Chapter 58 - Spinal operative exposure Flashcards
What is the spine exposure most used for
Anterior lumbar interbody fusion
Anterior thoracic interbody fusion
Benefit of anterior interbody fusion
1) preserve posterior element
2) decrease nerve injury
3) avoid epidural scarring
Approach to disk pathology in T1-T3
Posterior approach usually
otherwise medial claviculectomy/ministernotomy
T3-T6 exposure
Right thoracotomy
T7-T12 exposure
Left thoracotomy
Transperitoneal exposure to lumbar spine key disadvantages
1) retrograde ejaculation 10x more
2) post op ileus
3) third space fluid sequestration
4) longer hospital stay
Laparoscopic vs open surgery
laparoscopic are
1) longer
2) more complication
3) inadequate exposure
4) need to convert
5) increase genitofemoral nerve injury
Placement of SSEPs
1) PT nerve
2) ulnar nerve as control
Rib level to enter in relation to disk of interest for thoracic spine
2 intercostal levels above disk level of interest
Right thoracic spine exposure
1) remove lower rib to facilitate access and morselize rib to use as bone graft for later
2) intraoperative fluoroscopy to identify appropriate disk space
3) incise parietal pleura along lateral aspect of thoracic vertebra
4) divide ipsilateral intercostal arteries/veins
5) divide venous tributaries coursing into azygos vein
Left mid-distal thoracic spine exposure differences
1) descending thoracic aorta is encountered
2) retract aorta medially
3) ligate spinal branches close to aorta
4) divide diaphragm lateral to the central tendinous portion for L1-L2 exposure
T12-L2 exposure
1) right lateral decubitus
2) break the bed between ASIS and costal margin
3) flank incision over anterior extent of 12th rib (or 10-11)
4) resect 12th rib to safe entry to retroperitoneal space
5) Expose gerota’s fascia and left kidney and rotate inferomedially off diaphragm
6) identify proximal psoas muscle and left diaphragmatic crus
7) divide left diaphragmatic crus to reveal vertebra and aorta
L2-S1 exposure
1) super with small oblique/transverse or longitudinal left paramedian incision
2) expose rectus abdominis muscle after removing rectus sheath
3) dissect and mobilize rectus muscle laterally
4) incise into posterior rectus sheath/transversalis fascia
5) extraperitoneal plane entered
6) rotate all peritoneal contents to right superomedial area
7) mobilize left ureter medially (or leave it down)
8) vas deferens and testicular/ovarian vessels kept in normal position
9) divide vestigial ipsilateral umbilical artery that courses into the IIA
L5-S1 key points
1) rectosigmoid bowel swept from left to right
2) divide middle sacral artery and vein
L4-L5 key points
1) divide iliolumbar veins (toward posterolateral of left CIV
2) note the tethering of left CIV flattening over disk spaces
