1. Seminar
on
“Approaches to Spine”
01 – 12 - 2010
Moderator:
Presenter:
Dr. Muralidhar N
Dr. Somnath Machani
Professor and HOD
VIMS & RC.
Post Graduate
VIMS & RC
.
8. Posterior approach to the Lumbar spine
Indications
●
•
Excision of herniated discs
•
Exploration of nerve roots
•
Spinal fusion
•
Removal of tumours
•
Provides access to
•
Cauda equina
•
Intervertebral disc
•
Spinous process
•
Laminae
•
Facet joints
•
pedicles
9. position
●
Prone
The position of the patient
for the posterior approach to
the lumbar spine.
Alternatively, place the
patient in the lateral position
with the affected side up.
23. Transperitoneal Approach to Lumbar Spine
●
Indication
●
L 4 L5 Fusion
●
L5 S1 fusion
●
Position- supine
●
Catheterize
●
NG tube
●
Bare Area- Abd incision
and Iliac crest bone graft
30. ●
Identify aorta
●
Left common iliac artery
●
Left ureter
●
●
Danger of presacral
parasympathetic plexus
Extension- pack bowels
and superioly incise upto
the xiphisternum
36. Indications
●
●
Spinal fusion
Drainage of psoas abscess and curetting the infected
body
●
Resection of all or part of vertebral body
●
Biopsy of vertebral body and bone graft
●
Sympathetic chain exposure
47. Costotransversectomy approch to the
Thoracic Spine
●
Indication
●
●
Vertebral body biopsy
●
Partial verterbral body resection
●
Limited anterior spinal fusion
●
●
Abscess drainage
Ant. Lateral decompression of the spinal cord
Advantage
●
Need not enter the thoracic cavity
originally used to draining tubercular abscess
56. Transthoracic Approach to the Thoracic
Spine
●
Indication
•
Treatment of infections, such as tuberculosis of the thoracic vertebral bodies20
•
Fusion of the vertebral bodies
•
Resection of the vertebral bodies for tumor and reconstruction with bone grafting
•
Correction of scoliosis (Dwyer instrumentation technique and rods)
•
Correction of kyphosis
•
Osteotomy of the spine
•
Anterior spinal cord decompression
•
Biopsy
67. Posterior Approach to the Thoracic and
Lumbar spine for Scoliosis
●
Indications
●
Scoliosis
●
Posterior spine fusion
●
Removal of tumour of the posterior aspect of the vertebra
●
Open biopsy
●
Stabilization of fractures vertebrae
70. Superficial Dissection
●
Rotation in scoliosis
●
Midline incision only
Deep dissection
●
Paraspinal muscles from spinous process
●
Keep dissection open
74. ●
Superficial dissection dangers
●
Thoracic spine- more bleeding
●
Vertebral body rotation – convex side of curve
●
Intermediate surgical dissection
●
Deep portion●
lumbar facet joints are larger
●
Traumatic arthritis
75. Approach to the Posterio- lateral thorax for
excision of Ribs
●
After scoliosis surgery- removal of parts of ribs
●
Position- prone with bolsters
●
Land mark- prominent ribs
●
Incision- same like scoliosis surgery
●
Internervous plane- between Trapezius and Latismus
dorsi
76. Superficial surgical dissection
●
●
●
Lift the skin and
subcutaneous tissue
Centre the dissection over
the most prominent rib
Intermediate dissectionidentify the trapezius by
the rolled border
78. Deep surgical dissection
●
●
Split longitudinally over
the deformed ribs
Push the split periosteum
to upper and lower border
●
Stop lung expansion
●
Resect the pleura from rib
91. Posterior approach to C1 C2
●
Indication
●
●
●
●
●
Spinal fusion
Decompression
lamiectomy
Treatment of tumours
Position – same as
posterior approach
Incision from inion
93. Superficial dissection
Incise the nuchal ligament
down onto the large spinous
processes of C2. Lateral
view (inset). Note that the
ring of C1 is further anterior
than the spinous process of
C2.
94. Remove the paracervical muscles
from the posterior elements of C1 and
C2. Carry the dissection up to the
base of the occiput
97. Anterior approach to the Cervical Spine
●
Indication
•
Excision of herniated discs
•
Interbody fusion
•
Removal of osteophytes from the uncinate processes and from either the anterior or
the posterior lip of the vertebral bodies
•
Excision of tumors and associated bone grafting
•
Treatment of osteomyelitis
•
Biopsy of vertebral bodies and disc spaces
•
Drainage of abscesses
98. Position
Place the patient supine on the
operating table with a small sandbag
between the shoulder blades to
ensure an extended position of the
neck. Turn the patient's head away
from the planned incision
99. Landmarks
•
Hard palate-arch of the atlas
•
Lower border of the mandible-C2-3
•
Hyoid bone-C3
•
Thyroid cartilage-C4-5
•
Cricoid cartilage-C6
•
Carotid tubercle-C6
100. Incision
Incise the fascial sheath over the platysma in
line with the skin incision. Split the platysma
longitudinally, parallel to its long fibers
102. Retract the sternocleidomastoid laterally, and
the strap muscles and thyroid structures
medially. Cut through the exposed pretracheal
fascia on the medial side of the carotid
sheath. The cervical spine C3 through C5
(cross section). Retract the
sternocleidomastoid laterally and the strap
muscles medially, and incise the pretracheal
fascia immediately medial to the carotid
sheath
103. Deep dissection
Dissect the longus colli muscle
subperiosteally from the anterior portion of the
vertebral body and retract each portion
laterally to expose the anterior surface of the
vertebral body. The longus colli muscles are
retracted to the left and right of the midline to
expose the anterior surface of the vertebral
body
107. Anterior Retropharyngeal Approach
●
Upper cerivcal spine and graft
●
Extramucosal- less chance of infection
●
Extended sub total maxillectomy
●
Alternate to transoral
●
For exposure and removal of tumour from the base of skull
108. Low Anterior cervical approach
●
Same as Anterior cervical approach
●
From left side 1 finger breath above the clavicle
●
Extending across the midline
●
In 1989, Siliski, Mahring, and Hofer evaluated 52 intercondylar femoral fractures (AO type C) treated predominantly with blade plates. Three quarters of the fractures were caused by high-energy mechanisms, and 39% were open fractures. Overall, good or excellent results were obtained in 81% of fractures, and range of motion averaged 107 degrees. Results were better in type C1 fractures (92% good or excellent results) than in type C2 and type C3 fractures (77% good or excellent results). Only three (5.8%) fractures had malalignment in the sagittal plane; however, shortening of 1 to 3 cm occurred in 15 patients. Shortening was intentional to improve stability in 11 older patients (average age 60 years), but it was unintentional in four younger patients (average age 30 years). Infection occurred in four patients (7.7%) and accounted for three of the four poor results. Two fractures complicated by infection required amputation, and one required arthrodesis to treat the infection. Perioperative antibiotics were not used in closed and type I open fractures.