Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant...
-
Upload
noah-stone -
Category
Documents
-
view
219 -
download
0
Transcript of Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant...
![Page 1: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/1.jpg)
Surgical approaches to the spine
ABDULMONEM ALSIDDIKY, MD,SSCOAssistant professor ,consultant
Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA
![Page 2: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/2.jpg)
Objectives
•Anterior (Transthoracic) Approach to the Thoracic Spine
•Anterolateral (Retroperitoneal) Approach to the Lumbar Spine
•Anterior (Transperitoneal) Approach to the Lumbar and Lumbosaccral Spine
•Posterior Approach to the Lumbar Spine
![Page 3: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/3.jpg)
Anterior (Transthoracic) Approach to the Thoracic Spine
![Page 4: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/4.jpg)
Anterior (Transthoracic) Approach to the Thoracic Spine
• Offers exposure of the anterior portions of the vertebral bodies, from T2 to T12
• A surgeon might need a thoracic surgeon who can deal with the hazards of the area
• Indications– Treatment of infections– Fusion of the vertebral bodies – Resection of the vertebral bodies for tumor and reconstruction with bone grafting – Correction of scoliosis – Correction of kyphosis – Osteotomy of the spine – Anterior spinal cord decompression – Biopsy
![Page 5: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/5.jpg)
Position of the Patient• Place the patient on his or her side• stabilizing the patient with a kidney
rest or sandbags• Move the hand and arm on the side to
be approached above the patient's head or onto an airplane splint
• Place a small pad in the axilla of the dependent side to avoid compression of the axillary artery and vein
• Feel for a radial pulse after positioning; make sure that there is no venous obstruction in the arm
• The surgeon should be positioned behind the patient
![Page 6: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/6.jpg)
Landmarks
• tip of the scapula • spines of the thoracic
vertebrae• Observe the
inframammary crease on the anterior chest wall
![Page 7: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/7.jpg)
Incision
• Begin the incision two fingerbreadths below the tip of the scapula and curve it forward toward the inframammary crease
• Complete the incision by extending it backward and upward toward the thoracic spine
• ending at a point halfway up the medial border of the scapula and halfway between the spine and the scapula
![Page 8: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/8.jpg)
Superficial Surgical Dissection
• Divide the latissimus dorsi muscle posteriorly in line with the skin incision
![Page 9: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/9.jpg)
• Then, divide the serratus anterior muscle along the same line, down to the ribs
• This allows the scapula to be elevated and muscles to be cut proximally to expose the underlying ribs
![Page 10: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/10.jpg)
• Because the operation is not performed in an intermuscular plane, bleeding is a problem; cutting cautery (diathermy) can be used to control it
![Page 11: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/11.jpg)
• The thoracic cavity can be reached through – intercostal space – resection of one or more ribs
• Rib resection – creates a better exposure– The cut ribs can be used for bone grafting
• Which level – Depends on the location of the pathology– Apex of deformity– Two levels less (eg.T9 go through rib 7)
• Which side– Rt. Safer (away from aortic arch)
![Page 12: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/12.jpg)
• strip all muscular attachments from the rib
• using a periosteal elevator or cautery
• resect the posterior three fourths of the rib as far posterior as necessary
![Page 13: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/13.jpg)
![Page 14: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/14.jpg)
Deep Surgical Dissection
• deflate the lung• retract it anteriorly• using moist lap pads to
protect it• Identify the structures
– Oesophagus– Aorta– Azygous vein – Ant. Longitudenal lig. – Segmintal vessels
![Page 15: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/15.jpg)
![Page 16: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/16.jpg)
![Page 17: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/17.jpg)
Anterolateral (Retroperitoneal) Approach to
the Lumbar Spine
![Page 18: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/18.jpg)
Anterolateral (Retroperitoneal) Approach to the Lumbar Spine
• provides access to all vertebrae from L1 to the sacrum
• allows drainage of an infection, such as a psoas abscess
• Lower the risk of a postoperative ileius
• slightly more difficult to reach the L5-S1 disc space
![Page 19: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/19.jpg)
uses of this approach
Spinal fusion
Drainage of psoas
abscess of all or part of
a vertebral body
Instrumentation
Biopsy of a vertebral
body
![Page 20: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/20.jpg)
Position of the Patient
• semilateral position
• about a 45° angle to the horizontal
• facing away from the surgeon
• Stabilize the patient
• left side up, so that the “aortic” rather than the “caval” side is approached.
![Page 21: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/21.jpg)
Landmarks
• Palpate the 12th rib
• pubic symphysis
• lateral border of the rectus abdominis
![Page 22: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/22.jpg)
Incision
• oblique flank incision
• from the posterior half of the 12th rib toward the rectus abdominis muscle
• stopping at its lateral border
• about midway between the umbilicus and the pubic symphysis
![Page 23: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/23.jpg)
![Page 24: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/24.jpg)
![Page 25: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/25.jpg)
![Page 26: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/26.jpg)
• Place a needle into the involved lumbar vertebra and take a radiograph to identify the exact location
![Page 27: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/27.jpg)
Anterior (Transperitoneal) Approach to the Lumbar Spine
![Page 28: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/28.jpg)
Anterior (Transperitoneal) Approach to the Lumbar Spine
• reserved for fusing L5 to S1
• fusing L4 to L5
• mobilization of the great vessels
• general surgeon help is appreciated
![Page 29: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/29.jpg)
Position of the Patient
• Supine• two areas for incision
– Abdominal – iliac crest bone graft
• Insert – urinary catheter to keep
the bladder empty– nasogastric tube, ?
ileus
![Page 30: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/30.jpg)
Landmarks
• Umbilicus – (? opposite the L3-4 disc
space)
• pubic symphysis
![Page 31: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/31.jpg)
Incision
• midline longitudinal
• arches around the umbilicus
![Page 32: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/32.jpg)
![Page 33: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/33.jpg)
![Page 34: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/34.jpg)
![Page 35: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/35.jpg)
![Page 36: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/36.jpg)
![Page 37: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/37.jpg)
Posterior Approach to the Lumbar Spine
![Page 38: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/38.jpg)
Posterior Approach to the Lumbar Spine
• the most common approach to the lumbar spine
• providing access to the cauda equina and the intervertebral discs
• expose the posterior elements of the spine
• Uses– Excision of herniated discs– Exploration of nerve roots– Spinal fusion– Removal of tumors
![Page 39: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/39.jpg)
• Position of the Patient
• prone position
• On side– Flex the patient's hips and
knees to flex the lumbar spine and open up the interspinous spaces
![Page 40: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/40.jpg)
• Landmarks
• Spinou sprocesses
• Line drawn between the highest points on the iliac crest is in the L4-5 interspace
• To determine the exact level is use a radiograph
![Page 41: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/41.jpg)
• Incision
• midline longitudinal incision
• length of the incision depends on the number of levels to be explored
![Page 42: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/42.jpg)
![Page 43: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/43.jpg)
![Page 44: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/44.jpg)
![Page 45: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/45.jpg)
![Page 46: Surgical approaches to the spine ABDULMONEM ALSIDDIKY, MD,SSCO Assistant professor,consultant Pediatric ortho. &ped. spine RIYADH,SAUDI ARABIA.](https://reader035.fdocuments.net/reader035/viewer/2022062516/56649da75503460f94a936b2/html5/thumbnails/46.jpg)
Thank you