Surgical Approaches to the Spine

Second Edition
Springer-Science+Business Media, LLC
Robert G. Watkins, MD
Professor of Clinical Orthopedic Surgery,
University of Southern California
Co-Director of the Los Angeles Spine Surgery Institute at
St. Vincent's Hospital
Las Angeles, California

Surgical Appraaches
ta the Spine
Second Edition

With 457 Illustrations, 341 in Full Color

'SPringer
Robert G. Watkins, MD
Professor of Clinical Orthopedic Surgery
University of Southem California
Co-Director of the Los Angeles Spine Surgery Institute
al SI. Vincent's Hospital
Los Angeles, CA 90057
USA
spinergw@earthlinknet

Library of Congress Catalogmg-in-Publication Dala

Walkins. Robert G.
Surgical approaches la the spine / Robert G. Watkins.-2nd ed.
p. ;cm.
Includes bibliographical references aud index.
ISBN 978-1-4612-6508-5 ISBN 978-1-4613-0009-0 (eBook)
DOI 10.1007/978-1-4613-0009-0
1. Spine-Surgery-Allases. 1. Title.
[DNLM: 1. Spine-surgery-Atlases. WE 17 W335s 2003]
RD533.w34 2003
617.5'6059-dc21 2002036560

ISBN 978-1-4612-6508-5
© 2003 Springer Scienee+Business Media New York
Originally published by Springer-Verlag New York, Ine. in 2003
Softeover reprint of the hardeover 2nd edition 2003
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Preface to the Second Edition

In the years sin~e publication of the Hrst edition of SurgicaL Approaches to the Spine, a
revolution has taken place in spinal surgery, Spinal technology has exploded, thereby in-
creasing the need for multiple access sites to the spine. The book was originally written
because the spinal surgeon sometimes lacked the ability to approach the spine with the
ideal procedure. As a result, spinal problems were often handled with a posterior approach
when the treatment theories and biomechanical considerations of the spine dictated an
anterior approach. Then John O'Brien and other anterior surgeons began to emphasize
the need to perfect the approach so that the ideal operation was provided for each imli-
vidual patient. Through our work over the last 20 years, with surgeons such as Salvador
Brau, a spinal access surgeon, surgeons are now dedicated to providing a safe, pain-free
approach to the spine. This will ultimately be to the patient's great advantage. Advances
in intradiscal dcvices, prostheses, and fusion techniqucs have mandated a safe and effec-
tive anterior approach to the spine. An operation to relieve spinal pain cannot exist if the
approach produces more pain than the original problem.
This second edition contains chapters on very complicated operations, such as the ap-
proaches to the sacrum and pelvis, the total vertebrectomy, trans clavicular cervicothoraeic
approach, and anterior approach to the clivus of CI-C2. It is these major operations that
put the patient' s lif~~ in jeopardy and require expertise in the approach. The text also dis-
cusses minimally invasive approaches, such as thc laparoscopic fusion. Minimally invasive
surgery is the future of spinal surgery and represents a major advance in protection of the
patient, with lower morbidity than that associated with the minimally invasive approaches.
The challenge of the next decade will be adapting minimally invasive computer-assisted,
image-guided approaches to the patient's pathology and perfecting the available technol-
ogy for solving that pathology.
The first edition of Surgical Approaches to the Spine was appreciated by its audience
for its simple step-by-step, how-to method of presenting the surgical approach. The em-

v
vi PREFACE TO THE SECOND EDITION

phasis on how to avoid complications, what specific steps to take, and what specific tools
to use was a distinct advantage over publications with the more broad-stroke type of "ex-
pose the spine." The use of color illustrations and photographs and the emphasiS on a clear-
cut presentation in a step-by-step fashion have been preserved.
This book is intended for all spinal surgeons and for the newer category of spinal ac-
cess surgeon. Certainly, some spinal surgeons are very confident in performing their own
surgical approaches to the spine. As the expertise of spinal access surgeons increases, the
spinal surgeon may find this, as we have, to be a distinct advantage in producing a safe,
effective operation. The secondary market for this text is for all professionals involved in
treating the spine. Decision making in spinal surgery depends on a risk-benefit ratio.
Everyone participating needs to understand the approach to the spine to determine if sur-
gery is a viable option or not.
I would like to acknowledge Katherine Williams for her tireless work on this project.
Her contribution began in 1983 and has continued through this edition. Her dedication
to this project is indicative of her dedication to health and proper care of all spinal pa-
tients. Surgeons and patients owe a debt of gratitude to her for the eHort in this book and
other similar publications.

Robert G. Watkins, MD
Preface to the First Edition

This volume is designed to meet the need for a practical, well-illustrated ~ide to the nor-
mal anatomy of surgical approaches to the spine-the most fundamental information for
spinal surgery. Most of the basic approaches, anterior and posterior, are covered for each
level of' the spine. The speCific pathology and the operative procedure indicated for any
particular patient will naturally influence the choice of approach. While we have illustrated
only normal anatomy as seen through the surgical incision, we hope to have given the
reader a sound basis for chOOSing the most appropriate surgical approach for various clini-
cal conditions.
The illustrations are accompanied by a methodical description of operative techni'lue
for spinal exposure, emphasizing the critical anatomical landmarks. The bibliography ac-
companying each chapter is not comprehensive, nor does it necessarily cite the original
reports of each technique: rather, we have chosen to include good descriptive reports of
each approach. It is our hopc that an improved understanding of surgical anatomy and op-
erative approaches will free the spinal surgeon to implement the optimal treatment plan
for each patient.

Robert C. Watkins, MD

vii
Contents

Preface to the Second Edition .... . ...... . ...................... . v

Preface to the First Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. vii
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. xiii

Anterior Cervical Approaches to the Spine ...... . .... . ...... .

2A Transoral Approach to C1- 2 7

2B Transoral-TransphaI)'llgeal Approach to the Cervical Spine 12

Uttam K Sinha and Srinath Samudrala

3 Ventral Approaches to the Clivus, C1, and C2 19

Ranjeev Singh Bhangoo and H. Alan Crockard

4 Anterior Medial Approach to C1, C2 , and C3 ................ . .... . . 34

5 Anterior Lateral Approach to the Upper Cervical Spine .. . . . . . . . . . . . . .. 42

6 Anterior Medial Approach to the Midcervical Spine . . . . . . . . . . . . . . . 48

7 Lateral Approach to the Cervical Spine (Verbiest) ... . .... . ....... . ... 54

8 Lateral Approach to the Cervical Spine (Hodgson) . . . . . . . . . . . . . . . . . . .. 60

9 Supraclavicular Approach ... . . .. . . .. . . . . . . . .. .. .... 65

ix
X CONTENTS

10 Lincoln Highway Approach to the Cervical Spine. 72

11 Cervicothoracic Junction .................. . 79

12 Anterior Approach to the Cervicothoracic Spine .............. . 81

Salvador A. Brau

13 Transsternal Approach to the Cervicothoracic Junction . 87

Narayan Sundnresan. Alfred A. Steinberger, and Frank Moore

14 Transaxillary Approach to the Upper Dorsal Spine ...... . 101

Roger C. Breslaut

15 Third Rib Resection in the Transthoracic Approach 107

16 Thoracotomy Approach ..... 113

17 The Thoracolumbar Junction ................................... . 124

18 Tenth Rib: Thoracoabdominal Approach 127

19A Eleventh Rib Approach ....................................... . 133

19B Trans-Eleventh Rib Extrapleural Approach 140

Yutaka Hiraiwmi

20 Twelfth Rib Approach ........................................ . 149

21 Anterior Retroperitoneal Flank Approavh to L2-L5 of the Lumbar Spine . .. 1.54

22 Anterior Retroperitoneal Muscle-Sparing Approach to L2-S1

of the Lumbar Spine. . . . .............. . 165
Salvador A. Brau

23 Anterior Retroperitoneal Flank Approach to L5-51 182

24 Anterior Extraperitoneal Midline Incision of L2-S 1 188

25 Transperitoneal Midline Approach to L4-S 1 195

26 Superior Hypogastric Sympathetic Plcxus .. 202

27 En Bloc Sacrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20.5

Katsuro Tumita. Hiroyuki Tsuchiya. Noriu Ka.u;ahara, Masahiko Hata,
and Hideki Murakami

28 Approach to the Posterior Aspect of C l-C2 ........................ . 217

29 Posterior Approach to the C l-C2 Joints 224

Bernard Jeanneret

30 Cervical Foraminotomy: Indications and Technique 237

Peter Dyck

fDeceased
 CONTENTS xi

31 Microcervical Foraminotomy: An Alternative Posterior Technique

for Intractable Radicular Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 245
Robert Warren Willimns

32 Costotransversectomy ..... . 25,5

33 Posterior and Posterolateral Approaches to the Thoracic Disc. . . . . . . . . 261

Paul H. Young

34 Posterior Approach to the Lower Lumbar Spine 277

35 Lumbar Laminotomy, Foraminotomy, Root Decompression, and

Discectomy in the Lateral Position ............................... 289
Michael L.J. Apuzzo

36 Microscopic Lumbar Discectomy ................................ 297

37 Total En Bloc Spondylectomy: A New Surgical Technique

for Malignant Vertebral Tumors . . . . . . . . . . . . . . . . . . . . . . . .. 309
Norio Kawahara, Katsuro Tomita, and Hiroyuki Tsuchiya

38A Bilateral Paraspinous Lumbosacral Approach . . . . . . . . . . . . . . . . .. 326

Robert G. Watkins III and Robert G. Watkins IV

38 B Lateral Approach to the Disc ................................... 333

Robert G. Watkins III and Robert G. Watkins IV

39 Laparoscopic Approach to the L3-14 and 14-L5 Invertebral Discs 337

Namir Katkhouda, Sanjay Ghosh, and Srinath Samudrala

40 Transperitoneal Laparoscopic Approach to L5-S1 345

Salvador A Bmu

41 Balloon-Assisted Endoscopic Retroperitoneal Gasless (BERG)

Approach to the Lumbar Spine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 352
John S. Thalgott, John A. Ameriks, Frank T. Jordan, and James M. Giuffre

42 Video Endoscopic Approach to the Thoracic Spine 360

Salvador A. Bmu

43 Microendoscopic Discectomy for Lumbar Disc Herniations:

Paramedian and Far Lateral Approaches . . . . . . . . . . . . .. 367
Kevin T. Foley, Manrice M. Smith, and Y. Raja Rampersaud

Index .................................................... . 385

Contributors

John A. Ameriks, MD Frank Moore, MD

Michael L.J. Apuzzo, MD Hideki Murakami, MD
Ranjeev Singh Bhangoo, MD Y. Raja Rampersaud, MD, FRCSC
Salvador A. Brau, MD, FACS Srinath Samudrala, MD
tRoger C. Breslau, MD Uttam K. Sinha, MD
H. Alan Crockard, FRCS Maurice M. Smith, MD
Peter Dyck, MD Alfred A. Steinberger, MD
Kevin T. Foley, MD Narayan Sundaresan, MD
Sanjay Ghosh, MD John S. Thalgott, MD
James M. Giuffre, BA Katsuro Tomita, MD, PhD
Masahiko Hata, MD Hiroyuki Tsuchiya, MD, PhD
Yutaka Hiraizumi, MD, PhD Robert G. Watkins, MD III
Bernard Jeanneret, MD Robert G. Watkins, MD IV
Frank T. Jordan, MD Robert Warren Williams, MD
Namir Katkhouda, MD Paul H. Young, MD
Norio Kawahara, MD, PhD

1Deceased xiii