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28 I Patient Evaluation and Spine Overview
(a) The skin incision is made anterior to the left sternocleido-
mastoid muscle and extends along the midsternal area
down to the xiphoid process.
(b) After division of the platysma muscle and superficial
cervical fascia, blunt dissection is done between the lat-
erally situated neurovascular bundle and medial visceral
structures.
(c) The retrosternal adipose and thymus tissues are retracted
from the manubrium.
(d) Median sternotomy should be performed carefully to pre-
vent injury to the pleura. Sternohyoid, sternothyroid, and
omohyoid muscles are identified and transected as neces-
sary.
(e) The inferior thyroid artery is ligated and transected.
Figure 1–14 To complete the exposure, the esophagus, trachea, and brachiocephalic trunk are
gently retracted to the right, while the thoracic duct is retracted to the left. (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 29
Figure 1–15 (A) A T-shaped incision is performed during the sternal splitting approach.
(B) Deeper exposure reveals the sternocleidomastoid and pectoralis major muscles. (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
( f) Blunt dissection is performed from the cranial toward the
caudal portion until the left brachiocephalic vein is
exposed.
(g) Retraction of the carotid artery laterally, brachiocephalic
vein inferiorly, and trachea medially exposes the vertebrae.
30 I Patient Evaluation and Spine Overview
II. Thoracolumbar spine
A. Posterior approaches: the patient is usually positioned on the four-poster
or Relton-Hall frame for the thoracolumbar spine and kneeling position
for the lumbar spine.
1. Thoracic spine
a. Posterior: midline exposure of the posterior elements (spinous
process, lamina, facets, pedicle, and transverse processes)
(1) Transpedicular approach: the thoracic pedicle is located by
crossing a horizontal line at the midportion of the transverse
process and a vertical line at the junction between the lamina
and transverse process.
Figure 1–16 The sternal and clavicular heads of the sternocleidomastoid are detached at the level
of the manubrium. (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 31
Figure 1–17 (A) The medial third of the clavicle and a rectangular piece of the manubrium are
removed. (B) Retraction of the vessels and trachea exposes the cervicothoracic junction. (From An
HS, Riley L. An Atlas of Surgery of the Spine. London, England: Martin Dunitz; 1998 [illustrator: Carole
Russell Hilmer]. Reprinted with permission.)
32 I Patient Evaluation and Spine Overview
(2) Posterolateral: costotransversectomy approach
(a) A C-shape curved incision is made along the paraspinous
muscles, spanning about four to five ribs.
(b) The middle part of the incision should be 2.5 inches from
the midline.
(c) By undermining the skin and subcutaneous tissue, expo-
sure of the paraspinous muscles and posterior elements of
the spine is completed.
(d) The trapezius and latissimus dorsi muscles are divided
either longitudinally or transversely.
(e) The rib and transverse process are resected at one to four lev-
els, depending on the extent of the lesion. The rib is exposed
subperiosteally and excised 3.5 inches lateral to the verte-
bra and disarticulated at the costovertebral junction.
( f ) Careful retraction of the pleura will lead to the vertebrae.
Figure 1–18 (A) High transthoracic approach to the upper cervicothoracic spine. (B) The trapezius
muscle is divided close to the spinous processes and parallel to the skin. (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
Chapter 1 Anatomy and Surgical Approaches 33
2. Lumbar spine
a. Laminectomy or laminotomy
(1) Exposure of spinous process, lamina, and ligamentum flavum
(2) Excise the ligamentum flavum to enter the epidural space
(3) Removal of part of superior facet to decompress the lateral recess
(4) The nerve root is medially retracted to remove the offending
disk material
b. Transpedicular approach (Fig. 1–20): the pedicle is located by
crossing a horizontal line at the midportion of the transverse
processes and a vertical line at the lateral edge of the superior
facet.
A
Figure 1–19 (A) The rhomboid major is divided near its insertion, and the serratus anterior muscle is
divided as caudally as possible. (B) The scapula can then be retracted superolaterally and the perios-
teum can be incised. (From An HS, Riley L. An Atlas of Surgery of the Spine. London, England: Martin
Dunitz; 1998 [illustrator: Carole Russell Hilmer]. Reprinted with permission.)
B
34 I Patient Evaluation and Spine Overview
Figure 1–21 The incision employed for a transthoracic approach to the 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.)
Figure 1–20 Retractors are positioned and the upper thoracic spine is exposed. (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 35
Figure 1–22 (A) The anterior aspect of the latissimus is divided exposing the underlying rib.
(B) The underlying rib is dissected free of the periosteum. (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. Anterior approaches
1. Thoracic spine: transthoracic approach by removing a rib and dividing
the pleura (Fig. 1–21)
a. The skin incision is made along the rib intended for removal from
the anterior margin of the latissimus muscle anteriorly to the costo-
chondral junction.
b. The anterior aspect of the latissimus muscle can be undermined or
minimally incised, and the posterior border of the serratus anterior
muscle is mobilized or transected.
c. The lateral margin of the trapezius muscle is mobilized and tran-
sected if necessary.
d. Rib resection is then performed by first incising the overlying
periosteum in the midportion of the rib using electrocautery. A rib
stripper is then used to dissect off the intercostal musculature.
e. The rib is divided at the costochondral junction anteriorly, elevated
and resected as far posteriorly as the exposure will allow.
f. The chest is then sharply entered in the center of the rib bed, and
the lung retracted anteriorly and inferiorly.
g. The pleura overlying the vertebral bodies is then incised and the seg-
mental vessels ligated as needed in the middle of the vertebral bodies.
36 I Patient Evaluation and Spine Overview
2. Thoracoabdominal approach by removing the tenth rib and
dividing the diaphragm and through the retroperitoneal space
a. A skin incision is made over the tenth rib from the lateral border of
the paraspinous musculature to the costal cartilage. The incision is
curved anteriorly to the edge of the rectus sheath.
b. The dissection is extended down to the muscle layers to remove the
tenth rib.
c. Split the costal cartilage after removal of the tenth rib. The pleura is
incised and the lung is retracted, and the retroperitoneal space is
identified by the light areolar tissue.
d. Blunt dissection is performed to mobilize the peritoneum from the
undersurface of the diaphragm and abdominal wall.
e. After the peritoneum is retracted, the external oblique, internal
oblique, and the transverse abdominous muscles of the abdomen
are divided one layer at a time.
Figure 1–23 The overlying rib is resected near its articulation with the costovertebral junction. The
parietal pleura is incised, and the overlying prevertebral fasica is identified. Shown are the ligated seg-
mental vessels overlying the thoracic vertebrae. (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 37
f. The diaphragm is incised circumferentially 1 inch from its periph-
eral attachment to the chest wall. Marker stitches or clips are
placed for resuturing the diaphragm later.
g. For the exposure of the T12–L1 region, the crus of the diaphragm is
cut and mobilized.
h. The segmental vessels are tied and ligated as necessary to mobilize
the aorta.
2. Lumbar spine
a. Anterolateral retroperitoneal approach
(1) Dissection is through the external oblique, internal oblique, and
transverse abdominous muscles (skin incision depends on the
level of exposure).
(2) The retroperitoneal space is entered laterally by identifying the
retroperitoneal fat, taking care to avoid penetration of the peri-
toneum just lateral to the rectus sheath.
(3) Blunt finger dissection anterior to the psoas muscle should lead
to the spine.
(4) One should identify the genitofemoral nerve on the anterior
surface of the psoas muscle and the sympathetic chains medial
to the muscle.
(5) The ureter is under the peritoneum anteriorly.
(6) Vessels (aorta or vena cava) are mobilized, and segmental ves-
sels are identified in the middle portion of the vertebral bodies
and ligated as necessary.
(7) For exposure of the lumbosacral junction, the iliac vessels are
mobilized.
b. Anterior muscle-splitting approach
(1) A vertical paramedian incision is made from the umbilicus to
the pubis at the edge of rectus.
(2) The fascia of the rectus abdominous is divided and the muscle
is retracted medially.
(3) The posterior rectus sheath is carefully divided along the
peritoneal attachment.
(4) Blunt finger dissection of peritoneum leads to the lower lumbar
spine (L3–S1).
c. Transperitoneal approach to lumbosacral junction
(1) A vertical or transverse incision is made above to pubis
(Figs. 1–24, 1–25).
(2) Peritoneum is entered, and bowel structures are retracted
(Fig. 1–26A).
(3) Posterior peritoneum is lifted and divided.
(4) Iliac vessels are mobilized to expose L4–S1 (Fig. 1–26B).