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18 I Patient Evaluation and Spine Overview
Figures 1–7 (A, B) Bony anatomy of the thoracic spine. (From An HS. Principles and Techniques of
Spine Surgery. Baltimore: Williams and Wilkins; 1998. Reprinted with permission.)
A
B
Chapter 1 Anatomy and Surgical Approaches 19
e. Kidney-shaped vertebral bodies that are widest transversely
f. Facets are in a sagittal orientation, limiting the axial rotation.
Exception is the L5–S1 facet because it is more coronal to resist AP
translation.
g. More prominent pars interarticularis
h. Broad and tall spinous process
i. Smaller transverse process
(1) L5 transverse process attaches to the iliolumbar ligament
(2) Accessory process on the medial aspect of transverse process
where it joins the posterior bony arch
3. Sacrum and coccyx (Figure 1–9)
a. Bony structures of the sacrum: ala, promontory, median sacral
crest, sacral foramina, articular surface
b. Coccyx: three or four elements and the last two to three segments
are fused
(1) attachment site for the muscles of the pelvic floor
c. Sacroiliac joint
(1) Articular process: sacral hyaline cartilage and iliac fibrocarti-
lage
(2) Ligaments: interosseous sacroiliac ligament, posterior sacroiliac
ligament, and anterior sacroiliac ligament
d. Connecting ligaments
(1) Sacrotuberous ligament: sacrum to ischial tuberosity
(2) Sacrospinous ligament: divides pelvis into greater and lesser
sciatic notches
(3) Iliolumbar ligaments: L5 transverse processes to ala of sacrum
Figure 1–8 Bony anatomy of the lumbar spine. (From An HS. Principles and techniques of spine
surgery. Baltimore: Williams and Wilkins; 1998. Reprinted with permission.)
20 I Patient Evaluation and Spine Overview
B. Soft tissue structures
1. Muscles
a. Superficial
(1) Latissimus dorsi: origin from T6–T12, lumbar spine, sacrum,
and posterior iliac crest and lower four ribs to insert at the bot-
tom of intertubercular groove of the humerus
(2) Levator scapulae: origin from C1–C4 transverse processes to in-
sert at the medial border of the scapula above the spine
(3) Rhomboid minor: origin from C7 to T1 to insert at medial bor-
der of the scapula at the root of the spine
Figure 1–9 Anterior (A) and posterior (B) anatomy of the sacrum.
A
B
Chapter 1 Anatomy and Surgical Approaches 21
(4) Rhomboid major: origin from T2 to T5 and insertion at medial
border of the scapula below spine
b. Deep muscles of the back
(1) Superficial layer (transversocostal group or erector spinae):
iliocostalis, longissimus, and spinalis
(2) Deeper layer (transversospinal group): semispinalis, multifidus,
and rotators
(3) Deepest layer: interspinalis and intertransverse muscles
Surgical Approaches
I. Cervical spine
A. Posterior approaches: Reverse Trendelenburg position and Mayfield tongs
help to secure the head and minimize venous bleeding in the surgical
field.
1. Posterior approach to occiput to C1–C2 (Fig. 1–10).
a. Midline incision from the external occipital protuberance to C2
spinous process (6 to 8 cm)
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 (cervi-
cal ganglion and vertebral artery) and be careful not to fracture the
C1 ring.
d. Separate occipitoatlantal and atlantoaxial membranes from the
bone and wiring
e. Occiput: make drill holes above the foramen magnum and remove
bone distally for decompression. External occipital protuberance
can be used for wiring for fusion.
f. Neurovascular structures
(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 foramen to atlas transverse
foramen and pierces the lateral angle of the posterior atlanto-
occipital membrane
2. Posterior approach to the lower cervical spine
a. Midline incision down to the spinous processes and lamina (inter-
laminar space is wide and caution should be taken to avoid pene-
tration to the dura)
b. Lateral exposure to the transverse processes, exposing the facets
and lateral masses
c. Laminectomy, foraminotomy (resection of the medial aspect of su-
perior and inferior facets), or excision of disk or osteophytes of the
joints of Luschka to decompress the nerve roots
(1) C5 nerve root forms45 degrees with the spinal cord and this
angle increases as one descends is 90 degrees at C8 level
◆
22 I Patient Evaluation and Spine Overview
(2) Nerve roots (foramen borders): disks and joints of Luschka an-
teriorly, zygapophyseal joints posteriorly, pedicles superiorly
and inferiorly. Also, vertebral artery is anterior to the roots.
B. Anterior approaches: Gardner-Wells tongs are used for traction and to
keep the neck slightly extended.
1. Anterior medial approach to the midcervical spine
a. Landmarks
(1) Hard palate: arch of the atlas
(2) Lower border of mandible: C2–C3
(3) Hyoid bone: C3
(4) Thyroid cartilage: C4–C5
(5) Cricoid cartilage: C6
(6) Carotid tubercle: C6
Figure 1–10. An illustration of the course of the vertebral artery and the greater occipital nerve in
relation to the posterior midline. (From An HS. Principles and Techniques of Spine Surgery. Baltimore:
Williams and Wilkins; 1998. Reprinted with permission.)
Chapter 1 Anatomy and Surgical Approaches 23
b. Transverse incision from the midline to the posterior border of the
sternocleidomastoid
c. Split platysma longitudinally or transversely
d. Incise the pretracheal fascia immediately anterior to the sternoclei-
domastoid, followed by blunt finger dissection to the vertebral bod-
ies, retracting carotid sheath (carotid artery, internal jugular vein,
and vagus nerve) laterally and retract strap muscles, trachea, and
esophagus medially (Fig. 1–11).
e. Superior thyroid arteries may limit dissection above C3–C4 and
inferior thyroid artery below C6 (may ligate and divide).
f. Divide the prevertebral fascia and anterior longitudinal ligament in
the midline, retracting the longus colli laterally.
g. Neurovascular and vital structures
(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 sub-
clavian 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: carotid artery, internal jugular vein,
and vagus nerve anterior to the sternocleidomastoid muscle.
Figure 1–11 Blunt finger dissection is done through the Smith-Robinson interval toward the
anterior cervical spine. (From An HS, Riley L. An Atlas of Surgery of the Spine. London, England:
Martin Dunitz; 1998 [illustrator: Carole Russell Hilmer]. Reprinted with permission.)
24 I Patient Evaluation and Spine Overview
(4) Esophagus: take precaution on medial deep retraction.
C. Other anterior approaches: to the cervical spine
a. Transoral approach to C1–C2 (Fig. 1–12)
(1) Fiber-optic nasotracheal intubation and nasogastric tube are
used.
(2) The patient is placed in the supine position with the head held
in slight extension using the Mayfield frame.
(3) The oral cavity is cleansed with chlorhexidine, and periopera-
tive antibiotics with an intravenous cephalosporin and metron-
idazole are instituted for 72 hours as prophylaxis against
wound infection.
(4) The key surgical landmark is the anterior tubercle on the atlas
to which the anterior longitudinal ligament and longus colli
muscles are attached.
(5) The transoral retractors are inserted, exposing the posterior
oropharynx. The area of the incision is infiltrated with
1:200,000 epinephrine.
(6) A midline 3-cm vertical incision centered on the anterior tuber-
cle is made through the pharyngeal mucosa and muscle.
(7) The tubercle of the atlas and anterior longitudinal ligament are
exposed superiosteally, and the longus colli muscles are
mobilized laterally.
Figure 1–12 Diagram of the transoral approach, which allows exposure of the midline between
the arch of 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. (From An HS, Riley L.
An Atlas of Surgery of the Spine. London, England: Martin Dunitz; 1998 [illustrator: Carole Russell
Hilmer]. Reprinted with permission.)
Chapter 1 Anatomy and Surgical Approaches 25
(8) A high-speed burr may be used to remove the anterior arch of
the atlas to expose the odontoid process.
b. An anteromedial approach to the upper cervical spine by DeAn-
drade and Macnab
(1) The neck is hyperextended, and the chin is turned to the oppo-
site side.
(2) A skin incision is made along the anterior aspect of the stern-
ocleidomastoid muscle and curved toward the mastoid
process.
(3) The platysma and the superficial layer of the deep cervical fas-
cia are divided in the line of the incision to expose the anterior
border of the sternocleidomastoid.
(4) The sternocleidomastoid muscle is retracted anteriorly and the
carotid artery laterally.
(5) The superior thyroid artery and lingual vessels are ligated. The
facial artery is identified at the upper portion of the incision, which
helps to find the hypoglossal nerve adjacent to the digastric
muscle.
(6) The superior laryngeal nerve is in close proximity to the supe-
rior thyroid artery, and excessive retraction of this nerve should
be avoided.
(7) Stripping of the longus colli muscle exposes the anterior aspect
of the upper cervical spine and basiocciput.
c. Anterior retropharyngeal exposure of the upper cervical by McAfee.
(1) A right-sided submandibular transverse incision and division of
the platysma leads to the sternocleidomastoid muscle and its
deep cervical fascia.
(2) The mandibular branch of the facial nerve should be identified
with the aid of a nerve stimulator, and the retromandibular
vein is ligated during the initial stage of dissection.
(3) The anterior border of the sternocleidomastoid muscle is mobi-
lized. The submandibular salivary gland and the jugular
digastric lymph nodes are resected.
(4) Care should be taken to suture the duct in the salivary gland to
prevent a salivary fistula.
(5) The digastric tendon is divided and tagged for later repair.
(6) The hypoglossal nerve is next identified and mobilized. The
carotid sheath is opened, and arterial and venous branches
are ligated, including the superior thyroid artery and vein,
lingual artery and vein, ascending pharyngeal artery and
vein, and facial artery and vein, beginning inferiorly, pro-
gressing superiorly.
(7) The superior laryngeal nerve is also identified and mobilized.
(8) The prevertebral fasciae are transected longitudinally to expose
and dissect the longus colli muscles.
d. The anterolateral retropharyngeal approach by Whitesides and Kelley
(1) The skin incision is made from the mastoid along the anterior
aspect of the sternocleidomastoid.
26 I Patient Evaluation and Spine Overview
(2) The external jugular vein is ligated, and the greater auricular
nerve is spared if possible.
(3) The sternocleidomastoid and splenius capitus muscles are de-
tached from the mastoid, leaving a fascial edge for later repair.
The spinal accessory nerve should be identified and protected.
(4) Retract the carotid contents along with hypoglossal nerve ante-
riorly, while retracting the sternocleidomastoid posteriorly.
Blunt dissection leads to the transverse processes and anterior
aspect of C1–C3.
e. Lateral approach to the cervical spine by Verbiest
(1) The exposure is by dissecting anterior to the carotid sheath and
exposing the vertebral artery and nerve roots posterior to the
transverse processes.
(2) This lateral approach may be used for lesions that are localized
laterally or if the vertebral artery must be exposed.
f. Cervicothoracic junction: anterior exposure of the upper thoracic ver-
tebrae may be accomplished through the low cervical, supraclavicular
approach, sternum-splitting approach, or transthoracic approach.
(Figs. 1–13 to 1–17)
(1) Low cervical approach to C6–T2: an extension of the anterome-
dial approach to the lower cervical spine.
(2) The supraclavicular approach to C6–T2
(a) A transverse incision above the clavicle and a dissection
posterior to the carotid sheath
(b) After incision of the platysma muscle, division of the clav-
icular head of the sternocleidomastoid is done. The fascia
beneath is divided to release the omohyoid from its pulley.
(c) The subclavian artery and its branches, which include the thy-
rocervical trunk, suprascapular artery, and transcervical ar-
tery, must be identified. The dome of the lung and the phrenic
nerve are in close proximity to the scalenus anterior muscle.
(d) Division of the scalenus anterior muscle exposes the Sib-
son’s fascia in the floor of the wound, which covers the
dome of the lung.
(e) Sibson’s fascia is divided transversely using scissors, and
the visceral pleura and lung should be retracted inferiorly.
( f) The trachea, the esophagus, and the recurrent laryngeal
nerve must be protected during medial retraction. The pos-
terior thorax, stellate ganglion, and upper thoracic vertebral
bodies are now visible looking from above downward
through the thoracic inlet. The recurrent laryngeal nerve
should be identified and protected. Likewise, the inferior
thyroid artery and vertebral artery should be identified.
The thoracic duct should be identified if approached from
the left.
(3) Thoracotomy to T1–T4 (Figs. 1–18 to 1–23)
(a) The right-sided approach is preferred to avoid the left
subclavian artery, which is more curved than the right
brachiocephalic artery.
Chapter 1 Anatomy and Surgical Approaches 27
Figure 1–13 (A) A diagram of the sternal-splitting approach. (B) After division of the platysma, the
deep cervical fascia is divided sharply. (From An HS, Riley L. An Atlas of Surgery of the Spine. London,
England: Martin Dunitz; 1998 [illustrator: Carole Russell Hilmer]. Reprinted with permission.)
A
B
(b) The incision is medial and inferior to the scapula. The
scapula is retracted laterally by dividing the trapezius,
latissimus dorsi, rhomboids, and levator scapulae
muscles.
(c) The chest is entered through the third rib.
(d) The posterior 7 to 10 cm of each of the second, third,
fourth, and fifth ribs may be removed.
(e) Exposure of the vertebrae is made with an L-shape incision
in the pleura.
(4) The sternum-splitting approach to C4 to T4