Serge Nazarian, Cyril Solari
6 SURGICAL ANATOMY OF THE SPINE
6.4 THORACIC SPINE
1 ANATOMY RELATED TO POSTERIOR PROCEDURES
Posterior approaches to the thoracic spine are required to
expose the posterior aspect of the thoracic vertebrae, spinous
processes, laminae, zygapophyseal joints, transverse processes,
and costovertebral joints. The posterior approach requires
a midline skin incision and a detachment of the muscle
insertions from the vertebrae.
The skin and the bony palpable landmarks
The palpable bony landmarks consist mainly of the tips of the
spinous processes and the scapula. The posterior arches of the
ribs cannot be numerically identified. The inferior angle of the
scapula corresponds approximately to the 7th rib.
173
Muscular layers
Posteriorly, four muscular layers cover the thoracic spine.
• Trapezius muscle—its medial insertions are on the
spinous processes from C7 to T12.
• Rhomboid muscles
• Serratus posterior superior and inferior muscles
• “Spinal” muscles
Vasculonervous bundles
At each level, a neurovascular bundle composed of a branch
from the intercostal artery, a branch to the intercostal vein, and
the posterior ramus of the intercostal nerve, runs backward
below the transverse process and supplies the aforementioned
muscles.
174 6 Surgical anatomy of the spine

1.1 ANATOMY RELATED TO LAMINA HOOK INSERTION

In the thoracic spine lamina hooks are used in a supralaminar

position:

• At the upper end of an instrumentation, to make a claw

with an ipsilateral pedicle hook placed on the underlying
vertebra, or to secure the purchase of a pedicle screw.
• At the middle part of a construct, when a slight
distraction is required or when the use of a pedicle screw
is anatomically impossible.

The anatomical details for hook insertion are described in Fig

6.4-1.

cranial cranial cranial

right right right

a b c
Fig 6.4-1a–e
a The lamina of a thoracic vertebra is b Posterior view after section of the spinous c Posterior view of the lamina after resection
hidden by the spinous process and process and the lower part of the laminae. of the yellow ligament. Using a thin curette,
lamina of the overlying vertebra. Once the spinous process is removed, the the inferior attachment of the yellow
To expose the superior border of lamina appears; its upper border is hidden ligament is delicately detached. This
the lamina, the overlying spinous by the insertion of the yellow ligament (1 detachment exposes the superior border of
process should be cut and ligamentum flavum). This ligament shows the thoracic lamina which usually describes
removed. thin vertical striations. a concave line (arrow).

AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES

6.4 Thoracic spine 175

1.2 ANATOMY RELATED TO PEDICLE HOOK INSERTION

Pedicle hooks are inserted between the inferior and superior

facet of two contiguous thoracic vertebrae. Their bifid tip is
made to straddle the inferior border of the pedicle with its
bifurcated cranial end ( Fig 6.4-2b–c ).
cranial
The inferior zygapophyseal facet is roundly shaped from its
medial to lateral aspect. It is partly covered by the capsule. This
right
d capsule should be removed to clearly identify the limits of the
facet. After removal of the capsule, the inferior end of the facet
is cut out to fit the hook perfectly ( Fig 6.4-2a ).

* The medial limit should be correctly identified. It is located

6 mm
cranial
right
e is reached by the tip of the fi nder, its bifurcated end fits the
Fig 6.4-1a–e
d The lamina is sometimes irregularly delineated due to the
partial calcification of the yellow ligament.
e Posterior view of the lamina after preparation for hook
placement (asterisk). The width of the lamina hook is 3–5 mm.
Protecting the dura with a thin dissector and using a 2 mm
thin Kerrison rongeur, the upper border of the lamina is cut
out in order to obtain a 6 mm wide, straight lined, horizontal
border, which fits perfectly to the blade of the lamina hook.
at the point of junction between the lamina and the facet. A
pedicle hook fi nder, which has the same breadth as the hook,
is introduced between the superior and inferior facets. The
pedicle lies in the middle of the facet, in approximate cra-
nial alignment. The fi nder should be moved cranially, parallel
to the middle axis of the zygapophyseal column and aiming
for the middle of the overlying facet. Care should be taken
not to deviate medially, in order to avoid any injury to the
dural sac or spinal cord. Once the inferior border of the pedicle
inferior border of the pedicle, thereby avoiding any possibility
of lateral or medial displacement. The stability of the hook can
be improved to some extent by slightly impacting the hook in
the inferior border of the pedicle.
176 6 Surgical anatomy of the spine

cranial cranial

right anterior
a b c
Fig 6.4-2a–c
a The inferior border of the inferior articular process is round b The hook fi ts the inferior c Its bifurcated tip straddles the
shaped (arrow). To be mechanically able to receive and withstand border of the facet. inferior border of the pedicle.
the vertical strains transmitted by a pedicle hook, it must be
reshaped by a strictly transverse cut at its junction with the
lamina. A short vertical cut using a thin chisel is fi rst required
medially, at the junction between the joint and the lamina, to
mark the limit of the medial extent of the transverse cut. Then
the transverse cut is carried out using the same chisel, strictly
perpendicular to the vertical cut and the vertical axis of the
zygapophyseal mass. (Asterisk = preparation for pedicle hook.)

AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES

6.4 Thoracic spine
1.3 ANATOMY RELATED TO PEDICLE SCREW INSERTION
The main concerns in this procedure are in identifying the
correct entry point and in drilling in the accurate direction.
The screws, obliquely introduced toward the midline, should
be driven into the vertebral body as far as possible without
perforating the cortex.
Due to the anatomical variability and the close relationship
of the pedicles with the spinal cord and nerve roots, there
is no technique with a reliability of 100% reported today
which allows the positioning of pedicle screws without any
control device. Pedicle screw fi xation should be addressed
only if a navigational system or AP and lateral fluoroscopic
monitoring are available, or if an open laminar technique is
being applied.
The anatomical landmarks of the entry points and the direction
of the screws, from the entry point into the vertebral body,
vary according to the level and the individual anatomy.
Evaluation of pedicles
The fi rst hurdle is fi nding out whether the use of pedicle screws
is at all possible or not. This depends on the size of the pedicle,
and especially, its transverse diameter; the vertical diameter
is not a major issue. For a surgeon who is familiar with the
technique and the AP x-rays, a single AP and a lateral view
are enough. Another technique of evaluation and preopera-
tive planning consists of making a CT scan of the respective
pedicles at each level and measuring their transverse diameter
( Fig 6.4-3 ).
177
Identification of entry points
The second concern is in identifying the entry point with
reference to reliable and reproducible anatomical landmarks,
such as: the middle of the transverse diameter of the superior
facet of the vertebra, the lateral border of the superior facet,
the inferior and lateral borders of the overlying inferior facet,
the superior border of the transverse process, the midline of
the transverse process, and the upper ridge of the transverse
process. The anatomical landmarks should be easy to fi nd and
identify. Distances cannot be taken as reference values because
a given distance is not similarly applicable to any vertebra of
any individual. The anatomical landmarks described here are
related to the surgical technique.
a b
Fig 6.4-3a–b
Preoperative evaluation of the transverse diameter of the pedicles.
a Using a plain x-ray.
b Using a CT scan.
178 6 Surgical anatomy of the spine

An anatomical analysis of thoracic vertebrae from 20 spines
showed that craniocaudally the middle axis of the pedicle
is near the inferior border of the superior articular surface,
between the inferior border of the facet and the upper ridge of
the transverse process. These landmarks are easy to fi nd for
any thoracic vertebra from T1 to T11 ( Fig 6.4-4a ).
facet or by a point between its middle and lateral thirds. This
point is 2–3 mm lateral from the bottom of the posterior con-
cavity of the lamina ( Fig 6.4-4c ). The overlying inferior facet
is not a reliable landmark; its distal half can be resected with
a thin chisel to disclose the underlying superior facet (except
at the upper end of a construct).

Mediolaterally, the most reliable landmark is the superior 1

facet; the middle axis of the pedicle runs below the middle of 1/3 1/3 1/3
the facet or more often laterally to it; the middle of the superior
1/2 1/2
facet or the point at the junction of the middle and lateral
thirds of the facet can be taken as a primary landmark ( Fig 2
6.4-4b ). Combining these data, the entry point of the thoracic
pedicles, from T1 to T11, can be placed at the intersection of a
transverse line passing by the superior edge of the transverse
process and a vertical line passing by the middle of the superior b c
b Other landmarks. c Bottom of the posterior
4 1 1 border between the concavity of the lamina.
2 middle and lateral
thirds
3
2 middle of the
superior facet

cranial
1
a right 1

Fig 6.4-4a–d 2
The landmarks.
cranial
a The classic bony landmarks.
1 lateral border of the superior facet
d right
2 upper ridge of the transverse process
3 middle line of the transverse process d The mammillary process of the 12th thoracic vertebra.
4 middle of the transverse diameter of the 1 mammillary process
superior facet 2 accessory process

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6.4 Thoracic spine 179

The 12th thoracic vertebra (T12) is a special vertebra, Trajectory of drilling

characterized by the absence of transverse processes. However,
it displays a relevant anatomical landmark ( Fig 6.4-4d ) which is
the anatomical equivalent of the “mammillary process” in the
lumbar vertebrae. Another, smaller process lies lateral and infe-
rior to it. The entry point of the pedicle can be primarily placed
between these two processes or at the tip of the “mammillary”
process.
Once all the entry points are identified, a 1.6 mm K-wire is in-
troduced superficially (approximately 2 mm) through the cor-
tex of the vertebra ( Fig 6.4-4c ). A fluoroscopic control picture
is made; the AP view is of major relevance. A radiolucent table
should be used for such a surgery.
The third concern is the direction of the drilling. The screw
should enter through the pedicle and penetrate the vertebral
body, as far as possible. The pedicle feeler is the most
appropriate instrument for performing the drilling. It allows
progressive penetration of the pedicle as it adapts its direction
to the inner contour of the cortical walls of the pedicle, thus
reducing the risk of their perforation. In the sagittal plane for a
monoaxial screw, the drilling direction is perpendicular to the
spinal curve at the drilling level ( Fig 6.4-6 ). In the transverse
cranial

The tip of the K-wire should lie in the middle of the oval area anterior
of the pedicle, or between its middle and its lateral border ( Fig
6.4-5 ). If not, the wire should be replaced and a new control 90°
performed, if necessary.

Fig 6.4-6
For a monoaxial
screw the drilling
Fig 6.4-5 direction in the
The tip of the K-wire should sagittal plane is
cranial
lie in the area of the pedicle, perpendicular to the
preferably in its middle or its spinal curve at the
right
lateral half. drilling level.
180 6 Surgical anatomy of the spine

plane, the drilling direction in relation to the sagittal plane
is theoretically 20 –25° in T1, 15–20° in T2, 10 –15° in T3,
and 5–10° from T4 to T12 ( Fig 6.4-7 ). In case of a polyaxial
screw, the direction of the drilling may be oriented 10–20°
downward.
When the use of pedicle screws is impossible due to the narrow-
ness of the pedicle, a pedicle hook can be used instead, which
can easily fit the vertical rod because it is in the same pedicular
alignment as the neighboring screws. The inconvenience of
the screw-hook combination is that the hook is bulkier and
more superficial than the screws.
Another alternative consists of using extrapedicular screws.
These screws obliquely penetrate the tip of the transverse
processes in the transverse plane, in the direction of the

T1

T1 T1 Fig 6.4-7a–d
The landmarks of the entry point of the
pedicle screws at the different levels in
the thoracic spine.
a T1 and T2, posterior and superior
T2
views, AP x-ray. The point of entry in
T1, T2, and T3 is at the intersection of
T2 the superior ridge of the transverse
T2 process and a vertical line from the
lateral border of the inferior facet or
a the middle of the superior facet.
b T8, posterior view and superior views,
T8 AP x-ray. The point of entry in T4–9 is
at the intersection of the superior
edge of the transverse process and a
T8
vertical line from the middle or mid-
lateral thirds of the superior facet. It is
T8 2–3 mm lateral from the bottom of the
b posterior concavity of the lamina.

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6.4 Thoracic spine 181

vertebral body and the midline ( Fig 6.4-8 ). This construct

can be useful, although it is bulky, under the laterovertebral
muscles. This technique also involves the risk of violating the
pleural cavity.

T11

T11 T11

Fig 6.4-7a–d
c T11, posterior and superior views, AP x-ray. The entry point in T10
and T11 is at the level of a little tubercle located at the superior
T12
ridge of the transverse process.
T12 d T12, posterior view, AP x-ray. The entry point is at the level of the
mammillary process or between the mammillary process and the
d accessory process (a remnant of the transverse process).

Fig 6.4-8
Extrapedicular screws—superior view.
182 6 Surgical anatomy of the spine
2 ANATOMY RELATED TO THE ANTERIOR PROCEDURES
2.1 THORACIC WALLS
From the standpoint of the surgical approach, the distinction
between an anterolateral thoracic wall and a purely lateral
thoracic wall is important.
2.1.1 ANTEROLATERAL THORACIC WALL
The limits of the region are represented by the clavicle above,
the common costal cartilage below, the sternum on the midline,
and the midaxillary line laterally.
Skin, subcutaneous tissue, mammary gland
The breast extends in average from the 3rd to the 7th rib, its
inferior limit is the submammary fold usually used in wide
anterolateral thoracotomies. The mammary gland, the skin,
and subcutaneous tissue are easily mobilized on the fascia of
the pectoral muscle.
Superficial muscular layer
The superficial muscular layer is composed of the pectoralis
major and pectoralis minor muscles anteriorly, the serratus
anterior muscle medially, and the superior digitations of the
abdominal muscles. The pectoralis major muscle inserts on
the clavicle, the sternum, the ribs, and the anterior layer of
the sheath of the rectus abdominis muscle. The fibers converge
laterally toward the anterior aspect of the humeral metaphysis.
The pectoralis minor muscle extends its digitations from the
tip of the coracoid process to the 3rd, 4th, and 5th ribs. The
serratus anterior muscle is a large flat muscle extending from
the medial border of the scapula to the anterior arches of the
fi rst ten ribs; it curves around along the lateral thoracic wall;
its nerve supply is provided by the long thoracic nerve which
runs down along the posterior axillary line.
AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES
Branches of the superficial cervical plexus and superficial
cervical vessels
These vessels reach the region passing in front of the clavicle.
Anterior branches of the intercostal vessels and nerves
These structures lie 1–2 cm lateral to the sternum.
Branches of the external thoracic vessels and the lateral
branches of the intercostal nerves
They enter the region along the anterior axillary line. Numerous
hemostases are required during the surgical approach due to
the transection of these vessels.
Thoracic wall
The thoracic wall itself is composed of the anterior arch of the
ribs and the costal cartilages extending to the lateral border of
the sternum. The costal cartilages are 4–5 cm long. The fi rst
costal cartilage is under the medial end of the clavicle, the
second lies at the level of the sternal angle, the third, fourth,
and fi fth are at the lateral border of the sternal body, and the
sixth and seventh are on the basis of the xiphoid process. The
costal cartilages and ribs are counted from the second one,
which is easily identified at the lateral border of the sternal
angle.
Content of the intercostal space
The content of the intercostal space includes five layers: the
external intercostal muscle; the external fibrocellular layer; the
middle intercostal muscle; the middle intermuscular cellular
tissue containing the intercostal vein, artery, and nerve in its
upper part, in the costal groove (located at the inferior border
of the overlying rib); and the internal intercostal muscle.
6.4 Thoracic spine
The intercostal region is covered on its deeper surface by the
endothoracic fascia and the parietal pleura. Deeper than the
anterior part of the intercostal space, 10–15 mm from the lat-
eral border of the sternum, lie the internal thoracic artery and
vein.
Right anterolateral approach
The right anterolateral approach allows access to the six fi rst
intercostal spaces, and especially to the fourth and fi fth. The
opening of the fi fth intercostal space by an additional section
of the fi fth costal cartilage allows access to the thoracic cavity.
The thoracic cavity is thus clearly exposed, showing the dia-
phragmatic cupula below and the spine posteriorly, covered by
the intercostal bundles, the azygos vein, and the mediastinal
pleura. The exposure of the spine requires the anterior retrac-
tion of the lung. The thoracic vertebrae from T4 to T10 can
easily be approached. The approach to T2, T3, T11, and T12
necessitates special care.
2.1.2 LATERAL THORACIC WALL
Its exposure requires the abduction and elevation of the upper
limb. The limits of the lateral wall are represented by:
• The top of the axillary fossa, cranially.
• The lateral border of the pectoralis major muscle, anteriorly.
• The lateral border of the latissimus dorsi muscle,
posteriorly.
• The inferior border of the rib cage, caudally.
The lateral thoracic wall is composed of three parietal layers.
183
Superficial layer—skin and fat tissue
The skin is slightly adherent to the deeper layers in the axillary
fossa. The anterior wall of the axillary fossa is the pectoralis
major muscle, the posterior margin is the latissimus dorsi
muscle. The topography of the anterior axillary line is given by
the pectoralis major muscle. The posterior axillary line passes
by the latissimus dorsi muscle. The midaxillary line lies be-
tween the anterior and posterior lines.
Muscular layer
The muscular layer is composed of the lateral part of the
pectoralis major muscle, anteriorly; the lateral part of the
latissimus dorsi muscle covering the scapula, posteriorly; the
serratus anterior muscle medially against the rib cage; its
anterior and inferior digitations mix with those of the external
oblique muscle of the abdomen.
At the top of the middle axillary line are the upper insertions
of the medial muscles of the arm: the coracobrachialis muscle,
biceps muscle, and triceps muscle.
Axillary veins and artery, nerves of the upper limb
These vessels and nerves lie between the brachial muscles. The
collateral branches of these neurovascular elements, supplying
the thoracic wall, can be injured during the approach. The
lateral thoracic pedicle lies posterior to the pectoralis major
muscle. The collateral cutaneous branches of the intercostal
nerves, divide into anterior and posterior branches to the
subcutaneous tissue. The thoracodorsal artery and vein arise
from the subscapular vessels and run down the middle part of
the axilla. The long thoracic nerve lies behind the thoracodorsal
vessels under the latissimus dorsi muscle; it should be preserved
in order to avoid altering the respiratory function of the serratus
anterior muscle. Several lymph nodes lie along the vessels of
the axillary fossa, embedded in the fat tissue.
184 6 Surgical anatomy of the spine

Lateral thoracic wall the spine. It can be pushed down using a fan retractor. Costo-
The lateral wall itself is composed of the ribs and the intercostal vertebral joints are visible through the parietal pleura. The
layers. The lateral part of the costal arches and the intercostal mediastinal elements can be exposed by opening the parietal
spaces are positioned obliquely downward and forward. The pleura.
five layers of muscles and cellular tissue are the same as those
found in the anterolateral wall. Three mediastinal levels can be identified with respect to the
arch of the azygos vein.
Lateral approach
The lateral approach allows access to the spine through the
intercostal spaces. The patient is placed in a right or left
lateral decubitus position. The upper and middle thorac-
ic vertebrae are more easily approached by the right side, 1
whereas the thoracolumbar vertebrae are approached by the
2
left side. The thoracic cavity is thus clearly exposed, showing
3
the diaphragmatic cupula below and the spine posteriorly.
The thoracic spine is covered by the intercostal bundles, the
azygos vein on the right side, the aorta on the left side, and 4
12 Fig 6.4-9
the mediastinal pleura. The exposure of the spine requires an
Right lateral view of the
anterior retraction of the lung and an inferior retraction of the
mediastinum and spine.
diaphragmatic cupula.
11 1 brachiocephalic
artery
The approach to the thoracic vertebrae from T4 to T10 is easily
2 trachea
performed from the right side. The approach to T2 and T3 10
3 vagus nerve
require special care. T11, T12, L1, and L2 can be approached
5 4 azygos arch
from the left. 9 6 5 heart, right atrium
6 esophagus
7 diaphragm
2.2 RIGHT THORACIC CAVIT Y
8 azygos vein
8 9 intercostal bundle
The thoracic spine is located on the midline behind the
(artery and veins)
mediastinum ( Fig 6.4-9 ). Its exposure requires the retraction
10 right sympathetic
of the lung and the diaphragmatic cupula, and a longitudinal cranial trunk
incision of the parietal pleura. The exposure of the spine is
7 11 thoracic spine
possible if the right lung is collapsed and retracted anteriorly anterior 12 rib heads
and medially. The diaphragmatic cupula is also an obstacle to

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6.4 Thoracic spine 185

Supraazygos level—corresponding to T2 and T3 2.3 LEF T THORACIC CAVIT Y

In the anterior part of this level lie the brachiocephalic vein,
the internal thoracic artery anterior to it, and the phrenic The left side of the thoracic spine becomes visible after collapsing
nerve along its right flank. In the posterior part lie the brachio- and retracting the left lung ( Fig 6.4-10 ). The left diaphragmatic
cephalic artery, the trachea, and the right vagus nerve crossing cupula should also be retracted downward using a fan retractor.
them laterally; the esophagus is the most posterior element The opening of the mediastinal pleura along the costovertebral
in contact with the spine. The 2nd, 3rd, and 4th intercostal joints allows disclosure of the three mediastinal levels with
arteries and their corresponding veins run obliquely between respect to the aortic arch.
the spine and the esophagus; the sympathetic ganglions lie
laterally to the heads of the ribs.
1
Arch of the azygos vein 14
The azygos arch lies at the level of T4. It runs from the spine
posteriorly to the posterior aspect of the superior vena cava
13 Fig 6.4-10
anteriorly. During this course, it crosses the right flank of 2
Left lateral view of the
the esophagus, the right vagus nerve, the trachea, and the 12
mediastinum and
brachiocephalic artery. Its posterior superior angle receives
spine.
the intercostal veins from the right upper intercostal spaces.
1 thoracic spine
2 rib head
Infraazygos level
3 3 accessory
The infraazygos level extends from T5 to T10/11. From the
11 hemiazygos vein
front to the back, this area displays the right pulmonary hilus, 4
4 intercostal bundle
the right atrium covered by its pericardium, the esophagus
5 left sympathetic
and the right vagus nerve at its flank, and the azygos vein. The 5
trunk
intercostal vascular bundles lie between the azygos vein and
6 hemiazygos vein
the intercostal spaces. The intercostal arteries coming from 10
7 diaphragm
the thoracic aorta cross the midline, in front of the spine, at
8 thoracic aorta
the left of the azygos vein. The sympathetic ganglions and 9
9 left vagus nerve
splanchnic nerves run down between the azygos vein and the 6
8 10 heart, left atrium
costovertebral joints. A loose connective tissue surrounds the
11 vagus nerve
mediastinal viscerae, usually allowing an easy dissection.
12 thoracic duct
cranial
13 left subclavian
artery
anterior 7 14 esophagus
186 6 Surgical anatomy of the spine
Supraaortic level corresponds to T2 and T3
From the front to the back, the following elements are found:
the brachiocephalic vein with the left phrenic nerve along its
left flank, the left common carotid artery, the left vagus nerve
along its left flank, the left subclavian artery, the thoracic duct,
and the esophagus.
Aortic arch
The aortic arch lies at the level of T4. From the front to the
back, the aortic arch is in relation with the phrenic nerve, the
vagus nerve, the loop of the left inferior laryngeal nerve, and
the left superior intercostal arteries along the lateral aspect
of the spine. The upper intercostal veins form the accessory
azygos vein.
Infraaortic level
The infraaortic level is composed of the left lung and hilus, and
the left ventricle and atrium covered with their pericardium.
Behind the heart, the esophagus appears as well as the left
vagus nerve along its left anterior surface. The anterior surface
of the spine is hidden by the descending thoracic aorta. The
intercostal arteries arise from the posterior lateral aspect of the
aorta with the upper arteries running obliquely upward, the
middle arteries running horizontally, and the lower arteries
running slightly downward. The intercostal vascular bundles
lie against the flank of the spine, and the hemiazygos and
accessory hemiazygos vein cross over their left surfaces. These
veins pass posterior to the thoracic aorta at the T6/7 level and
join the azygos vein. The sympathetic trunk and splanchnic
nerves lie anterior to the heads of the ribs.
AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES
2.4 CLOSE RELATIONSHIPS OF THE THORACIC SPINE
The azygos venous system
The azygos venous system is shown in Fig 6.4-11 and it is
composed of the following veins.
Azygos vein
The azygos vein originates in front of the 12th thoracic vertebra
from the confluence of a medial vein arising from the inferior
vena cava and a lateral vein formed by the anastomosis of the
twelfth intercostal vein and the ascending lumbar vein. From
this origin, the azygos vein runs upward along the right lateral
aspect of the spine until the level of T4. Then it leaves the
spine and runs anteriorly, passing above the left pulmonary
pedicle to join and fi nish its course in the posterior aspect of
the superior vena cava. During its course, the azygos vein is
joined by the hemiazygos vein and the accessory hemiazygos
vein on its left side and the intercostal veins on its right side.
Hemiazygos vein
The hemiazygos vein is formed by the confluence of three veins
(a medial vein coming from the left renal vein and a lateral
vein formed by the anastomosis of the twelfth intercostal vein
with the ascending lumbar vein). It runs upward along the
left aspect of the spine until the T6/7 level. Then it crosses the
midline behind the thoracic aorta and joins the azygos vein.
Accessory hemiazygos vein
The accessory hemiazygos vein results from the confluence of
the upper intercostal veins. It runs down along the left aspect
of the thoracic spine until T6/7. At this level it crosses the spine
from left to right to join the azygos vein.
6.4 Thoracic spine 187

1 Thoracic duct
The thoracic duct penetrates the inframediastinal space behind
18 2
the aorta. It runs cranially and medially to the level of T4. Then
it runs progressively to the left side of the spine and enters the
1 left jugular vein
anterior cervical region.
2 left subclavian vein 3
17
3 left superior
Intercostal arteries
intercostal vein 16 The intercostal arteries arise from the posterior lateral surface
4 accessory
of the aorta. The fi rst four to six intercostal arteries run from
hemiazygos vein
4 T4 toward the upper adjacent vertebrae very obliquely, almost
5 hemiazygos vein
vertically, over the anterior aspect of the spine. The preservation
6 12th left
of these arteries necessitates an oblique or vertical surgical
intercostal vein
incision to approach to the spine. The middle intercostal
7 left renal vein
15 arteries run anterior to the spine in a transverse direction.
8 left ascending 5
The lower intercostal arteries from T9 to T12 run obliquely
lumbar vein 14
6 downward, anterior to the spine.
9 left iliac vein
10 right iliac vein 7
13 Sympathetic trunk
11 right ascending
12 The sympathetic trunks (see Fig 6.4-9, Fig 6.4-10 ) run along the
lumbar vein 8
lateral aspects of the spine. They are in a lateral position with
12 inferior vena cava
11 respect to the heads of the ribs in the upper half of the thoracic
13 right renal vein
spine and in a medial position in its lower half. The splanchnic
14 12th right intercostal
nerves rise from the level of T6 and then run caudally in a
vein
medial position with respect to the sympathetic trunks.
15 azygos vein
16 right superior 9 Anterior longitudinal ligament
intercostal vein
10 cranial The anterior longitudinal ligament covers the anterior surface
17 superior vena cava
of the spine. It adheres very strongly to the intervertebral
18 right brachiocephalic
left discs and the adjacent end plates. Its detachment is not easy
vein
to perform, and it is not recommended except in the case of a
perivertebral infection or pediatric spinal deformities.
Fig 6.4-11
The azygos venous system in its typical morphology.
188 6 Surgical anatomy of the spine
Intervertebral foramen
The intervertebral foramina are located at the level of the rib
heads and intervertebral discs. They contain the intercostal
nerve and its spinal ganglion, the spinal artery and the
foraminal veins. These veins are particularly numerous
and often form a foraminal plexus. The spinal arteries rise
from the intercostal arteries and penetrate the spine through
the foramina to supply the neuromeningeal elements. The
intercostal nerves run in close relationship with the medial
aspect and the lower border of the upper pedicle of each
foramen. In the middle and lower foramina the intercostal
nerves run transversely through the middle of the foramen or
obliquely toward the border of the lower pedicle.
Spinal canal
The spinal canal contains the epidural fat, the epidural venous
plexuses, the dura mater, the spinal cord, and the metameric
emergences of the spinal nerve roots. The cord is attached to
the dural sac on each side by the denticulate ligament.
AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES
2.5 ANATOMICAL VARIATIONS OF THORACIC VESSELS
2.5.1 VARIATIONS OF THE A ZYGOS VENOUS SYSTEM
Nine different types are distinguished, whereby type I was
described above.
Type 2
The hemiazygos vein is a short trunk joining the azygos vein
at the level of T10. The overlying veins are small trunks which
anastomose directly with the azygos vein.
Type 3
The hemiazygos vein does not exist. The twelfth intercostal
vein joins the inferior vena cava directly. The other intercostal
veins anastomose directly with the azygos vein. The accessory
hemiazygos vein does exist.
Type 4
The azygos system is reduced to a median azygos vein. It receives
the upper lumbar veins and the right and left intercostal veins.
The midline venous axis can be preserved during the approach.
Right and left superior intercostal veins anastomose with the
arch of the azygos vein.
Type 5
This is a symmetrical azygos system composed of two azygos
veins. The right one joins the superior vena cava, the left one
joins the brachiocephalic venous trunk.
6.4 Thoracic spine
Type 6
The azygos and hemiazygos veins fuse at the level of T7 on the
left flank of the spine and form a single paramedian venous
axis receiving the intercostal and lumbar veins on both sides.
At the level of T11, the azygos and the accessory azygos vein
display a typical position. The inferior part of the azygos vein
is lacking from T7 to T11.
Type 7
The origin of the azygos vein is in the lumbar region. It receives
the lumbar veins on both sides and the intercostal veins on the
left side only. The two hemiazygos veins anastomose and form
a common trunk anastomosing the azygos vein.
Type 8
Absence of the hemiazygos vein associated with a hypertrophy
of the accessory azygos vein.
Type 9
Absence of the suprahepatic part of the inferior vena cava com-
pensated by a very large azygos vein joining the superior vena
cava. During surgery this anomaly requires the preservation
of the azygos venous axis.
189
2.5.2 CARDIOVASCULAR VARIATIONS
Overlooking some of the following anomalies in the cardio-
vascular system may result in catastrophic outcomes.
Situs inversus
There is an inversion of the position of the great supracardiac
vessels.
Coarctation of the aorta proximal to a ductus arteriosus
A shunt persists between the descending aorta and the pulmo-
nary artery. This results in arterial hyperpressure in the vessels
arising from the aortic arch.
Coarctation of the aorta distal to a ductus arteriosus
The arterial ligament remains collapsed without the presence
of an aortopulmonary shunt.
Duplication of the aortic arch
This creates an arterial loop around the visceral axis of the
neck. It hinders the surgical mobilization. The duplication
must not be mistaken for a large vein which may be ligatured
and divided.
Retroesophageal right subclavian artery
This artery arises from the left side of the thoracic aorta and
runs behind the esophagus to reach the right upper limb. The
ligature of this artery must be avoided.
190 6 Surgical anatomy of the spine
Abnormal origin of the left common carotid artery
This artery arises from a common trunk with the right
brachiocephalic trunk. Care should be taken not to confuse
this artery with a left brachiocephalic venous trunk. Its ligature
may produce severe brain damage.
Abnormal termination of the superior vena cava
The superior vena cava lies to the left of the aorta and left atrium,
and it terminates directly in the coronary sinus. The superior
vena cava should not be mistaken for a left brachiocephalic
venous trunk and ligatured.
Duplication of the superior vena cava
One vein lies on the right side but does not receive the left
brachiocephalic venous trunk. The other is the vertical left
brachiocephalic trunk passing to the left of the aorta and left
atrium, and terminating directly in the coronary sinus.
Abnormal return of the pulmonary veins
The left brachial systemic venous trunk ends in the left atrium.
The interatrial shunt leads to an overloading of the right
atrium. Ligation of the brachiocephalic trunk on the midline
can induce venous stasis of the left hemiface.
AOSPINE MANUAL—PRINCIPLES AND TECHNIQUES
3 SUGGESTED READING
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