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34 Spine Core Knowledge in Orthopaedics
Box 3–1:
●
Arch of the atlas—Hard palate
●
C2-C3—Lower border of the mandible
●
C3—Hyoid bone
●
C4-C5—Thyroid cartilage
●
C6—Cricoid cartilage
●
C6—Carotid tubercle
Box 3–2:
●
Irreducible atlantoaxial subluxation
●
Midline anterior extradural or intradural spinal cord compression
●
Midbasilar artery aneurysms
Anatomic Landmarks of the Cervical
Spine
Indications for the Transoral Approach
interrupted 3-0 absorbable sutures, one layer for muscle
and one for mucosa.
Anterior Retropharyngeal Approach
●
The anterior retropharyngeal approach to the upper
cervical spine allows visualization from the clivus to C3.
●
This approach may be extended inferiorly to expose the
middle and lower cervical spine (Box 3–3).
Technique
●
A modified transverse submandibular incision is made
(Fig. 3–3).
●
An incision is made through the skin, the subcutaneous
tissue, and the platysma.
Figure 3–2: The arch of the atlas has been exposed.The
anterior longitudinal ligament and longus colli muscles have
been divided and retracted.
●
The mandibular branch of the facial nerve is identified
(Fig. 3–4).
●
It is important to use bipolar cautery on the
retromandibular and facial veins to avoid inadvertent
injury to the mandibular branch of the facial nerve.
●
If the mandibular branch of the facial nerve is injured,
the patient will have a noticeable droop of the ipsilateral
Box 3–3:
Indications for the Anterior
Retropharyngeal Approach
Figure 3–1: A midline vertical pharyngeal incision made
during a transoral approach.
●
Decompression and stabilization of fixed atlantoaxial subluxation
●
Anterior upper cervical vertebral debridement or decompression
Figure 3–3: The retropharyngeal approach to the upper
cervical spine. A submandibular incision is illustrated with an
optional vertical extension to the subaxial cervical spine.
Figure 3–4: The superficial neurovascular structures in the
anterolateral neck.
aspect of the mouth secondary to denervation of the
orbicularis oris muscle.
●
The common facial vein is usually continuous with the
retromandibular vein. The mandibular branch of the facial
nerve usually crosses the retromandibular vein
superficially and superiorly and is superficial to the
anterior facial vein.
●
The submandibular gland is displaced and the digastric
muscle is divided (Fig. 3–5).
●
The facial, lingual, and superior thyroid vessels, with the
exception of the superior thyroid artery, are isolated,
ligated, and divided.
●
The superior laryngeal nerve may run close to the
superior thyroid artery.
CHAPTER 3
●
After the superficial layer of the deep cervical fascia is
Surgical Approaches to the Spine 35
incised along the anterior border of the
sternocleidomastoid, the superior thyroid artery and vein
are ligated.
●
The hypoglossal and superior laryngeal nerves are
mobilized.
●
Branches of the carotid artery and internal jugular vein are
ligated to allow retraction of the carotid sheath posteriorly
and laterally when the pharynx is mobilized medially.
●
The submandibular gland may be resected if necessary
(its duct being sutured to prevent salivary fistula
formation).
●
The posterior belly of the digastric and stylohyoid
muscles is tagged with suture for later repair.
●
Care must be taken not to retract near the origin of the
posterior belly of the digastric and stylohyoid muscles to
avoid neuropraxic injury to the facial nerve.
●
Division of the posterior belly of the digastric and
stylohyoid muscles allows mobilization of the hyoid bone
anteriorly and medially, thus allowing mobilization of the
pharynx.
●
The hypoglossal nerve is mobilized from the base of the
skull to the posterior border of the mylohyoid bone,
where it is then retracted superiorly for the remainder of
the case.
●
The dissection continues within the retropharyngeal
space between the carotid sheath laterally and the
pharynx, larynx, and esophagus medially.
●
The alar and prevertebral fascia are split longitudinally
to expose the longus colli muscles that run
longitudinally on the anterior lateral aspects of the
spine (Fig. 3–6).
Figure 3–5: The neck after the submandibular gland has been
resected and the digastric muscle has been divided.
Figure 3–6: The prevertebral fascia is split longitudinally
between the longus colli muscles, exposing the anterior atlas
and the C2 body.
36 Spine Core Knowledge in Orthopaedics
Smith-Robinson Approach to the
Subaxial Spine
●
The most common anterior approach to the subaxial
(middle, lower) cervical spine is the Smith-Robinson
approach (Box 3–4).
Technique
●
The patient is positioned supine with a bump placed in
the interscapular region.
●
Extending the neck and slightly rotating the head toward
the contralateral shoulder helps to provide greater ease of
exposure to the spinal elements.
●
A transverse incision is used in most cases, but an
oblique incision may be used for exposure of multiple
levels.
●
A right- or left-sided approach may be selected.
●
If the surgeon extends the approach below the level of
C5, a left-sided approach is theoretically safer in
avoiding inadvertent injury to the recurrent laryngeal
nerve.
●
A transverse incision in line with the skin crease is made
from the midline to the anterior aspect of the
sternocleidomastoid muscle (Fig. 3–7).
●
The skin and subcutaneous tissues are undermined
slightly and the platysma is divided (Fig. 3–8).
●
Retraction of the platysma exposes the
sternocleidomastoid muscle laterally and the strap
muscles medially.
●
The sternocleidomastoid muscle is retracted laterally with
the carotid sheath (enclosing the common carotid artery,
internal jugular vein, and vagus nerve) (Fig. 3–9).
●
Carefully palpate the carotid sheath retracted laterally
with the sternocleidomastoid.
●
The sternohyoid and sternothyroid strap muscles (with
the trachea and esophagus) are retracted medially,
allowing blunt dissection through the pretracheal
fascia.
●
The prevertebral fascia and longus colli muscles are
exposed (Box 3–5).
●
The prevertebral fascia is divided longitudinally to expose
the disk and vertebral body (Fig. 3–10).
Figure 3–7: The Smith-Robinson approach to the subaxial
cervical spine. A transverse and oblique incision is illustrated.
●
The bony spinous processes are palpable posteriorly with
noted large, spinous processes at C2, C7, and T1.
●
The C2 and C7 spinous processes are large and the
C3-C6 spinous processes are usually bifid.
●
A direct midline interfascial, internervous approach is
used to expose the posterior vertebrae (Fig. 3–11,
Box 3–7).
●
The ligamentum nuchae, a fibroelastic septum with few
elastic fibers, originates from the occiput and inserts onto
the C7 spinous process.
●
The supraspinous ligaments are in continuity with the
ligamentum nuchae and spinous processes posteriorly, and
they blend with the interspinous ligaments anterior to
them.
●
The course of the vertebral artery (Fig. 3–12) along the
posterior superior arch of C1 makes it prone to injury if
Posterior Cervical Approach
●
The posterior cervical approach is commonly used to
perform a laminectomy, foraminotomy, or laminaplasty
with or without a fusion (Box 3–6).
Indications for the Smith-Robinson
Box 3–4:
●
Anterior cervical discectomy and fusion
●
Anterior cervical corpectomy and fusion
Approach to the Subaxial Cervical
Spine
Figure 3–8: An oblique incision is made through the skin,
followed by a horizontal incision through the underlying
platysma.
CHAPTER 3
Surgical Approaches to the Spine 37
Figure 3–9: Blunt finger dissection is used to divide the
pretracheal fascia while palpating and retracting the carotid
sheath laterally.
Box 3–5:
●
The superior thyroid artery is encountered above C4 and the infe-
rior thyroid artery is encountered below C6. These vessels should
be identified and ligated as necessary.
●
The thoracic duct may be exposed in surgical approaches below
the C7 level during a left-sided approach.
Smith-Robinson Approach
Box 3–6:
●
Decompress spinal cord or nerve root
●
Excision of herniated disks
●
Fusion of cervical vertebrae
Indications for the Posterior Cervical
Approach
dissection in the adult is performed more than 1.5 cm
from the midline of the C1 posterior tubercle. (The
distance is only 1 cm in the child).
●
The artery enters the operative field when it passes
from the transverse foramen of the atlas, immediately
behind the atlanto-occipital joint, and pierces the lateral
angle of the posterior atlanto-occipital membrane. It is
vulnerable in this region during surgical exposures
(Fig. 3–13).
●
The C1 nerve is also referred to as the suboccipital
nerve, and the C2 nerve is referred to as the greater
occipital nerve.
●
The posterior cervical musculature is elevated in a
subperiosteal manner with care taken not to disturb the
surrounding facet capsules.
Anterior Exposures of the
Cervicothoracic Junction
●
Anterior exposure of the cervicothoracic junction
(C7-T2) is a challenging surgical exercise because of the
overlying clavicle and sternum and the proximity of the
great vessels.
●
Three methods with various modifications of anterior
approaches to the cervicothoracic junction have been
described:
1. High transthoracic
2. Manubrium or sternal splitting partial resection
3. Low cervical and high transthoracic
Figure 3–10: The longus colli muscles are mobilized laterally
with the aid of a curette.
High Transthoracic
●
A periscapular J-shaped incision is made approximately
2.5 cm medial to the superior angle of the scapula
and continued down around its inferior angle
(Fig. 3–14).
●
Dissection continues in the line of the incision through
the subcutaneous fat to the level of the superficial
muscles of the back.
●
The trapezius is divided close to the spinous processes
and parallel to the direction of the skin incision to avoid
injuring the spinal accessory nerve (CN XI).
●
The latissimus dorsi is divided as medially as possible to
allow adequate retraction of the scapula and to avoid
injuring the thoracodorsal nerve.
●
The rhomboid major muscle is divided near its insertion
onto the scapula.
38 Spine Core Knowledge in Orthopaedics
Greater
Occipital nerve
Lesser
Occipital nerve
Occipital artery
Semispinalis
capitis muscle
Third
occipital nerve
Medial branch of
posterior primary
ramus of C5
Splenius
capitis muscle
Splenius
cervicis muscle
Sternocleidomastoid
muscle
Greater auricular nerve
External jugular vein
Levator scapulae muscle
Figure 3–11: The posterior aspect of the
cer
vical spine. Depicted ar
e the superficial
nerves and musculature.
●
Lying inferiorly and laterally, the serratus anterior muscle
is divided as caudally as possible to avoid injuring its
nerve supply, the long thoracic nerve (Fig. 3–15).
●
The scapula can be retracted superolaterally after
protecting its medial surface with a saline-soaked
sponge.
●
The periosteum of the third rib is incised along its
longitudinal axis and sharply dissected with the use of an
elevator.
●
The rib can be divided posteriorly 1-2 cm from its
attachment to the transverse process and anteriorly at its
junction with the costal cartilage (Fig. 3–16).
●
Exposure through the pleural cavity involves making an
incision through the parietal pleura and retracting the
dome of the lung inferiorly to expose the anterior
surface of the spine.
●
The parietal pleura overlying the upper thoracic
vertebrae are carefully incised to avoid injuring the
superior intercostal vein, artery, and the sympathetic
trunk and ganglion (Fig. 3–17).
Box 3–7:
●
Superficial layer—Trapezius
●
Intermediate layer—Splenius capitis
●
Deep layer—Semispinalis capitis (superficial), semispinalis cervicis
(intermediate), and multifidus (deep)
Posterior Paracervical Muscular Layers
Sternal Splitting Approach to the
Cervicothoracic Junction
●
An oblique incision is made along the anterior border of
the sternocleidomastoid muscle and courses inferiorly
over the midline of the manubrium and sternum
(Fig. 3–18).
●
Dissection continues through the subcutaneous tissue and
platysma in line with the skin incision.
●
The deep cervical fascia (which invests the anterior
border of the sternocleidomastoid) is divided sharply,
allowing the sternocleidomastoid muscle to be retracted
laterally.
●
While protecting the carotid sheath laterally, the
pretracheal fascia is divided sharply by spreading it with
the blunt tips of a forceps, allowing the carotid sheath to
be taken laterally and the strap muscles of the neck and
the underlying trachea or esophagus to be retracted
medially.
●
This allows exposure of the prevertebral fascia, which
invests the longus colli muscles on both sides of the
cervical spine.
●
The soft tissue aponeurosis investing the superior border
of the sternal notch is released, and blunt finger
dissection is used to clear the underlying retrosternal
adipose tissue from the undersurface of the manubrium.
●
The muscular aponeurotic soft tissue attachments to the
inferior xiphoid process are released sharply and the
retrosternal fatty tissue is separated from its undersurface.
●
A sternotomy is performed (Fig. 3–19).
CHAPTER 3 Surgical Approaches to the Spine 39
Figure 3–12: The coursing of the
v
erte
bral artery and greater occipital
nerve in relation to the posterior midline.
Posterior midline
Vertebral artery
Rectus capitis
posterior minor
Obliquus capitis
superior
Rectus capitis
posterior major
Greater occipital nerve
Obliquus capitis
inferior
Figure 3–13: The various muscular layers of the
poster
ior cervical spine
.
Semispinalis
capitis muscle
Splenius
capitis muscle
Longissimus
capitis muscle
40 Spine Core Knowledge in Orthopaedics
Figure 3–14: The incision for the transthoracic approach to the upper
thoracic spine.The trapezius muscle is divided close to the spinous
processes and parallel to the skin.
Figure 3–15: The rhomboid major is divided near its
inser
tion and the serratus anter
caudally as possible.
ior muscle is divided as
Teres major
muscle
Infraspinatus
muscle
Rhomboideus
major muscle
Third rib
Figure 3–16: The scapula can then be retracted superolaterally,
and the periosteum can be incised.
Figure 3–17: Retractors are
positioned and the upper thoracic
spine is exposed.
CHAPTER 3
Surgical Approaches to the Spine 41
Figure 3–18: The incision for the sternal splitting approach.
●
Dissection is continued from the exposed subaxial
cervical spine in a caudal direction through the
pretracheal fascia exposing the left innominate or
brachiocephalic vein.
●
The vein can be ligated with the inferior thyroid artery
if necessary.
●
To complete exposure of the prevertebral fascia, the
esophagus, the trachea, and the brachiocephalic truck are
retracted gently to the right using flexible spatulas; the
thoracic duct, the cupola of the pleura, and the left
common carotid artery are retracted to the left.
●
The prevertebral fascia is then divided in the midline to
allow sub-periosteal dissection of the vertebral body
(Fig. 3–20).
Figure 3–19: The omohyoid is divided along with the
traversing inferior thyroid artery. The sternotomy is performed
exposing the cervical spine.
●
Variations of this approach are now more popular in
which only the manubrium or the proximal portion of
the sternum is divided and separated.
●
In these modified approaches, a T-shaped incision may be
made with the vertical limb overlying the manubrium
and upper portion of the sternum and the horizontal
limb of the incision overlying the base of the neck
approximately 1 cm above the clavicle.
●
The medial third of the clavicle may be resected and later
replaced for further exposure.
●
The sternal and clavicular heads of the
sternocleidomastoid muscle on the side of the approach
are detached at the level of the manubrium, and the
clavicle is retracted.
42 Spine Core Knowledge in Orthopaedics
Figure 3–20: To complete the exposure, the esophagus,
trachea, and brachiocephalic trunk are gently retracted to the
right; the thoracic duct is retracted to the left.
●
The strap muscles on the ipsilateral side of the approach
are detached from the clavicle and retracted medially.
●
The sternal origin of the pectoralis major is stripped
laterally off the clavicle (Fig. 3–21).
●
The medial half of the clavicle is stripped subperiosteally
and its medial third is removed with a Gigli saw.
●
The sternoclavicular joint is disarticulated sharply and
curetted.
●
A rectangular piece of manubrium with its posterior
periosteum may be removed using power drill holes and
heavy scissors.
●
The remainder of the approach is similar to the sternal
splitting approach.
Combined Cervical and Thoracic
Approach
●
An oblique cervical incision is made parallel to the
clavicle with division of the platysma in line with the
incision, and a high thoracic incision is made around the
inferior and medial border of the scapula (Fig. 3–22).
●
For the cervical incision, the deep cervical fascia along
the anterior medial border of the sternocleidomastoid
muscle is incised, allowing rotation and retraction of this
muscle laterally to expose its deep surface.
Strap muscle
Sternocleidomastoid
muscle
Figure 3–21: The sternal and clavicular heads of the sternocleidomastoid are detached at the level of the
manubrium.
CHAPTER 3
Latissimus
dorsi muscle
Surgical Approaches to the Spine 43
Trapezius
muscle
Figure 3–22: The combined cervical and thoracic approach to
the cervicothoracic junction.
●
The carotid sheath is retracted anteriorly following gentle
blunt exposure of its posterior border.
●
The inferior thyroid artery is ligated when it courses
posterior to the carotid sheath to obtain better exposure.
●
The cervical vertebrae covered by the longus colli
muscles can be palpated.
●
The cervical wound is packed, and the transthoracic
approach is continued as described previously.
Posterolateral
(Costotransversectomy)
Approach to the Thoracic Spine
●
The classic posterolateral approach to the thoracic spine
was developed for drainage of tuberculous abscesses.
●
The major advantage of the posterolateral approach is that
it does not involve entering the thoracic cavity (Box 3–8).
●
The patient is placed prone on an operating table.
●
A linear incision is made over the midline or curvilinear
incision about 8 cm lateral to the desired spinous process;
the linear incision is 10-13 cm (Fig. 3–23).
●
There is no true internervous plane in this approach.
●
The approach involves splitting the trapezius muscle and
dividing the paraspinal muscles.
Rib to be
resected
Scapula
Figure 3–23: Following the skin incision, the trapezius is
divided.
●
The trapezius is cut parallel with its fibers close to the
transverse processes. Deep to it are the paraspinal muscles.
●
All muscle attachments are separated from the rib of
interest in a subperiosteal manner.
●
Dissection is performed laterally along the superior
border of the rib and medially along the inferior border.
●
The rib is cut 6-8 cm from the midline (Fig. 3–24).
●
The retropleural space is carefully entered with digital
palpation and dissection removing the parietal pleura
from the vertebral body.
●
Blunt dissection is used to avoid entering the pleural
cavity while exposing the vertebral body and disk space.
Anterior (Transthoracic) Approach to
the Thoracic Spine (Box 3–9)
●
The patient is placed in the lateral decubitus position and
stabilized with a kidney rest or sandbags.
●
Although the thoracic vertebrae can be approached from
either side, approaching it from the right side is easier
because the aortic arch and heart can be avoided.
Box 3–8:
●
Abscess drainage
●
Vertebral body biopsy
●
Partial vertebral body resection
●
Thoracic disk excision
●
Anterolateral decompression of the spinal cord
Indications for the Posterolateral
Approach to the Thoracic Spine
Figure 3–24: The periosteum is incised and elevated off the
rib using a periosteal elevator.
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