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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6025_Библиотеки_им_академика_М_И_Перельмана
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1 Anatomy and Surgical Approaches
b. Deep muscles of the back.
(1) Super cial layer (transversocostal group or erector spinae):
iliocostalis, longissim us, and spinalis.
(2) Deeper layer (transversospinal group): sem ispinalis, multi dus, and
rotators.
(3) Deepest layer: interspinales and intertransverse muscles.
1.4 Surgical Approaches
I. Ce r vical sp in e .
A. Po st e r io r a p pr o a ch e s : r e ve rs e Tr e n dele n bu rg p o s it io n a n d May eld t on gs h e lp
to secure the head and minimize venous bleeding in the surgical eld.
1. Posterior approach to occiput to C1–C2 (Fig. 1.14):
a. Midline incision from the external occipital protuberance to C2 spinous
process (6–8 cm).
Fi g . 1 . 1 4 Th e co u r s e o f t he ve rt eb ra l a r t e ry a nd t h e g re at e r o cc ip it a l n er ve in re la t io n t o t h e p ost e rio r
midline.
1 Anatomy an d Surgical Approaches 25
b. Ligamentum nuchae and paravertebral muscle dissection to the posterior
elements of C1 and C2.
c. Lateral exposure should not go beyond 1.5 cm on the C1 ring (cervical
ganglion and vertebral artery), w ith care not to fracture the C1 ring.
(1) Aberrant anatom y should be identi ed (ponticulus posticus).
d. Separate occipitoatlantal and atlantoaxial membranes from the bone and
wiring.
e. Occiput: make drill holes above the foram en m agnum and remove bone
distally for decompression. External occipital protuberance can be used
for w ir ing for fu sio n .
f. Neu r ova scu lar st ru ct u res:
(1) Suboccipital nerve (C1): within the suboccipital triangle (motor).
(2) Greater occipital nerve (C2): beneath and over the inferior oblique
muscle (sensory).
(3) Third occipital nerve (lateral to the suboccipital triangle [sensory]).
(4) Vertebral artery: from C6 transverse foram en to atlas transverse
foram e n an d p ierces t h e lat e ral a ngle o f t h e p ost er io r at la n t o occipital m em brane.
2. Posterior approach to the lower cervical spine:
a. Midline incision down to the spinous processes and lamina (interlaminar
space is w ide, and caution should be taken to avoid penetration to the
dura).
b. Lateral exposure to the transverse processes, exposing the facets and
lateral m asses.
c. Lam inectomy, foram inotomy (resection of the medial aspect of superior
and inferior facets), or excision of disk or osteophytes of the joints of
Lu s c h k a t o d e c o m p r e s s t h e n e r v e r o o t s .
(1 ) The C5 n er ve root form s ~ 45° w it h the spin al cord ; t h is angle
in creases as on e d escends an d is ~ 90° at th e C8 level.
(2) Nerve roots (foram en borders): disks and joints of Luschka anteriorly,
zygapophyseal joints posteriorly, pedicles superiorly and inferiorly.
Als o, t h e ve r t e b r a l a r t e r y is a n t e r io r t o t h e r o o t s.
B. An te r i o r a p p ro a c h e s: Ga r d n er– We ll s t on gs a re u se d fo r t ra ct io n a n d t o ke e p t h e
neck slightly extended (Fig. 1.15).
1. Anterior medial approach to the midcervical spine (Smith–Robinson).
a. Landmarks:
(1) Hard palate: arch of the atlas.
(2) Lower border of m andible: C2–C3.
(3) Hyoid bone: C3.
(4) Thyroid cartilage: C4–C5.
(5) Cricoid cartilage: C6.
(6) Carotid tubercle: C6.
b. Use a transverse incision from the midline to the anterior border of the
sternocleidomastoid.
c. Split the platysm a longitudinally or transversely.
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1 Anatomy and Surgical Approaches
Fig . 1 . 1 5 Th e in fra hyo id an d st e rn o cle id o m as toid muscles.
d. Incise the pretracheal fascia immediately anterior to the
sternocleidom astoid, followed by blunt nger dissection to the
vertebral bodies, retracting the carotid sheath (carotid ar ter y, intern al
jugular vein, and vagus nerve) laterally, and retract th e strap muscles,
trachea, and esophagus medially (Fig. 1 .1 6).
e. The superior thyroid arteries may limit dissection above C3–C4 and the
inferior thyroid artery below C6 (m ay ligate and divide).
f. Divid e t h e p r e ve r tebral fa scia an d a n t e r io r longit u d in al liga m en t in t h e
midline, retracting the longus colli laterally.
g. Neurovascular and vital structures (Fig. 1.17):
(1) Recurrent laryngeal nerve: ascends in the neck between the trachea
and esophagus from the arch of the aorta on the left side and runs
along the trachea after hooking around the subclavian artery on the
right side. It crosses from lateral to medial to the midline trachea in
the lower part of the neck, making the right-sided approach slightly
more vulnerable. Protect it by placing the retractor below longus colli
muscles.
(2) Sympathetic nerves and stellate ganglion: avoid dissection out onto
the transverse processes and keep dissection subperiosteal.
(3) Carotid sheath contents: from the medial to lateral carotid
artery, internal jugular vein, and vagus nerve anterior to the
sternocleidomastoid muscle.
(4) Esophagus: take precaution on deep medial retraction.
1 Anatomy an d Surgical Approaches 27
Fi g . 1 . 1 6 Blu n t n g e r d is s e c t i o n i s d o n e t h r o u g h t h e S m i t h – Ro b in s o n i n t e r v a l t o w a r d t h e a n t e r io r
cervical spine.
Fi g . 1 . 1 7 The neural and vascular structures of the neck.
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1 Anatomy and Surgical Approaches
C. Ot h e r a n t e r io r a p p ro a c h e s t o t h e ce r v ica l s p in e:
1. Transoral approach to C1–C2 (Fig. 1.18):
a
b
Fi g . 1 . 1 8 ( a , b ) Th e t ra nso ra l ap pro ach , wh ich a llo ws e xp o su re of t h e m id lin e b e t w ee n t he a rch o f
the atlas and C2. The exposure may be extended cephalad by dividing the soft and hard palate to allow
access to the foramen magnum and lower half of the clivus.
1 Anatomy an d Surgical Approaches 29
a. Fiberoptic nasotracheal intubation and nasogastric tube are used.
b. The patient is placed in the supine position with the head held in slight
extension using the May eld frame.
c. The oral cavity is cleansed with chlorhexidine, and perioperative
antibiotics with an intravenous cephalosporin and metronidazole are
inst it uted for 72 hou rs as prophylaxis against woun d infection.
d. The key surgical landmark is the anterior tubercle on the atlas to which
the anterior longitudinal ligament and longus colli muscles are attached.
e. The transoral retractors are inserted, exposing the posterior oropharynx.
Th e a r ea o f t h e in cisio n is in lt rat ed w it h 1 :2 00 ,0 0 0 e p in e p h r in e.
f. A m id lin e 3 cm ver t ical in cision ce n tere d on t h e a n t e r ior t u b e rcle is
made through the pharyngeal mucosa and muscle.
g. The tubercle of the atlas and anterior longitudinal ligam ent are exposed
superiosteally, and the longus colli m uscles are mobilized laterally.
h. A high-speed bur may be used to remove the anterior arch of the atlas to
expose the odontoid process.
2. An anteromedial approach to the upper cervical spine by de Andrade and
Macnab:
a. The neck is hyperextended, and the chin is turned to the opposite side.
b. A skin incision is made along the anterior aspect of the sternocleidomastoid
muscle and curved toward the mastoid process.
c. The platysm a and the super cial layer of the deep cervical fascia are
divided in the line of the incision to expose the anterior border of the
sternocleidomastoid.
d. The sternocleidomastoid muscle is retracted anteriorly and the carotid
artery laterally.
e. The superior thyroid artery and lingual vessels are ligated. The facial
artery is identi ed at the upper portion of the incision, which helps to
nd the hypoglossal nerve adjacent to the digastric muscle.
f. The su per io r lar yn ge a l n e r ve is in close p r oxim it y t o th e su per ior t h yroid
artery, and excessive retraction of this nerve should be avoided.
g. Stripping of the longus colli m uscle exposes the anterior aspect of the
upper cervical spine and basiocciput.
3. Anterior retropharyngeal exposure of the upper cervical by McAfee:
a. A right-sided submandibular transverse incision and division of the platysma
leads to the sternocleidom astoid m u scle and its deep cervical fascia.
b. The mandibular branch of the facial nerve should be identi ed with the
aid of a nerve stimulator, and the retromandibular vein is ligated during
the initial stage of dissection.
c. The anterior border of the sternocleidom astoid muscle is m obilized. The
submandibular salivary gland and the jugular digastric lymph nodes are
resected.
d. Care should be taken to suture the duct in the salivary gland to prevent a
salivary stula.
e. The digastric tendon is divided and tagged for later repair.
f. Th e hyp oglossal n er ve is n ext id en t i e d an d m obilized. Th e carot id
sheath is opened, and arterial and venous branches are ligated, including
the superior thyroid artery and vein, lingual artery and vein, ascending
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1 Anatomy and Surgical Approaches
pharyngeal artery and vein, and facial artery and vein, beginning
inferiorly, progressing superiorly.
g. The superior laryngeal nerve is also identi ed and mobilized.
h. The prevertebral fasciae are transected longitudinally to expose and
dissect the longus colli muscles.
4. The anterolateral retropharyngeal approach by Whitesides and Kelley:
a. The skin incision is made from the mastoid along the anterior aspect of
the sternocleidomastoid.
b. The external jugular vein is ligated, and the greater auricular nerve is
spared if possible.
c. The sternocleidom astoid and splenius capitus muscles are detached from
the mastoid, leaving a fascial edge for later repair. The spinal accessory
nerve should be identi ed and protected.
d. Retract the carotid contents along with the hypoglossal nerve anteriorly,
while retracting the sternocleidomastoid posteriorly. Blunt dissection
leads to the tran sverse processes an d anterior aspect of C1–C3.
5. Lateral approach to the cervical spine by Verbiest:
a. The exposure is achieved by dissecting anterior to the carotid sheath and
exposing the vertebral artery and nerve roots posterior to the transverse
processes.
b. This lateral approach may be used for lesions that are localized laterally
or if the vertebral artery must be exposed.
6. Cervicothoracic junction: anterior exposure of the upper thoracic vertebrae
may be accomplished through the low cervical, supraclavicular approach,
sternum-splitting approach, or transthoracic approach (Fig. 1.19, Fig. 1.20,
Fi g . 1 .2 1 , Fi g . 1 .2 2 , and Fig. 1.23).
a. Low cervical approach to C6–T2: an extension of the anteromedial
approach to the lower cervical spine.
b. The supraclavicular approach to C6–T2.
(1) A transverse incision above the clavicle and a dissection posterior to
the carotid sheath.
(2) After incision of the platysm a muscle, the clavicular head of the
sternocleidomastoid is divided. The fascia beneath is divided to
release the omohyoid from its pulley.
(3) The subclavian artery and its branches, which include the
thyrocervical trunk, suprascapular artery, and transcervical artery,
must be identi ed. The dome of the lung and the phrenic nerve are in
close proxim ity to the scalenu s anterior m u scle.
(4) Division of the scalenus anterior muscle exposes the Sibson’s fascia in
the oor of the wound, which covers the dome of the lung.
(5) Sibson’s fascia is divided transversely using scissors, and the visceral
pleura and lung should be retracted inferiorly.
(6) The trachea, the esophagus, and the recurrent laryngeal nerve must
be protected during medial retraction. The posterior thorax, stellate
ganglion, and upper thoracic vertebral bodies are now visible looking
from ab ove d ow nw ard t hrough th e t h ora cic in let . Th e recu rren t
laryngeal ner ve sh ould be ident i ed and protected. Likew ise, the
inferior thyroid arter y an d vertebral artery shou ld be identi ed. Th e
thoracic duct should be identi ed if approached from the left.
1 Anatomy an d Surgical Approaches 31
a
b
Fi g . 1 . 1 9 ( a ) The sternal-splitting approach. (b) After division of the platysma, the deep cervical
fascia is d ivided sharp ly.
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1 Anatomy and Surgical Approaches
Fi g . 1 . 2 0 To c o m p l e t e t h e e x p o s u r e , t h e e s o p h a g u s , t r a c h e a , a n d b r a c h i o c e p h a l i c t r u n k a r e g e n t l y
retracted to the right, and the thoracic duct is retracted to the left.
1 Anatomy an d Surgical Approaches 33
a
b
Fi g . 1 . 2 1 ( a ) A T-shaped incision is performed during the sternal splitting approach. (b) Deeper
exposure reveals the sternocleidomastoid and pectoralis major muscles.
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