1. different angles must be used when drilling from these sites. and (3) the mammillary process technique. which also is more lateral than the pars interarticularis starting point. Vertical diameter (c) increases from 0. Anteroposterior view. Direction is almost sagittal from T4 to L4. The pars interarticularis is the area of bone where the pedicle connects to the lamina. Orthop Clin North Am 17:147. Panjabi et al. 1986. showed that the cortical shell is of variable density throughout its perimeter and that the lateral wall is significantly thinner than the medial wall. Orthop Clin North Am 17:147. We use three techniques for localization of the pedicle: (1) the intersection technique. coaxial fluoroscopy images are a reliable guide to the true bony cortex of the pedicle. With this in mind. It involves dropping a line from the lateral aspect of the facet joint. With the help of preoperative CT scanning at the level of the pedicle and intraoperative . Saillant G. and lumbar injuries with pedicle screw plates. Mazel CH: Plating of thoracic. and lumbar injuries with pedicle screw plates. An opening is made in the pedicle with a drill or hand-held curet.5 cm in T5. Saillant G. The respective facet joint space and the middle of the transverse process are the most important reference points. The locations for screw insertion have been identified and described in several studies. horizontal diameter (d) increases from 0. direction is more oblique: T1 = 36 degrees. This mammillary process can be used as a starting point for transpedicular drilling. Inferior to the medial wall of the pedicle is the nerve root in the neural foramen. T8 (B). Lateral view.) The thoracic pedicle is a convoluted. Mazel CH: Plating of thoracic. 1986.7 to 1. thoracolumbar. L5 is oblique (30 degrees) but is large and easy to drill. which intersects a line that bisects the transverse process at a spot overlying the pedicle (Figs. Angle (e) seldom extends beyond 10 degrees.

Posterior view. B. a pair of segmental arteries supplies the extraspinal and intraspinal structures. Oheneba BA: Atlas of spinal diseases. The segmental arteries divide into numerous branches at the intervertebral foramen. The thoracic and lumbar segmental arteries arise from the aorta. it is located on . Orthop Clin North Am 17:147. radiographs. spinal canal. it is 1 mm below articular joint. 7. This occurs at all levels. 5. (Redrawn from Bullough PG. Lateral view. the iliolumbar. Anteroposterior view.) 4. iliolumbar. This is because the metabolic demands of the gray matter are greater than those of the white matter. and posterior elements. Segmental arteries of the spine. B. which has been termed the distribution point (Fig. In 60% of individuals. thoracolumbar. Cross-sectional view. anastomosing arterial supply of vertebral body. A second anastomotic network lies within the spinal canal in the loose connective tissue of the extradural space. Philadelphia. and the middle sacral arteries are important in the sacral region. The presence of the rich anastomotic channels offers alternative pathways for arterial flow. 2. “Distribution point” of the segmental arteries. preserving spinal cord circulation after the ligation of segmental arteries. CIRCULATION OF SPINAL CORD The arterial supply to the spinal cord has been determined from gross anatomical dissection. Mazel CH: Plating of thoracic. A.1528 PART XII  THE SPINE Spinal branch Dorsal branch Ventral branch Segmental artery A B FIGURE 37-7 Vertebral blood supply. to a lesser extent. On typical bony crest. There are two to 17 anteriorly and six to 25 posteriorly. the fifth lumbar. Relative demands of gray matter and white matter. the cervical segmental arteries arise from the vertebral arteries and the costocervical and thyrocervical trunks. Sacral medullary feeders arise from the lateral sacral arteries and accompany the distal roots of the cauda equina. 37-7). Dependence on three vessels. Saillant G. JB Lippincott. stating that the principles that govern the blood supply of the cord are constant. The lateral sacral. He emphasized the following factors: 1. arteries in the thoracic and lumbar areas arise from the aorta. which contains fewer capillary networks. The vertebral arteries supply 80% of the radicular arteries in the neck. laminae removed to show anastomosing spinal branches of segmental arteries. 1988. The lateral sacral arteries and. At every vertebral level. Artery of Adamkiewicz. with the greatest concentration in the cervical and lumbar regions. and lumbar injuries with pedicle screw plates. and intercostal arteriography. The longitudinal arterial trunks are largest in the cervical and lumbar regions near the ganglionic enlargements and are much smaller in the thoracic region. The artery of Adamkiewicz is the largest of the feeders of the lumbar cord. latex arterial injections. (Redrawn from Roy-Camille R. 1986. These are the anterior median longitudinal arterial trunk and a pair of posterolateral trunks near the posterior nerve rootlets. and middle sacral arteries supply segmental vessels in the sacral region. A. whereas the patterns vary with the individual. 3. The vertebral and posterior inferior cerebellar arteries are important sources of arterial supply. The flow in these vessels seems reversible and the volume adjustable in response to the metabolic demands. These arteries reinforce the longitudinal arterial channels. an additional source arises from the ascending pharyngeal branch of the external carotid artery. the angle of the pedicle to the sagittal and horizontal planes can be determined. Dommisse contributed significantly to knowledge of the blood supply. the fifth lumbar. 6.) A B FIGURE 37-6 Pedicle entrance point in lumbar spine at intersection of two lines. Medullary feeder (radicular) arteries of the cord. Supplementary source of blood supply to the spinal cord.

and the communications with the inferior vena caval system. Advances in major surgical procedures. more attention has been placed on the anterior approach to the spinal column. the spinal cord enjoys reserve sources of blood supply through a degree of anastomosis lacking in the inner circle. this indication has been expanded to include anterior interbody fusions for discogenic pain and instability. The dominance of the anterior spinal artery system has been challenged by the fact that many anterior spinal surgeries have been performed in recent years with no increase in the incidence of paralysis. In principle. yet there is absolute conformity with a principle of a rich supply for the cervical and lumbar cord enlargements. Direction of flow in the blood vessels of the spinal cord. postmyelogram CT. and that it protects the spinal cord. but it is more extensive and more complicated. and abdomen. 9. however. anterior approaches to the spine are indicated for decompression of the neural elements (spinal cord. including anesthesia and intensive care. In the lumbar spine. Variability of patterns of supply of the spinal cord. the lumbar veins. T4-9 should be considered the critical vascular zone of the spinal cord. which includes the segmental veins of the neck. degenerative. The longitudinal venous trunks of the spinal cord are the anterior and posterior venous channels. The “outlet points” are limited. chest. In general. we empirically follow these principles: (1) ligate segmental spinal arteries only as necessary to gain exposure. This internal arterial circle of the cord is surrounded by at least two outer arterial circles. usually at the level of T9-11 (in 80% of individuals). to the perforating sulcal arteries and the pial arteries of the cord. The blood supply to the spinal cord is rich. inflammatory. 8. or nerve roots) when anterior neural compression has been documented by myelography. which are the counterparts of the arterial trunks. and the veins of the bony structures of the spinal column. or MRI. This interconnection allows metastatic spread of neoplastic or infectious disease from the pelvis to the vertebral column. conus medullaris. The supply for the thoracic cord from approximately T4 to T9 is much poorer. The three components of the Batson plexus are the extradural vertebral venous plexus.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES the left side. cauda equina. have made it possible to perform spinal surgery with acceptable safety. These channels permit reversal of flow and alterations in the volume of blood flow in response to metabolic demands. although it functions with identical principles. It is well known that the venous system is highly variable. 1988. including traumatic. The anterior longitudinal arterial channel of the cord rather than any single medullary feeder is crucial. the extravertebral venous plexus. leaving the circulation intact on the opposite side. neoplastic. and congenital lesions. Venous drainage of the spinal cord is more difficult to define clearly than is the arterial supply (Fig. The venous system plays no 1529 Internal venous plexus External venous plexus FIGURE 37-8 Venous drainage of vertebral bodies and formation of internal and external vertebral venous plexuses. The Batson plexus is a large and complex venous channel extending from the base of the skull to the coccyx. SURGICAL APPROACHES ANTERIOR APPROACHES With the posterior approach for correction of spinal deformities well established. the intercostal veins. 37-8). Philadelphia. By virtue of the latter. it communicates directly with the venous system draining the head. (2) ligate segmental spinal arteries near the aorta rather than near the vertebral foramina. The preservation of this large feeder does not ensure continued satisfactory circulation for the spinal cord. The variability of blood supply is a striking feature. The three longitudinal arterial channels of the spinal cord can be compared with the circle of Willis at the base of the brain. the first of which is situated in the extradural space and the second in the extravertebral tissue planes. Many pathological entities can cause significant compression of the neural elements. . and (4) limit dissection in the vertebral foramina to a single level when possible so that collateral circulation is disturbed as little as possible. It communicates directly with the superior and inferior vena cava system and the azygos system. Dommisse pointed out that there are two sets of veins: veins of the spinal cord and veins that fall within the plexiform network of Batson. a zone in which interference with the circulation is most likely to result in paraplegia.) specific role in the metabolism of the spinal cord. it would seem of practical value to protect and preserve each contributing artery as far as is surgically possible. During anterior spinal surgery. The veins of the spinal cord are a small component of the entire system and drain into the plexus of Batson. JB Lippincott. the azygos communications in the thorax and pelvis. (3) ligate segmental spinal arteries on one side only when possible. Oheneba BA: Atlas of spinal diseases. (Redrawn from Bullough PG. The evidence suggests that the posterior spinal arteries may be as important as the anterior system but are as yet poorly understood. This would seem to indicate that a rich anastomotic supply does exist. Many pioneers in the field of anterior spinal surgery recognized that anterior spinal cord decompression was necessary in spinal tuberculosis and that laminectomy not only failed to relieve anterior pressure but also removed important posterior stability and produced worsening of kyphosis. but the spinal canal is narrowest and the blood supply is poorest at T4-9.

Extradural metastatic disease b. POSTOPERATIVE CARE  An endotracheal tube is left in place overnight to maintain an adequate airway. ■ Palpate the anterior ring of C1 beneath the posterior pharynx. there is a high risk of significant morbidity. Cervical spondylitic myelopathy c. perform a meticulous débridement of C1 and C2 with a high-speed air drill. Débridement and anterior strut grafting 3. ■ Prepare the oropharynx with hexachlorophene (pHisoHex) and povidone-iodine (Betadine). physiology. as a rule. ■ If the cervical spine is to be fused anteriorly. a team approach is preferred to employ the skills of an orthopaedic surgeon. The surgeon may sit directly over the patient’s head. Thoracic disc herniation d. and these approaches should be used with care and only in appropriate circumstances. ■ Insert a McGarver retractor into the open mouth and use it to retract and hold the endotracheal tube out of the way. or idiopathic 37-1 Figure 37-9 Anterior approaches to the spine generally are made by an experienced spine surgeon. fashion it to fit. and close the posterior pharynx in layers. neurosurgeon. . A halo vest can be applied. or neurological structures. ■ 1. OCCIPUT TO C3 ANTERIOR RETROPHARYNGEAL APPROACH The anterior retropharyngeal approach to the upper cervical spine. ■ Under direct vision. Scoliosis—congenital. and insert it. The orthopaedic surgeon still must have a working knowledge of the underlying viscera. and the presence or absence of signs of neural compression. Fractures with documented neurocompression secondary to bone or disc fragments anterior to dura b. taking care not to cause necrosis of the septal cartilage by excessive pressure. subperiosteally dissect the edges of the pharyngeal incision from the anterior ring of C1 and the anterior aspect of C2. with the operating microscope or with magnification loupes and headlights. ■ When adequate débridement of infected bone and necrotic tissue has been accomplished. is excellent for anterior débridement of the upper cervical spine and allows The anterior approach to the upper cervical spine (occiput to C3) can be transoral or retropharyngeal. a diamond burr is safer to use in removing the last remnant of bone. Complications of anterior spine surgery are rare. The choice of approach depends on the preference and experience of the surgeon. visceral. producing thermal necrosis of tissue and increased risk of infection. ■ Irrigate the operative site with antibiotic solution. Herniated intervertebral disc 2. Late pain or paralysis after remote injuries with anterior extradural compression e. rongeur. Cervical. or skeletal traction may be maintained before mobilization. Monitoring of the spinal cord through somatosensory evoked potentials is recommended. or head and neck surgeon. fluid balance. decompress the upper cervical spinal cord. Traumatic a. as described by McAfee et al. Degenerative a. it is inappropriate for surgeons who only occasionally perform spinal techniques to perform this type of surgery.. and suture it to the uvula. depending on the pathological process present and the experience of the surgeon. Open biopsy for diagnosis b. and other elements of intensive care.1530 PART XII  THE SPINE BOX 37-1  Relative Indications for Anterior Spinal Approaches ANTERIOR TRANSORAL APPROACH TECHNIQUE (SPETZLER) Position the patient supine using a Mayfield head-holding device or with skeletal traction through Gardner-Wells tongs. In many centers. The operating microscope is useful to improve the limited exposure. Cervical spondylitic radiculopathy b. Neoplastic a. ■ Pass a red rubber catheter down each nostril. ■ With a periosteal elevator. Apply traction to the catheters to pull the uvula and soft palate out of the operative field. thoracic surgeon. A thorough understanding of anatomical tissue planes and meticulous surgical technique are necessary to prevent serious complications. Primary vertebral body tumor 5. Kyphosis—congenital or acquired b. When approaching the posterior longitudinal ligament. Infectious a. and. the underlying pathological process.  ANTERIOR APPROACH. Complete spinal cord injury (for root recovery) with anterior extradural compression d. and make an incision in the wall of the posterior pharynx from the superior aspect of C1 to the top of C3. thoracic. Use traction stitches to maintain the flaps out of the way. ■ Obtain hemostasis with bipolar electrocautery. Commonly accepted indications for anterior approaches are listed in Box 37-1. Potential dangers include iatrogenic injury to vascular. or curet. however. taking care not to overcauterize. The exact incidence of serious complications from anterior spinal surgery is unknown. the patient’s age and medical condition. Incomplete spinal cord injury (for cord recovery) with anterior extradural compression c. harvest a corticocancellous graft from the patient’s iliac crest. Deformity a. the segment of the spine involved. acquired. and lumbar interbody fusions 4.

In contrast to the transoral approach. and tag and divide the tendon of the former. ■ Identify the digastric and stylohyoid muscles. perform bone grafting with autogenous iliac or fibular bone. if indicated. editor: Surgery of the musculoskeletal system. 1983. by dividing the digastric and stylohyoid muscles. Three to 5 days before the surgery. preferably on a turning frame with skeletal traction through tongs or a halo ring.) SEE TECHNIQUE 37-1. ■ Identify the hypoglossal nerve. If the approach does not have to be extended below the level of the fifth cervical vertebra. Cocke et al. Take care to maintain the head in a neutral position and identify the midline accurately. which prevent retraction of the carotid sheath laterally (Fig. ■ Carry the dissection through the platysma muscle with the enveloping superficial fascia of the neck and mobilize flaps from this area.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES Resect the submandibular gland (Fig. ■ Identify and mobilize the superior laryngeal nerve. It should be performed by a team of surgeons. Feel for the pulsations of the carotid artery. ■ Remove the longus colli muscles subperiosteally from the anterior aspect of the arch of C1 and the body of C2. ■ Keep the dissection deep to the retromandibular vein to prevent injury to the superficial branches of the facial nerve. there is no increased risk of damage to the recurrent laryngeal nerve. however. the size. and an orthopaedist. The facial nerve can be injured by superior retraction on the stylohyoid muscle. the hyoid bone and hypopharynx can be mobilized medially. if needed. Before surgery. Increase exposure by ligating branches of the carotid artery and internal jugular vein. preventing exposure of the esophagus. placement of bone grafts for stabilization if necessary. using the appropriate imaging techniques. or. and repair the digastric tendon. (Redrawn from Spetzler RF: Transoral approach to the upper cervical spine. and retract it superiorly. The patient can be extubated and mobilized in a halo vest. ■ Close the wound over suction drains. ■ Mobilize the anterior border of the sternocleidomastoid muscle by longitudinally dividing the superficial layer of the deep cervical fascia. TECHNIQUE (MCAFEE ET AL. position. usually by 48 hours. 37-10E). 37-10C and D). This procedure is technically demanding and requires a thorough knowledge of head and neck anatomy. and ligate the duct to prevent formation of a salivary fistula. ■ Meticulously débride the involved osseous structures (Fig. described an extended maxillotomy and subtotal maxillectomy as an alternative to the transoral approach for exposure and removal of tumor or bone anteriorly at the base of the skull and cervical spine to C5. and pharyngeal secretions are cultured to determine the proper antibiotics needed. ■ 1531 FIGURE 37-9 Anterior transoral approach (see text). avoiding injury to the vertebral arteries. and nasopharynx. ■ POSTOPERATIVE CARE  The patient is maintained in skeletal traction with the head of the bed elevated to reduce swelling. Cephalosporin and aminoglycoside antibiotics are given before and after surgery if the floral cultures are normal and are adjusted if the flora is abnormal or resistant to these drugs. ■ Make a right-sided transverse skin incision in the submandibular region with a vertical extension as long as required to provide adequate exposure (Fig. oral. Churchill Livingstone. ■ Identify the marginal mandibular branch of the seventh nerve with the help of a nerve stimulator.  EXTENDED MAXILLOTOMY AND SUBTOTAL MAXILLECTOMY . In Evarts CM. Intubation is continued until pharyngeal edema has resolved. Somatosensory evoked potential monitoring of cord function is suggested during the procedure. ■ Continue dissection to the retropharyngeal space between the carotid sheath laterally and the larynx and pharynx medially. and extent of the tumor or bone to be removed should be determined. including an otolaryngologist.) 37-2 Position the patient supine. 37-10B). a neurosurgeon. ■ Following adequate retraction of the carotid sheath laterally. ■ Perform fiberoptic nasotracheal intubation to prevent excessive motion of the neck and to keep the oropharynx free of tubes that could depress the mandible and interfere with subsequent exposure. nasal. ■ Ligate the retromandibular vein as it joins the internal jugular vein. hypopharynx. divide the alar and prevertebral fascial layers longitudinally to expose the longus colli muscles. and ligate the retromandibular veins superiorly. a posterior stabilization procedure can be done before mobilization. it is entirely extramucosal and is reported to have fewer complications of wound infection and neurological deficit. Close the platysma and skin flaps in layers. 37-10A). New York. and protect the contents of the carotid sheath.

Anterior retropharyngeal approach (see text). . (Redrawn from McAfee PC.1532 PART XII  THE SPINE Incision Sternomastoid muscle Digastric muscle Submandibular gland Hypoglossal nerve A B Divided digastric muscle Hypoglossal nerve Submandibular gland resected Hypoglossal nerve Superior laryngeal nerve Carotid sheath opened C Divisions of common facial. lingual. et al: The anterior retropharyngeal approach to the upper part of the cervical spine. 1987. Riley LH Jr.) SEE TECHNIQUE 37-2. Bohlman HH. J Bone Joint Surg 69A:1371. and superior thyroid veins Division of common facial and lingual arteries D Internal jugular vein Common carotid artery C2 corpectomy E Incision in longus colli muscle FIGURE 37-10 A-E.

Extended maxillotomy and subtotal maxillectomy (see text). ■ Extract the central incisor tooth. ■ Expose the superior maxilla through a modified WeberFerguson skin incision (Fig. Intubate the patient orally. ■ Perform a percutaneous endoscopic gastrostomy if the wound is to be left open or if problems are anticipated. nasopharynx. Arch Otolaryngol Head Neck Surg 116:92. nasal septum. ■ Make a vertical midline incision through the mucoperiosteum of the anterior maxilla from the gingivobuccal gutter to the central incisor defect and transversely ■ . This step usually is unnecessary. ■ Infiltrate the soft tissues of the upper lip. pterygoid fossa. ■ 37-3 Pack each nasal cavity with cottonoid strips saturated with 4% cocaine and 1% phenylephrine. Extend the lower end to the midline and vertically in the midline through the buccal mucosa to the gingivobuccal gutter. Extend the external skin incision transversely from the upper end of the lip incision in the nasolabial groove to beyond the nasal ala and superiorly along the nasofacial groove to the lower eyelid. nasal floor. Robertson JH. or if there are severe pulmonary problems.) Position the patient on the operating table with the head elevated 25 degrees. and lateral nasal wall with 1% lidocaine and 1 : 100. and suture the eyelids closed with 6-0 nylon. (Redrawn from Cocke EW Jr. gingiva. Drape the operative site with cloth drapes held in place with sutures or surgical clips and covered with a transparent surgical drape. et al: The extended maxillotomy and subtotal maxillectomy for excision of skull base tumors. palate.000 epinephrine.) SEE TECHNIQUE 37-3. cheek. 1990. Robertson JR. ■ Perform a tracheostomy if the exposure may be limited. and move the tube to the contralateral side of the mouth. 37-11A). Divide the upper lip and ligate the labial arteries.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1533 Superior turbinate base Buccal mucosa External lip Gingiva Sinonasal defect Pterygoid base Vertical pharyngeal incision Inferiorly based pharyngeal flap Masseter muscle divided Lateral pterygoid plate Coronoid defect A B C D E F G FIGURE 37-11 A-G. ■ Prepare the skin with povidone-iodine and then alcohol. SUBTOTAL MAXILLECTOMY TECHNIQUE (COCKE ET AL. ■ Insert a Foley catheter. Make a vertical incision through the upper lip in the philtrum from the nasolabial groove to the vermilion border.

medium-size. 37-11C). 37-11B). 37-11E and F). nasal bone. 37-11E) through the nose into the nasopharynx behind the posterior nares of the hard palate. 37-11D). The posterior pharynx is now fully exposed. 37-11B). ■ Remove the offending bone with a high-speed burr. hard palate mucoperiosteum adjacent to the teeth from the central incisor defect to join the retromolar incision. and pharynx medially from the prevertebral fascia.000. posterior to the posterior tonsillar pillar behind the soft palate (see Fig. It is usually unnecessary to detach and retract the soft palate from the posterior or lateral pharyngeal walls. ■ Detach the soft palate with its nasal lining from the posterior margin of the hard palate. malar bone. and protect the soft tissues from injury. anterior tonsillar pillar. and masseter muscle (see Fig. tonsil. ■ Divide and electrocoagulate the greater palatine vessels and nerves. ■ Extend the pharyngeal wall incision inferiorly to the level of the hyoid bone or beyond. ■ Mobilize. ■ Close the nasopharyngeal mucous membrane and the subcutaneous tissue in one layer with interrupted sutures. Use an operating microscope or loupe magnification for improved vision. Engage the saw between the blades of the clamp and thread it through the nose into position for division of the hard palate (see Fig. to expose the lateral pterygoid plate and the internal maxillary artery. ■ Remove the maxilla after division of its muscle attachments. ■ Remove the coronoid process of the mandible above the level of entrance of the inferior alveolar vessels and nerves. and retract the anterior tonsillar pillar. ■ Divide the anterior margin of the masseter muscle at its malar attachment. It is unnecessary to separate the soft palate completely from the pharyngeal wall. . ■ Position the lower Gigli saw by passing a Kelly forceps (see Fig. ■ Ligate the distal end of the internal maxillary artery. Pack the palatine foramen with bone wax. ■ Make a vertical midline incision through the soft tissues of the posterior wall of the nasopharynx extending from the sphenoidal sinus to the foramen magnum. ■ Elevate. ■ Pass a Kelly forceps through the nose to behind the hard palate to retrieve the medial end of the silk suture in the ligature carrier. ■ Extend the retromolar incision medial to the mandible lateral to the tonsil and to the retropharyngeal space to the level of the hyoid bone or lower pharynx. Avoid entangling the saws.1534 PART XII  THE SPINE through the buccal gingiva adjacent to the teeth to the retromolar region. ■ Make an incision in the lingual. piriform aperture of the nose. 37-11E). and the tonsillar area to the level of the hyoid bone with 1% lidocaine and epinephrine 1 : 100. ■ Infiltrate the mucous membrane covering the posterior wall of the nasopharynx. 37-11F). ■ Place traction sutures in the soft tissues of the lip on either side of the initial lip incision and in the mucoperiosteum of the hard and soft palates. after dividing its temporalis muscle attachment. ■ Direct the suture behind the lateral pterygoid plate into the nasopharynx and behind the posterior margin of the hard palate into the oropharynx (see Fig. ■ Elevate the skin. ■ Divide the pterygoid muscles with a Shaw knife or the cutting current of the Bovie cautery until the sharp. tonsil. if necessary. divide. 37-11E and F) using a sharp-pointed. and remove a wedge of malar bone. ■ Make a more extensive exposure by extending the lateral pharyngeal wall incision through the anterior tonsillar pillar to join the retromolar incision. ■ Remove a bony wedge of the ascending process of the maxilla to accommodate the upper Gigli saw (see Fig. and mucoperiosteum of the maxilla to expose the anterior and lateral walls of the maxilla. Take care to position the saw as high as possible behind the pterygoid plate. 37-11C). Use a broad periosteal elevator beneath the saw on the pterygoid plate to maintain the elevated position (see Fig. ■ Elevate the mucoperiosteum of the hard palate from the central incisor defect and alveolar ridge to and beyond the midline of the hard palate. and soft palate toward the midline with a traction suture. ligate. inferior orbital nerve. ■ Use a split-thickness skin or dermal graft from the thigh to resurface the buccal mucosa and any defects in the nasal surface of the hard palate. and divide the internal maxillary artery near the pterygoid plate. and separate the superior constrictor muscle. ■ Retract the mucoperiosteum of the hard palate. Use this wedge to accommodate the Gigli saw as it divides the maxilla (see Fig. ■ Position the upper Gigli saw (see Fig. ■ Engage the medial arm of the saw into the ascending process wedge and its lateral arm into the malar wedge. ■ Attach a Gigli saw to the lateral end of the suture. curved. 37-11B). longus capitis muscle. subcutaneous tissues. and thread the saw into position to divide the upper maxilla. ■ Duplicate this incision on the opposite side. and anterior longitudinal ligaments from the bony skull base and upper cervical spine ventrally. soft palate. periosteum. 2 black silk suture. ■ Divide the bony walls of the maxilla (see Fig. avoiding penetration of the dura. right-angle ligature carrier threaded with No. ■ Use a quilting stitch to hold the graft in place without packing. posterior bone edge of the lateral pterygoid plate is seen or palpated. 37-11F). clip. Extend this incision into the retropharyngeal space. prevertebral fascia. producing an inferiorly based pharyngeal flap (see Fig. oropharynx. ■ Expose the nasal cavity by detaching the nasal soft tissues from the lateral margin and base of the nasal piriform aperture (see Fig. First divide the hard palate and then the upper maxilla. Another option is to make a transverse incision from the sphenoidal sinus to the lateral nasopharyngeal wall posterior to the eustachian tube along the lateral pharyngeal wall inferiorly. ■ Expose the amount of bone to be operated on from the foramen magnum to C5.

esophagus. localize the carotid pulse by palpation. ■ Hinge the maxilla on the hard palate. and soft palate. A left-sided skin incision is preferred because of the more constant anatomy of the recurrent laryngeal nerve and the lower risk of inadvertent injury to the nerve. ■ 1535 EXTENDED MAXILLOTOMY TECHNIQUE ■ 37-4 Expose the base of the skull and upper cervical spine as by the maxillectomy technique. an incision three to four fingerbreadths above the clavicle is needed to expose C3-5. A thorough knowledge of anatomical fascial planes allows a safe. The shorter. ■ Place a nylon sack impregnated with antibiotic into the nasal cavity. and thyroid medially (Fig. Extend this elevation medially to the nasal septum and laterally to the inferior turbinate. depending on the surgeon’s preference (Fig. C3 TO C7 TECHNIQUE 37-5 (SOUTHWICK AND ROBINSON) As with other approaches to the cervical spine. having a variable relationship with the inferior thyroid artery. Antibiotic therapy is continued until the risk of infection is minimized. ■ Carefully divide the middle layer of deep cervical fascia that encloses the omohyoid medial to the carotid sheath. POSTOPERATIVE CARE  Continuous spinal fluid drainage is maintained.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES Replace the zygoma and stabilize it with wire if it was mobilized. ■ Identify the anterior border of the sternocleidomastoid muscle. 37-12A). and retract the trachea. and rotate it medially. or asymptomatic paralysis may be underestimated. 37-11G). The most frequent complication of the anterior approach is vocal cord paralysis caused by injury to the recurrent laryngeal  ANTERIOR APPROACH.000 epinephrine solution assists with hemostasis. Exposure can be carried out through either a transverse or a longitudinal incision. Exposure of the middle and lower cervical region of the spine is most commonly done through an anterior approach medial to the carotid sheath. Injury to the recurrent laryngeal nerve may be less common on the left side because the nerve has a more vertical course and lies in a protected position within the esophagotracheal groove. On the right the nerve leaves the main trunk of the vagus nerve and passes anterior to and under the subclavian artery. Although many spine surgeons use the rightsided approach with a low incidence of symptomatic paralysis of the recurrent laryngeal nerve. but omit the extraction of the central incisor and the gingivolingual incision. ■ Divide the fibromuscular attachment of the soft palate to the pterygoid plate and hard palate. Half-strength hydrogen peroxide is used for mouth irrigation to help keep the oral cavity clean. whereas on the left it passes under and posterior to the aorta at the site of origin of the ligamentum arteriosum. C3 TO C7 . an incision two to three fingerbreadths above the clavicle allows exposure of C5-7. skeletal traction is suggested and spinal cord monitoring should be used. ■ As the sternomastoid and carotid sheath are retracted laterally. and longitudinally incise the superficial layer of the deep cervical fascia. partial. We believe that using the left-sided approach may reduce the risk of such injuries. nasal mucoperiosteum. making the recurrent laryngeal nerve on the right side highly vulnerable to injury if the inferior thyroid vessels are not ligated as laterally as possible or if the midline structures along with the recurrent laryngeal nerve are not retracted intermittently. exposing the nasopharynx. The endotracheal tube is removed when the risk of occlusion by swelling is minimized. The nasopharyngeal cavity is cleaned with saline twice daily for 2 months after pack removal. and hold it in place with wire or compression plates. more lateral position of the right recurrent laryngeal nerve places it at risk for injury from direct trauma or from the retraction that is necessary to expose the anterior cervical vertebrae. Infiltration of the skin and subcutaneous tissue with a 1 : 500. and the head is elevated 45 degrees if the dura was repaired or replaced. the anterior aspect of the cervical spine can be palpated. the incidence of temporary. nerve. An ice cap is used on the cheek and temple to reduce edema. ■ Center a transverse incision over the medial border of the sternocleidomastoid muscle. and oral sutures are removed at 2 weeks. ■ Divide the bone of the nasal floor with a Stryker saw without lacerating the underlying hard palate periosteum. ■ Use a degloving procedure for elevation of the facial skin over the maxilla and nose to avoid facial scars. In general. ■ Return the maxilla to its original position. Facial sutures are removed at 4 to 6 days. ■ Elevate the mucoperiosteum of the adjacent floor of the nose from the piriform aperture to the soft palate. ■ Incise the platysma muscle in line with the skin incision or open it vertically for more exposure. ■ Place the upper Gigli saw with the aid of a ligature carrier for division of the maxilla beneath the infraorbital nerve. The nerve runs upward. ■ Close the facial wound with 5-0 chromic and 6-0 nylon sutures. These procedures are omitted if there was no dural tear or defect. A left-sided exposure medial to the carotid artery and internal jugular vein can be used to minimize the risk of injury. 37-12B). ANTERIOR APPROACH. ■ Close the oral cavity incision with vertical interrupted mattress 3-0 polyglycolic acid sutures (see Fig. Identify the esophagus lying posterior to the trachea. direct approach to this area.

. et al. ■ Close the wound over a drain to prevent hematoma formation and possible airway obstruction. whereas the inter­ mediate ganglion varied at its level of the cervical spine. however. The frequency of Horner syndrome reported in the literature is as high as 4%. A disadvantage is the difficulty of the dissection with the potential injury to the vertebral artery. The greatest risk to the sympathetic chain is during sectioning of the longus coli muscle transversely and dissection of the prevertebral fascia. veins. C2 TO C7 Chibbaro et al. the longus capitis muscle (Lc). We have no experience with this procedure.6 mm from the medial border of the longus coli muscle (Fig. and Bruneau et al. ■ Subperiosteally reflect the longus colli from the anterior aspect of the spine out laterally to the level of the uncovertebral joints. (Left side is cranial and right side is caudal. trachea. the inferior thyroidal artery (ita). and esophagus have been retracted medially. Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to the cervical spine. The resulting exposure is sufficient for wide débridement and bone grafting. Incision.1536 PART XII  THE SPINE Thyroid cartilage Cricoid cartilage Omohyoid Sternohyoid Sternocleidomastoid Skin incision A Thyroid gland B FIGURE 37-12 Anterior approach to C3-7 (see text). and three had infections. which can result in Horner syndrome (ptosis.) authors stressed that there is a steep learning curve with this procedure. Civelek et al. Chibbaro et al. SEE TECHNIQUE 37-5. XI cranial nerve. Also shown are the sternocleidomastoid muscle (SMC). The superior ganglion was always at the level of C4. Cited advantages of this technique include wide decompression at a single level or multiple levels while providing direct vision of the vertebral artery and nerve roots. and anhidrosis). the anterior longitudinal ligament (ALL). A. which became permanent in four. 2008. ■ Approximate the platysma and skin edges in routine fashion. In 459 procedures done since 1992. and carotid sheath and its contents have been retracted laterally in opposite direction. noted no vertebral artery injury. or nerve root palsy. This technique also allows the direct exposure of the vertebral artery and veins by direct exposure of the vertebral foramen. Karasu A. and the sympathetic chain. dysphagia. The FIGURE 37-13 Anatomical dissection showing the relation of the cervical sympathetic chain (SC) to the longus coli muscle (LC). 37-13). determined that the cervical sympathetic chain was on average 11. 14 patients (3%) developed Horner syndrome. This technique allows the removal of a wedge of cervical vertebra without the need for grafting or instrumentation. ■  ANTEROLATERAL APPROACH. Cansever T. Thyroid gland. Bluntly divide the deep layers of the deep cervical fascia. cerebrospinal fluid leaks. ipsilateral miosis.) (From Civelek E. and the superior ganglion of the sympathetic trunk (sg). It is recommended for elderly patients and smokers with unilateral anterior or lateral bony compression without instability. consisting of the pretracheal and prevertebral fascia overlying the longus colli muscles. described an anterolateral approach to the cervical spine that allows decompression of the body and roots that are affected with unilateral myelopathy and/or radiculopathy. B. From anatomic studies. Eur Spine J 17:991.

■ Confirm the level of decompression again radiographically. 37-14A). Also. HIGH TRANSTHORACIC APPROACH TECHNIQUE ■ 37-8 A kyphotic deformity of the thoracic spine tends to force the cervical spine into the chest. ■ Identify the fatty sheath surrounding cranial nerve XI and expose the nerve from C2 to C4. ■ Extend it well across the midline. taking particular care when dissecting around the carotid sheath in the area of entry of the thoracic duct. ■ Open the vertebral foramen laterally by removing the anterior portion of the transverse foramen with a Kerrison rongeur. ■ Close the subcutaneous tissue and skin as desired. ■ ■ Immobilization with a collar may be desired for soft tissue healing. using a burr for longitudinal removal of bone from upper to lower disc spaces (Fig. ■ Make an oblique corpectomy in the vertebra. and remove the retractors. which lies on top of the longus coli. This frees the cervical root from the dural root to the vertebral artery margin. 37-15).) ■ Incise the platysma muscle along the plane of the skin incision. in which instance a high transthoracic approach is a logical choice. Individual anatomical structure should be considered carefully in preoperative planning. Retract the sternocleidomastoid muscle laterally and the undissected great vessels.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1537 ANTEROLATERAL APPROACH. ■ Subperiosteally dissect the lateral aspect of the uncovertebral joint and medial border of the vertebral artery. C4. ■ Start with a longitudinal trench just medial to the vertebral artery and continue the bone removal medially. ■ Divide the aponeurosis of the longus coli longitudinally to identify the sympathetic chain. The three approaches to this area are (1) the low anterior cervical approach. Excision of the first or second rib is adequate in adults or in the absence of an exaggerated kyphosis. Exposure is limited at the upper thoracic region but generally is adequate for placement of a strut graft if needed. ■ Obtain good hemostasis. CHIBBARO ET AL) Place the patient supine with the head rotated to the side opposite the incision and the neck in extension. ■ Make a periscapular incision (Fig. The low anterior cervical approach provides access to T1 at the inferior extent and the lower cervical spine at the superior extent of the dissection. C2 TO C7 TECHNIQUE 37-6 (BRUNEAU ET AL. removing the latter is necessary to provide sufficient working space in a child or if a kyphotic deformity is present. this is a confluent area of vital structures that are not readily retracted. (2) the high transthoracic approach. ■ Identify the transverse processes with a finger. For equal exposure of the thoracic and cervical spine from C4 to T4. and (3) the transsternal approach. ■ Retract the aponeurosis and the sympathetic chain laterally. ■ Identify the involved level radiographically. the sternal splitting approach is recommended. Prepare and drape the neck as for any usual anterior cervical disc surgery. 37-14B-D). Confirm the level of dissection radiographically. C7 TO T1 LOW ANTERIOR CERVICAL APPROACH TECHNIQUE ■ 37-7 Enter on the left side by a transverse incision placed one fingerbreadth above the clavicle. trachea. ■ Make a longitudinal incision along the medial border of the sternocleidomastoid muscle. TRANSSTERNAL APPROACH TECHNIQUE ■ 37-9 Make a Y-shaped or straight incision with the vertical segment passing along the midsternal area from the . ■ Further steps in exposure follow those of the conventional anterior cervical approach. and esophagus medially (Fig. ■ Take care to be sure the vertebral artery is not entering at an abnormally high level such as C3. and remove the second or third rib. but variations are common. ■ Divide the longus coli longitudinally at the interval of the junction of the vertebral body and the transverse processes. ■ Resect the posterior cortex and the posterior longitudinal ligament to decompress the cord. or C5. The latter approaches the jugular vein from its lateral side. ■ Open the space between the sternocleidomastoid muscle and the internal jugular vein with sharp dissection. Preserve the posterior cortex until the wedge is completed. ■ Clear the transverse processes and the lateral aspect of the vertebral body. ■ Recheck the decompression radiographically. irrigate the wound. There is no ready anterior access to the cervicothoracic junction. This exposes the interval between C6 and T4. The tissues will fall into place. (At the C2-3 level the incision extends to the tip of the mastoid process superiorly and to the sternal notch for exposure of C7-T1 inferiorly. it is commonly used in cardiac surgery.  ANTERIOR APPROACH TO CERVICOTHORACIC JUNCTION. The rapid transition from cervical lordosis to thoracic kyphosis results in an abrupt change in the depth of the wound. ■ A drain can be used if necessary.

Postoperative MRI showing decompression. CT after wedge decompression.1538 PART XII  THE SPINE External carotid artery Internal carotid artery Internal jugular vein Accesory nerve (CN XI) Sternomastoid muscle Vertebral artery and veins A B C D FIGURE 37-14 A. Mirone G. (From Chibbaro S. B. George B: Cervical spine lateral approach for myeloradiculopathy: technique and pitfalls.) SEE TECHNIQUE 37-6. The foramen is opened over the vertebral artery (V). 2009. The longus coli aponeurosis is longitudinally opened and the sympathetic chain is identified and carefully protected while exposing the uncovertebral joints and the anterior surface of the transverse process. C. Anterolateral approach to the cervical spine through the interval between the sternocleidomastoid (SCM) laterally and along the internal jugular vein (IJV) medially with the other vascular structures including the internal carotid (IC) and external carotid (EC). D. Surg Neurol 72:318. Bony exposure through wedge-shaped lateral decompression. The XI cranial nerve is identified at C2 to 4. Bresson D. .

Fang et al. provides excellent exposure from C3 to T4 without the associated morbidity related to the division of the manubrium or the innominate vein. Incision. B. To avoid entering the abdominal cavity. Approach completed.) ■ 37-10 FIGURE 37-15 Patient positioning and periscapular incision for high transthoracic approach. In children. avoid the inferior thyroid vein. Others have combined this approach with osteotomy of the clavicle or resection of the left sternoclavicular joint. This procedure is technically simple and avoids the risk of injury to the subclavian vessels that can occur with resection of the clavicle or sternoclavicular junction. Place the patient supine. ■ Extend the proximal end diagonally to the right and left along the base of the neck for a short distance. A. A disadvantage of ligation is that it leaves a slight postoperative enlargement of the left upper extremity that is not apparent unless carefully assessed. Spread the split sternum. the innominate vein now may be divided as it crosses the field. recommended this division. TECHNIQUE (DARLING ET AL. 37-16A).) SEE TECHNIQUE 37-9. SEE TECHNIQUE 37-8. Boston. ■ Develop the left side of this area bluntly. Pass one finger or an instrument above and below the suprasternal space. . and split the sternum. ■ By blunt dissection. Little. take care to keep the dissection beneath the periosteum while exposing the distal end of the sternum. 1977. Brown. 1539 MODIFIED ANTERIOR APPROACH TO CERVICOTHORACIC JUNCTION Several authors have described an anterior approach to the cervical thoracic junction using a combined full median sternotomy and a cervical incision. At the proximal end of the sternal notch. reflect the parietal pleura from the posterior surfaces of the sternum and costal cartilages and develop a space.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES suprasternal notch to just below the xiphoid process (Fig. ■ In patients with kyphotic deformity. Nickel VH. ■ This approach provides limited access. it may be very tense and subject to rupture. (Redrawn from Pierce DS. and its success depends on accuracy in preoperative interpretation of the deformity and a high degree of surgical precision. insert a Gigli saw. 37-16B). the upper portion of the exposure is posterior to the thymus and bounded by the innominate and carotid arteries and their venous counterparts. If the neck is stable. and gain access to the center of the chest (Fig. The approach described by Darling et al. editors: The total care of spinal cord injuries. place a sandbag transversely behind the shoulders to extend the neck and position the head in a head ring turned to the T3 Cut sternum Right innominate artery Vein Left subclavian artery Left carotid artery A B Aorta arch FIGURE 37-16 Transsternal approach to cervicothoracic spine (see text).

although some surgeons favor a right-sided thoracotomy for approaching the upper thoracic spine to avoid the subclavian and carotid arteries in the left superior mediastinum. ■ Incise the sternal fascia and divide the sternum in the midline from the sternal notch to the level of the second intercostal space. ■ Close the platysma and skin. whereas views of the upper and lower extremes of the spine are more limited. ■ Retract the sternum laterally to the left through the synostosis between the manubrium and body of the sternum. ■ Identify and cut the sternal ends of the sternocleidomastoid muscle and infrahyoid muscles 2 cm from their sternal insertions. then extend it caudally by following the vesselfree area anterior to the vertebrae along the deep cervical fascia. ■ Retract the retrosternal fat and large vessels caudally and anteriorly to expose the upper thoracic vertebra. ■ Retract the carotid sheath laterally. and continue in the midline to the level of the third costal cartilage. or fusion. ■ Reattach the strap muscles to the sternum. if multiple levels are involved. ■ Begin the dissection as in a standard anterior cervical approach. connecting the two portions of the incision. and attach the drain to closed suction. . avoid injuring the thoracic duct as it ascends to the left of the esophagus from the level of T4 to its junction with the left internal jugular and subclavian veins. ■ Gently retract the esophagus. and develop a plane of dissection. 37-17). Because of the normal thoracic kyphosis. decompression. ■ Divide the platysma in the line of the incision. ■ After spinal decompression and stabilization are completed. the rib at that level can be removed. 37-18A). and adjacent recurrent laryngeal nerve to the right. and elevate them away from the vertebral column. Excise the remaining bone with a Kerrison rongeur to complete the exposure. 37-18B). that exposure of T3 and T4 may require a median manubrial resection. TECHNIQUE 37-11 (POINTILLART ET AL. ■ Make an incision along the anterior border of the left sternocleidomastoid muscle to the sternal notch. The level of the incision should be positioned to meet the level of exposure required. ■ Drain the prevertebral space with a soft Silastic drain through a separate stab wound. however. but resection is unnecessary if a limited exposure is adequate for biopsy. The left side is used to protect the left recurrent laryngeal nerve. In general.1540 PART XII  THE SPINE right. Ordinarily. trachea.) Incise the skin along the medial border of the sternocleidomastoid muscle and extend it distally over the manubrium (Fig. The transthoracic approach adds a significant operative risk and is more hazardous than the more commonly used posterior or posterolateral approaches. In a left-sided thoracotomy approach the heart may be retracted anteriorly. ■ Place a small chest retractor. Take care not to injure the recurrent laryngeal nerve or the superior laryngeal nerve through pressure or traction. ■ Ligate and divide the inferior thyroid artery and middle and inferior thyroid veins. ■ Expose the manubrium to the medial portion of the sternoclavicular joint. ■ If exposure to T3-4 is required. and close the presternal fascia. and divide the omohyoid muscle. a left-sided thoracotomy incision is preferred. dissection is easier from proximal to distal. ■ Cut the sternoclavicular ligament with scissors. retract the sternocleidomastoid laterally. ■ Divide the strap muscles near their origin from the sternum to permit reconstruction. an intercostal space is selected at or just above the involved segment. Do not divide the sternocleidomastoid muscle. and open the partial sternotomy. The increased risk of thoracotomy must be weighed against the more limited exposure provided by alternative posterior approaches. reported that exposure of the cervi­ cothoracic junction can be achieved with the usual anterior approach without a sternotomy. Exposure is improved by resection of a rib. resect the manubrium down to the posterior cortex to allow the exposure desired (Fig. ■ Dissect the thymus and mediastinal fat away from the left innominate vein. divide the thymic and left innominate veins if necessary to expose the level of the aortic arch anteriorly and T4-5 posteriorly (Fig. and the rib provides a satisfactory bone graft. enter the prevertebral space. ■  ANTERIOR APPROACH TO THE THORACIC SPINE ANTERIOR APPROACH TO THE CERVICOTHORACIC JUNCTION WITHOUT STERNOTOMY Pointillart et  al. ■ With a high-speed drill. In completing the dissection. close the wound by approximating the manubrium with two or three heavy-gauge stainless steel wires using standard techniques. the rib at the upper level of the proposed dissection should be removed. The midthoracic vertebral bodies are best exposed by this approach. ■ Use finger dissection to free the posterior aspect of the manubrium for resection. They noted The transthoracic approach to the thoracic spine provides direct access to the vertebral bodies T2-12. whereas in a right-sided approach the liver may present a significant obstacle to exposure. If only one vertebral segment is involved.

Incise the parietal pleura and reflect it off of the spine. (Redrawn from Pointillart V. Gangnet N.) SEE TECHNIQUE 37-11. Spine 32:2875. and expose it subperiosteally. Up Left Brachiocephalic vein Endoring retractor Trachea Esophagus A Manubrium Aortic arch Heart Chest wall B FIGURE 37-18 Anterior approach to cervicothoracic junction without sternotomy. Perrin R: Modified anterior approach to the cervicothoracic junction. McBroom R. 37-19A). usually one vertebra above and one below ■ . Vital JM: Anterior approach to the cervicothoracic junction without sternotomy: a report of 37 cases. Sagittal section of the chest reflecting the thoracic spine exposure possible with upper manubrium resection and retraction. 1995.) SEE TECHNIQUE 37-10. Use electrocautery to maintain hemostasis during the exposure. Incision for exposure at cervicothoracic junction. an inflatable beanbag is helpful in maintaining the patient’s position. ■ Disarticulate the rib from the transverse process and the hemifacets of the vertebral body.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1541 Esophagus Trachea Recurrent laryngeal nerve Common carotid artery Internal jugular vein Sternocleidomastoid muscle FIGURE 37-17 Modified anterior approach to cervicothoracic junction. Identify and preserve the intercostal nerve lying along the inferior aspect of the rib as it localizes the neural foramen leading into the spinal canal. B. ANTERIOR APPROACH TO THE THORACIC SPINE TECHNIQUE ■ 37-12 Place the patient in the lateral decubitus position with the right side down. Spine 20:1519. (Redrawn from Darling GE. Make an incision over the rib corresponding to the involved vertebra. and the table may be flexed to increase exposure (Fig. 2009. A. Aurouer N.

■ Count the ribs by “palpation” with a blunt grasping instrument. Operative procedures routinely are performed by a spine surgeon and thoracic surgeon. including an arterial pressure line. and place the patient in a Trendelenburg position for the lower thoracic spine or reverse Trendelenburg for the upper thoracic spine. ■ Rotate the patient anteriorly. In addition. 37-19B). Although the indications for the thoracoscopic approach apparently remain the same as for open thoracotomy. Use a 0-degree end-viewing scope and a 30-degree scope for direct vision of the intervertebral disc space to avoid impeding surgical instrumentation or obscuring the operative field. ■ Place the initial trocar in the seventh intercostal space in the posterior axillary line. patients should be informed before surgery that the thoracoscopic procedure may have to be abandoned in favor of an open procedure. and the 12th ribs. ■ When the correct level is ascertained. however.  VIDEO-ASSISTED THORACIC SURGERY Video-assisted thoracic surgery (VATS) has been used successfully in the anterior thoracic and thoracolumbar spine for treatment of scoliosis. thoracic lesions should be exposed through the chest. Remove disc material using rongeurs and curets. Also.1542 PART XII  THE SPINE the involved segment. and incise the anulus. perform the specific spinal procedure. ■ Perform an initial exploratory thoracoscopy to determine the correct spinal level for operative intervention. recommended placing the viewing port in the posterior axillary line directly over the spine and two or three access sites for working ports in the anterior axillary line to allow better access to the spine. Reported complications include intercostal neuralgia. and ligate and divide these (Fig. depending on the level of the thoracic spine to be approached.  ANTERIOR APPROACH TO THE THORACOLUMBAR JUNCTION VIDEO-ASSISTED THORACIC SURGERY TECHNIQUE (MACK ET AL. Anteriorly and laterally. it attaches to the cartilaginous ends of the lower six ribs and xiphoid. Somatosensory evoked potentials should be monitored routinely for patients undergoing spinal deformity correction or corpectomy. Division of these major . Posteriorly. ■ Use a small elevator to delineate the pedicle of the vertebrae and a Kerrison rongeur to remove the pedicle. ■ The lung usually falls away from the operative field when completely collapsed. In most instances. excessive epidural blood loss (2500 mL). In contrast to other VATS procedures in which the surgeon and assistant are positioned on opposite sides of the operating table. The diaphragm is a domeshaped organ that is muscular in the periphery and tendinous in the center. exposing the dural sac. Mack et al. angled rigid telescope through the 10-mm trocar. 37-19C). and fractures and seems to have less morbidity than the standard thoracotomy. and the anterior margin of the neural canal is identified with the posterior longitudinal ligament lying in the slight concavity on the back of the vertebral body. the arcuate ligaments. The diaphragm is innervated by the phrenic nerve. to allow adequate exposure for débridement and grafting (Fig. 30-degree ■ 37-13 Occasionally. pulse oximeter. atelectasis. tumors. which descends through the thoracic cavity on the pericardium. Place a 10-mm. both surgeons are positioned on the anterior side of the patient viewing a monitor on the opposite side. it may be necessary to expose simultaneously the lower thoracic and upper lumbar vertebral bodies.) Routine intraoperative monitoring for thoracic procedures is used. it originates from the upper lumbar vertebrae through crura. kyphosis. 37-20). and the surgical team always should include a thoracic surgeon who is competent in thoracoscopy and a spine surgeon who is well trained in endoscopic techniques. The phrenic nerve joins the diaphragm adjacent to the fibrous pericardium. which can result in respiratory problems or pain after thoracotomy. dividing into three major branches that extend peripherally in anterolateral and posterior directions. the camera and the viewing field are rotated 90 degrees from the standard VATS approach so that the spine is viewed horizontally. ■ Identify the disc spaces above and below the vertebrae. ■ Expose sufficient segmental vessels and disc spaces to accomplish the intended procedure—usually corpectomy and strut grafting. and end-tidal carbon dioxide measurement. ■ When the target level has been defined. Technically. Relative contraindications include preexisting pleural disease from previous surgeries. place a 20-gauge long needle percutaneously into the disc space from the lateral aspect and confirm radiographically. ■ Carefully reflect the periosteum overlying the spine with elevators to expose the involved vertebrae. obviating the need for retraction instruments. ■ Use the portals for placement of surgical instruments (Fig. some procedures require extensive internal fixation and may not be suitable for VATS. ■ A departure from the standard VATS approach is the positioning of the operative team. ■ An entire cross section of the vertebral body is developed. this is a more difficult exposure because of the presence of the diaphragm and the increased risk involved in simultaneous exposure of the thoracic cavity and the retroperitoneal space. ■ Identify the segmental vessels that cross the midportion of each vertebral body. whereas lesions predominantly involving the upper lumbar spine can be exposed through an anterior retroperitoneal incision. and temporary paraparesis related to operative positioning. Thoracoscopy has evolved rapidly and is capable of providing adequate exposure to all levels of the thoracic spine from T2 to L1. This “reverse L” arrangement can be moved cephalad or caudad. the learning curve is significant.

and tag it with sutures for later accurate closure. ■ .CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1543 A B C FIGURE 37-19 Transthoracic approach (see text). and expose the bone as previously described. branches may interfere with diaphragmatic function. ANTERIOR APPROACH TO THE THORACOLUMBAR JUNCTION TECHNIQUE ■ 37-14 Place the patient in the right lateral decubitus position. B. We recommend a left-sided approach at the thoracolumbar junction because the vena cava on the right is less tolerant of dissection and may result in troublesome hemorrhage. ligate them in the midline. and place supports beneath the buttock and shoulder. 37-21B). incise the diaphragm 2. SEE TECHNIQUE 37-12. A. dissect with caution and identify the two cavities on either side of the diaphragm. reflect the diaphragm from the lower ribs and the crus from the side of the spine (Fig. ■ Make the incision curvilinear with ability to extend the cephalad or the caudal end (Fig. Positioning of patient and incision. Isolate these. ■ Take care in entering the abdominal cavity. To achieve confluence of the two cavities.5 cm away from its insertion. 37-21C). resect the 10th rib. Rib removal and division of pleura. To gain the best access to the interval of T12-L1. it tends to approximate closely the wall of the thoracic cage. ■ Identify the segmental arteries and veins over the midportion of each vertebral body. allowing the edge of the lung to penetrate into the space beneath the knife as the pleura is divided (Fig. and the liver may be hard to retract. ■ Incise the prevertebral fascia. Exposure of spine and division of segmental vessels over one vertebral body. It is best to make an incision around the periphery of the diaphragm to minimize interference with function when making a thoracoabdominal approach to the spine. exposing lung. Because the transversalis fascia and the peritoneum do not diverge. 37-21A). C. ■ Alternatively. The only difficulty is in identifying the diaphragm as a separate structure. which allows exposure between T10 and L2.

) SEE TECHNIQUE 37-13. A B C FIGURE 37-21 Thoracolumbar approach (see text). Louis. B. or grafting at multiple levels in the lumbar spine. 1995. débridement. SEE TECHNIQUE 37-14.1544 PART XII  THE SPINE  ANTERIOR RETROPERITONEAL APPROACH. the incision may be varied in placement between the 12th rib and the superior aspect of the iliac crest. (Redrawn from Regan JJ. A. Skin incision. ■ Flex the table to increase exposure between the 12th rib and the iliac crest. Retroperitoneal detachment of diaphragm. editors: Atlas of endoscopic spine surgery. It is an excellent approach that should be considered for extensive resection. which is more difficult to repair than the aorta if vascular injury occurs during the approach to the spine. McAfee PC. . The approach is made most often from the left side to avoid the liver and the inferior vena cava. L1 TO L5 The anterior retroperitoneal approach to the lumbar vertebral bodies is a modification of the anterolateral approach commonly used by general surgeons for sympathectomy. Mack MJ. L1 TO L5 TECHNIQUE ■ 37-15 FIGURE 37-20 Thoracoscopic instrument placement for thoracic spine procedures. Position the patient in the lateral decubitus position. St. Depending on which portion of the lumbar spine is to be approached. Transthoracic detachment of diaphragm. Flex the hips slightly to release tension on the psoas muscle. generally with the right side down. Quality Medical Publishing. The major dissection in this approach is behind the kidney in the potential space between the renal fascia and the quadratus lumborum and psoas muscles. C. ANTERIOR RETROPERITONEAL APPROACH.

■ The sympathetic chain is found between the vertebral bodies and the psoas muscle laterally.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1545 L1 L2 L3 L4 A B C D FIGURE 37-22 Anterior retroperitoneal approach (see text). elevate the psoas muscle bluntly off the lumbar vertebrae and retract it laterally to the level of the transverse process with a Richardson retractor. Exposure of spine before ligation of segmental vessels. Skin incisions for lumbar vertebrae. internal oblique. and locate the neural foramen with the exiting nerve root. 37-22B and C). and muscle of the external oblique. and identify and protect with a Deaver retractor the great vessels lying anterior to the spine. Incision into fibers of internal oblique muscle. ■ Delineate the pedicle of the involved vertebra with a small elevator. place the incision several fingerbreadths below and parallel to the costal margin when exposure of the lower lumbar vertebrae (L3-5) is necessary. Sometimes. transversus abdominis. ■ Palpate the vertebral bodies from T12 to L5. A. Bipolar coagulation of vessels around the neural foramen is recommended. D. removal of the transverse process with a rongeur is helpful in allowing adequate retraction of the psoas muscle. and reflect it anteriorly by blunt dissection. and transversalis fascia in line with the skin incision (Fig. and the relatively avascular discs are prominent on each adjacent side of the vessels (Fig. 37-22A). fascia. ■ When the appropriate involved vertebra is identified. SEE TECHNIQUE 37-15. 37-22D). it must be repaired. ■ Place a Finochietto rib retractor between the costal margin and the iliac crest to aid exposure. ■ Alternatively. ■ Ligate and divide the lumbar segmental vessel overlying the involved vertebra. Make an oblique incision over the 12th rib from the lateral border of the quadratus lumborum to the lateral border of the rectus abdominis muscle to allow exposure of the first and second lumbar vertebrae (Fig. C. ■ Identify the psoas muscle in the retroperitoneal space. ■ Use electrocautery to divide the subcutaneous tissue. The lumbar segmental vessels lie in the midportion of the vertebral bodies. If the peritoneum is entered during the approach. whereas the genitofemoral nerve lies on the anterior aspect of the psoas muscle. ■ Carefully protect the peritoneum. ■ . Incision of fibers of external oblique muscle. B. and allow the ureter to fall anteriorly with the retroperitoneal fat.

scoliosis. obtain meticulous hemostasis. 37-23). neural monitoring is recommended while traversing the psoas. and less significant psoas irritation in five. resulting in a very narrow safe zone at L4-5. ■ Adjust the patient so a true 90-degree lateral image can be obtained with image intensification. analyzed the distance from a guide wire placed in 10 human cadavers using the usual lateral approach and concluded that the intrapsoas nerves are a safe distance from the radiographic center of the disc in most cases. No significant differences in complications were noted between the XLIF and DLIF procedures. and close the wound in layers over a drain in the retroperitoneal space. (Redrawn from Hu WK. The plexus was at the greatest risk of injury at the L4-5 level. He SS. Eur Spine J 20:557-562. ■ Identify the midlateral position of the disc space to be entered using a Kirschner wire marker and fluoroscopic imaging (Fig. Using MR images of the lumbar spine with the vertebral body divided into four zones. Park et al. 37-24A and B). ■ Sweep the retroperitoneal space anteriorly and palpate the psoas muscle (Fig. 18 were degenerative. and make an incision at this mark. or spondylolisthesis. irritation of the lateral femoral cutaneous nerve in six patients. avoid entering the peritoneum (Fig. et al: An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach. evaluated the position of the lumbar plexus in the psoas muscle of three fresh frozen human cadavers and noted that the lumbar plexus rests on the dorsal surface of the psoas muscle in a cleft created by the transverse process/vertebral body junction. and use the index finger to safely direct the dilator to the psoas muscle (Fig. and expose the dura. ■ 37-16 . reported that 13 (22%) of 58 patients had complications after a minimally invasive direct lateral anterior lumbar fusion (DLIF) and XLIF. L1 TO L4-5 (DLIF OR XLIF) P Ozgur et al. ■ Insert the initial dilator. Alteration in the anatomical location of the nerve root and the retroperitoneal vessels in patients with scoliosis further decreases this safe zone. and use blunt dissection with the index finger through the muscle layers to the retroperitoneal space.1546 ■ PART XII  THE SPINE Remove the pedicle with an angled Kerrison rongeur.) After the induction of a general endotracheal anesthesia. ■ After completion of the spinal procedure. first described the technique of extreme lateral interbody fusion (XLIF) as a refinement of the laparoscopic lateral approach. ■ Prepare and drape the patient for a direct lateral lumbar approach. ■ Make a second mark posterior to the first mark at the border of the erector spinae and the abdominal oblique muscles. place the patient in a right lateral decubitus position on a radiolucent operating table. the overlap between the adjacent neurovascular structures and the vertebral body end plate gradually increased from L1-2 to L4-5. ■ Secure the patient in this position with taping and a bean bag or similar device. 37-27B). Major complications occurred in five (8. 37-26). Approach-related complications included ipsilateral L4 nerve root injury in two patients. The primary use for this approach has been the placement of an anterior lumbar interbody graft for degenerative disc disease without central canal stenosis. Because of the risk of nerve injury in a small number of individuals. and zones I-II on the left at L4-5 and zone II on the right at L4-5 (Fig. 37-27A). 37-25). Benglis et  al. Most levels evaluated (247) were normal.6%) patients.) PERCUTANEOUS LATERAL APPROACH. On the MR images. FIGURE 37-23 Zones of the lumbar vertebral body. including reoperation for implant subsidence in one patient and persistence of the L4 root injury at 1 year in two patients. and 19 were scoliotic. Knight et al. Abdominal aorta Anterior margin of vertebral body Vertebral body A´ B´ Vena cava A I II III IV Psoas major muscle Posterior margin of vertebral body  PERCUTANEOUS LATERAL APPROACH TO LUMBAR SPINE.28 of the vertebral diameter at L4-5 (Fig. L1 TO L4-5 TECHNIQUE (OZGUR ET AL. each being 25% of the vertebral diameter (Fig. ■ Adjust the table to allow maximal distance between the left rib cage and the iliac crest. 2011. MRI studies have been analyzed to determine the safe zones for a minimally invasive lateral approach in both normal and abnormal spines. Hu et  al. ■ Turn the index finger up in a direct lateral position toward the lateral skin mark. zone II at L3-4. 37-27C). significant psoas spasm that lengthened the hospital stay in one patient. Zhang SC. ■ Make a 2-cm skin incision at this second mark. The plexus progressed in a dorsal fashion from near the posterior aspect of the vertebral body at L1-2 to 0. Mark this point on the skin. confirm the position of the dilator with fluoroscopy. identified the safe zones for approach using the minimally invasive lateral lumbar interbody fusion to be zones II-III at L1-2 and L2-3.

c. neural distribution. ■ Avoid the genitofemoral nerve by observing it directly until the disc is reached. The stimulus necessary to elicit an EMG response will vary with the distance from the nerve. b.) Expand the retractor blades to minimize nerve pressure and maximize disc exposure. B. ■ Confirm the final position with anteroposterior and lateral fluoroscopy before excising the disc. Right-sided XLIF approach as related to anatomical structure: a. ■ Take care to minimize trauma to the psoas muscle. vena cava distribution. b. ■ Monitor the progress of the dilator in the psoas muscle using electromyography. Eur Spine J 20:557-562.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES P IV III II I A L1/2 P IV III II I A L1/2 P IV III II I A L1/2 1547 L2/3 L2/3 L2/3 L3/4 L3/4 L3/4 L4/5 L4/5 L4/5 Vena cava distribution Neural distribution ii A I II III IV P L1/2 L1/2 Safe zone iii A I II III IV P A i A I II III IV P L1/2 L2/3 L2/3 L2/3 L3/4 L3/4 L3/4 L4/5 L4/5 L4/5 Abdominal aorta distribution Neural distribution ii Safe zone iii B i FIGURE 37-24 A. using blunt dissection at the level determined to be in the safe zone for the level to be accessed. Zhang SC. et al: An MRI study of psoas major and abdominal large vessels with respect to the X/DLIF approach. c. ■ Continue the dissection by spreading the midpsoas fibers laterally (Fig. safe zone. ■ Reconfirm placement of the initial dilator with fluoroscopy. ■ Introduce subsequent dilators until the retractor can be inserted (Fig. Left-sided XLIF approach associated with anatomical structures: a. 37-27D). (This instrument varies with the system used. neural distribution. 2011. ■ Observe the progress of the dilator directly to check for nerves that may lie in the safe zone.) Gently separate the psoas with the initial dilator. (From Hu WK. safe zone. ■ . distribution of abdominal aorta. He SS. 37-28). Threshold values of more than 10 mA indicate a distance that is safe for the nerves and adequate for working.

and until the anulus of the L5-S1 disc is clearly exposed. especially at the L5-S1 level. Patient positioning and placement of Kirschner wires. and transect the rectus abdominis muscle. ■ .) SEE TECHNIQUE 37-16. In addition. J Neurosurg Spine 10:139. ■ Palpate the aorta and the common iliac vessels through the posterior peritoneum. (From Benglis DM Jr. and make a vertical midline or a transverse incision (Fig. ■ Open the posterior rectus sheath and abdominal fascia to the peritoneum. (Redrawn from Ozgur BM. ■ Carefully open the peritoneum to avoid damage to bowel content. Longitudinal dark line is the course of the lumbar plexus as seen in the lateral view of a frozen human cadaver spine. ■ Extend the incision distally and to the right along the right common iliac artery to its bifurcation at the external and internal iliac arteries. Pimenta L. however. ■ Make a longitudinal incision in the posterior peritoneum in the midline around the aortic bifurcation. Levi AD: An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine. Taylor WR: Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. 2006. electrocautery should be kept to a minimum when dissecting within the aortic bifurcation. B FIGURE 37-26 Percutaneous lateral approach to L1 to L4-5. L5 TO S1 TECHNIQUE ■ 37-17 Position the patient supine on the operating table.)  ANTERIOR TRANSPERITONEAL APPROACH TO THE LUMBOSACRAL JUNCTION. Fluoroscopic image showing wire placement. ■ Carefully pack off the abdominal contents and identify the posterior peritoneum over the sacral promontory. no transverse scalpel cuts on the front of the disc should be made. and damage of this structure in men can cause complications such as retrograde ejaculation. A. Identify and open the sheath. The transverse incision is cosmetically superior and gives excellent exposure. damage to the superior hypogastric plexus should not produce impotence or failure of erection. The advantage of the transperitoneal route is a more extensive exposure. Aryan JE. ANTERIOR TRANSPERITONEAL APPROACH. The posterior rectus sheath. L5 TO S1 Transperitoneal exposure of the lumbar spine is an alternative to the retroperitoneal approach. Injury to the hypogastric plexus can be avoided by careful opening of the posterior peritoneum and blunt dissection of the prevertebral tissue from left to right and by opening the posterior peritoneum higher over the bifurcation of the aorta and extending the opening down over the sacral promontory.1548 PART XII  THE SPINE A FIGURE 37-25 White lines show the ratio measurements: plexus to posterior end plate (short white line) to total length of the disc (long white line). Vanni S. abdominal fascia. A disadvantage is that the great vessels and hypogastric nerve plexus must be mobilized before the spine is exposed. B. and peritoneum are conjoined in this area. 2009. The superior hypogastric plexus contains the sympathetic function for the urogenital systems. 37-29A). it requires transection of the rectus abdominis sheath. Spine J 6:435.

Because the L5-S1 disc and the sacrum often are angled horizontally. Taylor WR: Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:435. 2006. A. ■ After adequate exposure of the L5-S1 disc.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1549 A B C D FIGURE 37-27 Percutaneous lateral approach to L1 to L4-5. With patient in lateral decubitus position.) SEE TECHNIQUE 37-16. anterolateral extraperitoneal. 2006. crossing the right iliac artery. Guidance of the initial dilator into position. 37-29B). ■ If bleeding is encountered. and anterior retroperitoneal approaches. we recommend the bipolar rather than the unipolar machine because there is less likelihood of injuring the hypogastric plexus with a thermal burn. positioned directly on the lateral intervertebral disc space. Aryan JE. penetrating the psoas major. Pimenta L. After identification of the left common iliac artery and vein. the body of L5 may be mistaken for the sacrum. Spine J 6:435. Retractor inserted into retroperitoneal space. ■ FIGURE 37-28 Operative photograph of laterally inserted dilators. ■ Carefully dissect the middle sacral artery and vein from left to right (Fig. use direct finger and sponge pressure rather than electrocautery. (Redrawn from Ozgur BM. Surgeon’s index finger inserted into paraspinal incision site. Identification of retroperitoneal space. obtain a radiograph after inserting a 22-gauge spinal needle into the disc space. Taylor WR: Extreme lateral interbody fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. use blunt dissection to the right of the artery and hypogastric plexus and mobilize the soft tissue from left to right. ■ Avoid the use of electrocautery anterior to the L5-S1 disc space to prevent damage to the superior hypogastric plexus. penetrating the psoas major. Longitudinal blunt dissection allows better mobilization of these vascular structures. the endoscopic technique is evolving rapidly in terms of its role in procedures involving the . Aryan JE. and curve the incision medially to avoid this structure. (From Ozgur BM. and resting on the desired disc space. Identify the right ureter. Pimenta L. D.  VIDEO-ASSISTED LUMBAR SURGERY Standard anterior approaches to the lower lumbar and lumbosacral spine include the anterior transperitoneal. ■ The left common iliac vein often lies as a flat structure across the L5-S1 disc within the aortic bifurcation. sequentially larger dilators are shown inserted. C. B. ■ Further development of the exposure proceeds as in other anterior approaches to the lumbar vertebrae.) SEE TECHNIQUE 37-16. If electrocautery is used in this area. As with thoracoscopy.

dissect on the left side between the posterior sheath of the rectus abdominis and posterior aspect of this muscle. if necessary. SEE TECHNIQUE 37-17. Introduction of the endoscope gives good exposure of the prevertebral area and allows the operation to be continued under endoscopic and direct vision. retract the iliac vessels caudally. extraperitoneal approach that fully preserves the abdominal innervation and is optimized with video assistance. improved lighting. a more cosmetic horizontal suprapubic incision is available for the L5-S1 approach. ■ More acute endoscopic exposure of the vertebral plates is possible by using a 30-degree angulated arthroscope. ■ Introduce a 10-mm endoscope through a lateral portal between the umbilicus and anterior superior iliac spine for exposure of L5-S1 and at the level of the umbilicus for exposure of L4-5. although not reported. standard midline. ■ After division of the linea alba.) Place the patient supine and angulate the operative table to place the lumbar spine in slight extension. ■ Make a 4-cm vertical incision on the midline at the umbilicus for the L4-5 approach and halfway between the umbilicus and the pubic symphysis for the L5-S1 approach. Complications include vascular and peritoneal injuries. ■ The next landmark is the prominence of the psoas muscle and the iliac vessels. In addition. an improved fusion rate. allowing a better resection and perhaps. Dissection of middle sacral artery and vein. ■ Expose the anterior aspect of the intervertebral disc by blunt dissection through the midline incision. giving direct access to the anterior aspect of the disc. surgical assistants can observe the operation despite the small incision and. The division begins at the linea arcuata. McAfee et al. Median longitudinal or transverse Pfannenstiel incision. The lateral cleavage of the peritoneum can be increased by use of an inflatable balloon. good exposure of the vertebral end plates is achieved. Video assistance allows for a smaller incision. Reflect the ureter and peritoneum together. VIDEO-ASSISTED LUMBAR SURGERY TECHNIQUE (ONIMUS ET AL. B. The procedure can be completed with disc and vertebral plate resection. ■ Divide the posterior sheath at the lateral edge of the rectus returning to the subperitoneal fascia. anterior aspect of the lumbar spine. described a minimally invasive anterior retroperitoneal approach to the lumbar spine using an endoscopic technique. ■ 37-18 In women. ■ For exposure of L5-S1. the incision can be extended cephalad or caudad if conversion to a laparotomy is necessary. This procedure avoids peritoneal complications. ■ Intervertebral distraction allows iliac autogenous graft insertion. In addition. . A. and Onimus. and Gangloff described a less invasive. are true endoscopic procedures that are performed with carbon dioxide insufflation and may be impeded by abdominal wall adhesions. Papin. and easier presacral dissection. Divide the iliolumbar vein to allow caudal retraction of the left iliac vein. Use blunt dissection with a finger and dissecting swabs.1550 PART XII  THE SPINE Common iliac artery and vein L5 Middle sacral artery A B FIGURE 37-29 Transperitoneal appro­ ach to lumbar and lumbosacral spine (see text). Retract the common iliac vessels cranially with a specially designed retractor that is introduced through the midline incision and held in position by two Steinmann pins inserted in L5 and S1. which have been used for discectomy or fusion. hemoclip the middle sacral vessels and divide them. Transperitoneal laparoscopic approaches. ■ For exposure of L4-5. and it is anterior and midline oriented.

2008. a three-point head rest can be used to provide rigid immobilization of the cervical spine during surgery.000 epinephrine solution helps to provide hemostasis. The area in between contains the ring of C1. Surg Radiol Anat 30:239. POSTERIOR APPROACH TO THE CERVICAL SPINE. thoracic. the choice of approach to the spine should be dictated by the site of the primary pathological condition. and insert self-retaining retractors. Position the patient prone on a turning frame with skeletal traction through tongs. Posterior approaches to the spine commonly are used for degenerative or traumatic spinal disorders and allow excellent exposure to perform a wide variety of fusion techniques. ■ When necessary. expose the post­ erior elements subperiosteally. ■ Close the wound on a retroperitoneal suction tube inserted through the endoscope’s lateral port. Under most circumstances. Gupta measured the distance from the midline of C1 to the vertebral artery groove in 55 adult vertebrae and found that at least 1. avoiding excessive pressure on the eyes. may result in subluxation. causing increased compression of the neural elements and worsening of any neurological deficit.5 cm of the posterior arch could be safely exposed without mobilization of the vertebral artery (Fig. do not expose any spinal levels unnecessarily to avoid spontaneous fusion at adjacent levels. The posterior elements usually are not involved in the pathological process and provide stabilization for the uninvolved structures of the spinal column. Often the ring of C1 is thin. Removal of the uninvolved posterior elements. 37-31). or severe angulation of the spine. In addition. as in laminectomy. (Redrawn from Gupta T: Quantitative anatomy of vertebral artery groove on the posterior arch of atlas in relation to spinal surgical procedures. attach the drapes to the neck with stay sutures or staples.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1551 Occiput C1 B C C2 Vertebral artery A FIGURE 37-30 Distance between the posterior midline and the medial end of the vertebral artery groove at outer (A) and inner (B) cortex and the length of vertebral artery groove (C    ). Posterior approaches to the spine rarely are indicated when the anterior spinal column is the site of an infectious process or a metastatic disease. and lumbosacral. In children.) FIGURE 37-31 Posterior approach to upper cervical spine (see text). ■ While maintaining lateral retraction of the soft tissues. with or without internal stabilization.5 cm laterally on either side to avoid the vertebral arteries. The median raphe of the cervical spine is a wandering avascular ligament and does not follow a straight midline incision. It is the most direct access to the spinous processes. this is often deep compared with the spinous process of C2. With mobilization of the vertebral artery. including the occiput. do not carry the dissection farther than 1. ■ Make a midline longitudinal skin incision from the occiput to C2 (Fig. ■ After routine skin preparation. POSTERIOR APPROACHES The posterior approach through a midline longitudinal incision provides access to the posterior elements of the spine at all levels. and direct pressure can fracture it or cause the instrument to slip off the ring and . ■ Using electrocautery and elevators. OCCIPUT TO C2 TECHNIQUE ■ 37-19 POSTOPERATIVE CARE  Standing and ambulation are allowed 2 to 3 days after surgery. A body jacket orthosis is worn for 3 months. laminae. ■ It is important to deepen the incision in the midline through the thin white median raphe and avoid cutting muscle tissue. SEE TECHNIQUE 37-19. 37-30). including cervical. and facets. the spinal canal can be explored and decompressed over a large area after laminectomy. expose the occiput with elevators and insert the self-retaining retractors to expose the base of the skull and the dorsal spine of C2. Infiltration of the skin and subcutaneous tissue with a dilute 1 : 500. Alternatively. identify the posterior tubercle of C1 longitudinally in the midline and begin subperiosteal dissection to the bone. another 10 mm of arch could be exposed in either direction. dislocation. ■ When exposing the upper cervical spine.

the intended surgical procedure may be performed. To maintain dry field. It is helpful to maintain tension on the soft tissue by inserting self-retaining retractors. surgeon must stay within ligament. which is the extent of dissection on either side of the midline. Costotransversectomy should be considered for simple biopsy or local débridement. the knife blade or periosteal elevator would tend to follow the direction of the fibers into the muscle and divide the vessels. 37-33). POSTERIOR APPROACH TO THE THORACIC SPINE. ■ After identifying the lateral edge of the facet joint.5 cm from the midline. SEE TECHNIQUE 37-20. 37-20 Position the patient prone on a turning frame with skeletal traction through tongs or with the head positioned in the three-point head fixation device that is attached to the table. SEE TECHNIQUE 37-20. C3 TO C7 TECHNIQUE ■ FIGURE 37-32 Posterior approach to lower cervical spine (see text). increasing hemorrhage. the wound is closed in layers over a drain. pack each level with a taped sponge to keep blood loss to a minimum.1552 PART XII  THE SPINE penetrate the atlantooccipital membrane. and the posterior elements of C2. Alternatively. 37-32). ■ The vertebral artery may be damaged by penetration of the atlantooccipital membrane off the superior border of the ring of C1 more lateral than the usually safe 1. ■ The second cervical ganglion is an important landmark on the ring of C1 laterally. Nuchal ligament is irregular. the ring of C1. Nuchal ligament FIGURE 37-33 Posterior approach to lower cervical spine. ■ The large spinous processes of C2 and C7 are prominent and can be identified by palpation. if any. If exposure in the opposite direction is attempted. It is important to note on preoperative radiographs any posterior element deficiencies. and inject the skin and subcutaneous tissues with a 1 : 500. The dura may be vulnerable on the superior and the inferior edges of the ring of C1. T1 TO T12 The posterior approach to the thoracic spine can be made through a standard midline longitudinal exposure with reflection of the erector spinae muscle laterally to the tips of the transverse processes. ■ After this. ■ Make a midline skin incision over the appropriate vertebrae (Fig. the thoracic vertebrae can be approached through a costotransversectomy when direct access to the transverse processes and pedicles of the thoracic spine and limited access to the vertebral bodies are indicated. C3 C7 POSTERIOR APPROACH TO THE CERVICAL SPINE. ■ Below C2. ■ After exposure of the posterior occiput. There is little. before exposure of the posterior elements. ■ It is helpful to expose the spinous processes distal to proximal because the muscles can be stripped from the spinous processes in the acute angle between their insertions and the bone. ■ Deepen the dissection in the midline. the lateral margins of the facet joints are the safe lateral extent of dissection. It lies approximately 1. indication for dissection lateral to this groove.5 cm laterally on the lamina of C1 in the groove for the vertebral artery. using the electrocautery knife and staying within the thin white median raphe to avoid cutting the vascular muscle tissue (Fig. ■ Using electrocautery and elevators. such as an occult spina bifida. This approach does not provide the working operative area or . detach the ligamentous attachments to the spinous processes and expose the posterior elements subperiosteally to the lateral edge of the facet joints.000 epinephrine solution to aid in hemostasis.

subcutaneous tissue. L1 TO L5 The posterior approach to the lumbar spine provides access directly to the spinous processes. and facet joints as necessary. where both sides of the spine require exposure. ■ Make a straight longitudinal incision about 2. ■ After completion of the spinal procedure. proceed with dissection directly anteriorly on the pedicle to the vertebral body along a path that is relatively free of major vessels or nerves (Fig.) ■ Palpate the slight depression between the dorsal paraspinal muscle mass and the prominent posterior angle of the rib and center the incision over this groove lateral to the spinous processes. pedicle. ■ Deepen the dissection through the subcutaneous tissues and the trapezius and latissimus dorsi muscles and the lumbodorsal fasciae. close the wound in layers over a suction drain. ■ Pack each segment with a taped sponge immediately after exposure to lessen bleeding. 37-35B). ■ Expose the transverse process and posterior aspects of the associated rib subperiosteally. ■ Close the wound in layers over a drain to prevent hematoma collection. Anterior to the transverse process is the vertebral pedicle. 37-35A). laminae. TECHNIQUE ■ 37-21 Position the patient prone on a padded spinal operating frame. POSTERIOR APPROACH TO THE LUMBAR SPINE.000 epinephrine solution helps to provide hemostasis. and facet joints . ■ When the pedicles. SEE TECHNIQUE 37-21. ■ Make a long midline incision over the area to be exposed (Fig. ■ After completion of the spinal procedure. ■ Repeat the procedure until the desired number of vertebrae are exposed. ■ Obtain a chest radiograph to document the absence of air in the pleural space. which may occur if the pleura is inadvertently entered during the exposure. obtain a radiograph to confirm proper localization of the intended level. which are divided longitudinally. fill the wound with saline and inflate the lungs to check for air leaks. ■ After satisfactory exposure of the posterior elements. giving off a dorsal and ventral ramus. (Alternatively.5 inches (6. ■ Deepen the dissection in the midline using a scalpel or the electrocautery knife through the superficial and lumbodorsal fasciae to the tips of the spinous processes. The costotransverse ligament and joint capsule are strong and increase the inherent stability of the thoracic spine.5 inches (~9 cm) lateral to the vertebra at its prominent posterior angle. 37-34). make a curved incision with its apex lateral to the midline.3 cm) lateral to the spinous processes centered over the level of the desired vertebral dissection (Fig. raising the sympathetic trunk and parietal pleura. Place the patient prone on a padded spinal operating frame. The nerve roots emerge from the superior portion of the foramina. Infiltration of the skin. The rib generally is transected with rib cutters about 3. ■ Exposure may be increased by removal of the transverse process. neural foramina.5 cm long at the level of involvement. length of exposure to the thoracic vertebral bodies that is afforded by a transthoracic approach or the midlongitudinal posterior approach. and retract them medially. and above and below the pedicle lie the neural foramina. and erector spinae to the level of the laminae with 1 : 500. ■ Expose subperiosteally the posterior elements by reflecting the erector spinae muscle laterally to the tips of the transverse processes distal to proximal. using periosteal elevators. ■ Carefully dissect the parietal pleura with elevators anteriorly to expose the anterolateral aspect of the vertebral body. ■ Remain subperiosteal and extrapleural during this part of the exposure. and neurovascular structures have been identified. and remove a section of rib 5 to 7. ■ Dissect the paraspinal muscles sharply from their insertions on the ribs and transverse processes. and protect the intercostal neurovascular bundle. use the same technique on each side. The ventral ramus becomes the intercostal nerve and is joined by the intercostal vessels.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1553 COSTOTRANSVERSECTOMY TECHNIQUE ■ 37-22 T1 T12 FIGURE 37-34 Posterior approach to thoracic spine (see text).

■ After completion of the spinal procedure. B. ■ Carry the dissection down in the midline through the skin. ■ Pack each segment with a taped sponge immediately after exposure to lessen bleeding. ■ Make a midline skin incision centered over the involved lumbar segment (Fig. Use self-retaining retractors to maintain tension on soft tissues during exposure. ■ Subperiosteally expose the posterior elements from distal to proximal using electrocautery and periosteal elevators to detach the muscles from the posterior elements. By allowing the abdomen to hang free.5 inches (6. ■ . 37-36). A. close the wound in layers over a drain. We recommend accurate localization of the involved segment with a permanent radiograph in the operating room. centered over level of vertebral dissection. Straight longitudinal incision about 2. intravenous pressure is decreased and blood loss is decreased as a result of collapse of the epidural venous plexus. SEE TECHNIQUE 37-23.000 epinephrine aids hemostasis. and inserting pedicle screws. Wiltse and Spencer refined the paraspinal approach to the lumbar spine. which involves a longitudinal separation of the sacrospinalis muscle group to expose the posterolateral aspect of the lumbar spine. subcutaneous tissue. Infiltrating the skin and subcutaneous tissue with 1 : 500. Resection of costotransverse articulation. and lumbodorsal fascia to the tips of the spinous processes. decompressing a “far out” syndrome. In addition.1554 PART XII  THE SPINE Lung Aorta Esophagus A B FIGURE 37-35 Costotransversectomy.3 cm) lateral to spinous processes. This approach is especially useful in removing far-lateral disc herniation. L5 Sacrum FIGURE 37-36 Posterior approach to lumbar spine (see text). ■ If the procedure requires exposure of both sides of the spine. use the same technique on each side. SEE TECHNIQUE 37-22. the transverse processes and pedicles can be reached through this approach. at all levels. L1 TECHNIQUE ■ 37-23 Position the patient prone or in the kneeling position on a padded spinal frame.

) SEE TECHNIQUE 37-24. and laminae subperiosteally. separate the transverse fibers of the multifidus from their heavy fascial attachments. Avoid carrying the dissection anterior to the transverse processes because the exiting spinal nerves lie just in front of the transverse processes and can be injured. Midline skin incision. ■ After the fascial layers have been divided. PARASPINAL APPROACH TO LUMBAR SPINE TECHNIQUE 37-24 (WILTSE AND SPENCER) Position the patient prone or in the kneeling position on a spinal frame. A. 37-37D and E). Fascial incisions. ■ . 37-37B and C). a natural cleavage plane is entered lying between the multifidus and longissimus muscles.000 epinephrine helps to provide hemostasis. and denude them of soft tissue. Blunt finger dissection between muscle groups to palpate facet joints.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1555 A B C Longissimus Iliocostal Multifidus Longissimus Iliocostal Psoas major Psoas major D L5 E L5 FIGURE 37-37 Paraspinal approach to lumbar spine (see text). Spencer CW: New uses and refinements of the paraspinal approach of the lumbar spine. B and C. ■ Using electrocautery or an elevator. ■ Make a fascial incision approximately 2 cm lateral to the midline (Fig. ■ Make a midline skin incision centered over the involved lower lumbar segment (Fig. palpate the facet joints at L4-5. Spine 13:696. ■ Expose the lumbar transverse processes. and retract the skin and subcutaneous tissue laterally on either side. intravenous pressure is decreased and blood loss is decreased as a result of collapse of the epidural venous plexus. Place self-retaining Gelpi retractors between the two muscle groups. Using blunt finger dissection between the muscle groups (Fig. 37-37A). facet joints. By allowing the abdomen to hang free. Infiltration with 1 : 500. 1988. ■ Carry dissection down to the lumbodorsal fascia. D and E. (Redrawn from Wiltse LL.

37-38B). ■ Divide the supraspinous ligament precisely over the tip of the spinous processes. (Modified from Wagoner G: A technique for lessening hemorrhage in operations on the spine. and articular facets exposed. and incise the superficial fascia. ■ Perform unilateral or bilateral decompression and fusion of the lumbosacral spine. ■ If exposure in the opposite direction is attempted. if desired. blunt periosteal elevator through this opening so that its end rests on the junction of the spinous process with the lamina of the more proximal vertebra (Fig. and the supraspinous ligament longitudinally. and repeat the procedure as described. laminae. expose the posterior surface of the laminae and the articular facets. ■ Insert a small. ■ Repeat the procedure until the desired number of vertebrae have been exposed (Fig.1556 ■ PART XII  THE SPINE Use bipolar cautery to control bleeding from the lumbar arteries and veins coursing above the base of the transverse processes. B. A. the access to the sacroiliac joint is limited. Muscle insertions are freed subperiosteally from lateral side of spinous processes and interspinous ligaments. precisely over the tips of the processes. ■ Place the end of the elevator in the wound so that its end rests on the junction of the spinous process with the lamina of the next most proximal vertebra. Ebraheim et al. dissection proceeds proximally. ■ Close the wound over a suction drain. divide longitudinally the ligament between the two spinous processes in the most distal part of the wound. ■ This approach exposes the spinous processes and medial part of the laminae. by further subperiosteal reflection along the laminae. the arterial supply to the muscles is encountered (Fig. 37-38A). Move the handle of the elevator proximally and laterally to place under tension the muscles attached to this spinous process. described a transosseous approach to the . Replace blood as it is lost. 1937. L1 TO SACRUM TECHNIQUE (WAGONER) Make a longitudinal incision over the spinous processes of the appropriate vertebrae. ■ Expose the spinous processes from distal to proximal as just described because the muscles can then be stripped from the spinous processes in the acute angle between their insertions and the bone. Spinous processes. however. ■ Pack each segment with a tape sponge immediately after exposure to lessen bleeding. and suture the skin flaps down to the fascia to remove dead space. ■ For operations requiring exposure of both sides of the spine. showing proximity of internal muscular branches to spinous processes. ■ With a scalpel moving from distal to proximal. otherwise. Courses of arteries supplying posterior spinal muscles. the knife blade or periosteal elevator tends to follow the direction of the fibers into the muscle and divides the vessels. and denude subperiosteally the sides of the processes because this route leads through a relatively avascular field. J Bone Joint Surg 19:469. 37-38C). use the same technique on each side. ■ First lumbar vertebra 37-25 A B C FIGURE 37-38 Approach to posterior aspect of spine. C. ■ Blood loss can be decreased further by using electrocautery and a suction apparatus.) SEE TECHNIQUE 37-25. the lumbodorsal fascia. with periosteal elevator being held against bases of spinous processes. increasing hemorrhage. POSTERIOR APPROACH TO THE LUMBOSACRAL SPINE. ■ With a scalpel. ■ Increase the exposure. POSTERIOR APPROACH TO THE SACRUM AND SACROILIAC JOINT The posterior sacrum and sacroiliac joint are approached most commonly through a standard posterior exposure. strip the muscles subperiosteally from the lateral surface of the process.

leading to dysfunction in hip abduction. sacroiliac joint that they suggested improves access for débridement and arthrodesis with only minimal soft tissue dissection and iliac bone resection. Surg Neurol 72:318. Am J Surg 194:98. PIIS.5 cm 1 cm 1 cm Sciatic notch Inferior A B FIGURE 37-39 Posterior approach to sacroiliac joint. 2007. Lu J. posterior inferior iliac spine. Benglis DM Jr. ■ Divide the superficial fascia. ■ Sharply dissect the origin of the gluteus maximus from the posterior ilium. 2008. Right triangle on outer table of posterior ilium. Eur Spine J 17:991. George B: Anterolateral approach to the V2 segment of the vertebral artery. Instr Course Lect 54:559. A. The dimensions of the right-angle triangle in the outer table of the posterior ilium are illustrated in Figure 37-39B. Skin incision. Vanni S. Mirone G. et al: Anatomic considerations for posterior approach to the sacroiliac joint. PSIS. ■ Extend the incision laterally and distally approximately 5 cm (Fig. Bitan FD. George B: Cervical spine lateral approach for myeloradiculopathy: technique and pitfalls. 2005.) 37-26 After removal of the articular cartilage. Bridwell KH: Indications and techniques for anterior-only and combined anterior and posterior approaches for thoracic and lumbar spine deformities. Bruneau M. 2009. 37-39A). Indications include trauma. ■ Insert one or two Steinmann pins into the ilium to assist in retracting the gluteus maximus laterally and distally. Cansever T. et al: Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine. Bloom ND. ■ Place the patient prone on padded bolsters or a spinal frame.5 cm 2–2. Levi AD: An anatomical study of the lumbosacral plexus as related to the minimally invasive transpsoas approach to the lumbar spine: laboratory investigation. J Neurosurg Spine 10:139. which may retract into the pelvis.) SEE TECHNIQUE 37-26. ■ REFERENCES Beisse R: Video-assisted techniques in the management of thoracolumbar fractures. Biyani A. and inflammatory processes. Karasu A. ■ Make an incision beginning at the level of the posterior superior iliac spine and extending distal to the midpoint between the posterior superior iliac spine and the posterior inferior iliac spine. ■ Elevate a right-angle triangular bone window from the posterior ilium using an osteotome or power saw. Cornelius JF. Gupta T: Quantitative anatomy of vertebral artery groove on the posterior arch of atlas in relation to spinal surgical procedures. making hemostasis difficult. Spine 21:2709. 2009. and incise the gluteus medius muscle along the line of the skin incision. It is important not to injure the superior gluteal neurovascular bundle. . Hanan SH: Open anterior approaches for lumbar spine procedures. Bresson D. Surg Radiol Anat 30:239. ■ Expose the posterior external surface of the ilium between the posterior superior iliac spine above and the superior border of the greater sciatic notch below.CHAPTER 37  SPINAL ANATOMY AND SURGICAL APPROACHES 1557 Superior Posterior Anterior PSIS PIIS PIIS 3–3. ■ Accurate localization of the bone window in the iliac crest is important to avoid laceration to the superior gluteal artery. Débride the joint with curets. B. TECHNIQUE (EBRAHEIM ET AL. degenerative disease. 1996. Civelek E. place the previously elevated bone window into its original position and carefully tamp it back into place. infection. and remove the articular cartilage from the sacrum and ilium (Fig. Gumbs AA. Injury to the superior gluteal nerve may denervate the gluteus medius. Chibbaro S.5 cm 1. and identify the superior border of the greater sciatic notch. This approach allows direct exposure of the corresponding sacral articular surfaces. (Redrawn from Ebraheim NA. ■ Subperiosteally elevate the gluteal musculature laterally. 2008. posterior superior iliac spine. 2005. Neurosurgery 57(ONS Suppl 3):ONS-262. 37-39B). 2007. Orthop Clin North Am 38:419.

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