Surgical Approaches to the Spine PDF
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Surgical Approaches to the Spine Surgical Approaches to the Spine Robert G. Watkins, M.D. With Contributions by Michael L.l. Apuzzo, M.D Roger C. Breslau, M.D. Peter Dyck, M.D. Medical Illustrator: Ted Bloodhart With 197 Illustrations in Color Springer-Verlag New York Heidelberg Berlin Robert G. Watkins, M.D., Southwestern Orthopaedic Medical Group, Inc., Centinela Hospital Medical Center, Inglewood, California; Assistant Clinical Professor, Department of Orthopedic Surgery, University of Southern California; Attending Staff and Consultant, Spinal Disorders Service, Los Angeles County-University of Southern California Medical Center; Senior Consultant in Spinal Surgery, Spinal Cord Injury Service, Rancho Los Amigos Hospital, Downey, California; Executive Board, Southern California Regional Spinal Cord Injury Center. Michael L.J. Apuzzo, M.D., Professor of Neurological Surgery, University of Southern California Medical School, Los Angeles, California Roger C. Breslau, M.D., F.A.C.S., Attending Surgeon, Downey Community Hospital, Downey, California Peter Dyck, M.D., Clinical Professor of Neurological Surgery, University of Southern California Medical School, Los Angeles, California Library of Congress Cataloging in Publication Data Watkins, Robert G. Surgical approaches to the spine. 1. Spine-Surgery. I. Title. [DNLM: 1. Spine Surgery. WE 725 W297s] RD533.W34 1983 617'.56 82-19677 ISBN-13: 978-1-4684-0157-8 © 1983 by Springer-Verlag New York Inc. Softcover reprint of the hardcover 1st edition 1983 All rights reserved. No part of this book may be translated or reproduced in any form without written permission from Springer-Verlag, 175 Fifth Avenue, New York, New York 10010, U.S.A. The use of general descriptive names, trade names, trademarks, etc., in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. Designed by Caliber Design Planning, Inc. Composition and color separations by Kingsport Press. 9 8 7 6 5 4 3 2 1 ISBN-13: 978-1-4684-0157-8 e-ISBN-13: 978-1-4684-0155-4 DOl: 10.1007/978-1-4684-0155-4 To Andy, Robert, Susan, Claire, Elisa, Scott, Krista, Michael, Kym, Kevin, Leslie, Sarah, T.K., Briar, Geoff, Ashley, Maury, Moses, Margot, Jamie, and Larry Acknowledgments I wish to acknowledge the following physicians: John P. O'Brien, F.R.C.S., Oswestry, England-For my fellowship in spinal surgery Augusto Sarmiento, M.D., Los Angeles, California J. Paul Harvey, M.D., Los Angeles, California Fritz Magerl, M.D., St. Gall, Switzerland David Selby, M.D., Dallas, Texas J. William Fielding, M.D., New York, New York Robert A. Robinson, M.D., Baltimore, Maryland Jacquelin Perry, M.D., Downey, California Ralph Cloward, M.D., Honolulu, Hawaii Additional thanks for specific contributions to this volume: Susan Swank, M.D., Downey, California Ken Sentor, M.D., Los Angeles, California Thomas Berne, M.D., Los Angeles, California Edgar Dawson, M.D., Los Angeles, California Martin Weiss, M.D., Los Angeles, California Additional thanks for photographic contributions: Medical Photography Department, Los Angeles County/University of Southern California Medical Center: Andy Gero, Thomas Meichelbock, Frank Park, and Ralph Hamabe. Medical Photography Department, Rancho Los Amigos Hospital, Downey, California: Maurice Mazur and Bill Porter. Susan Sparling, Manhattan Beach, California Abe Thomas, Los Angeles Orthopaedic Hospital, Los Angeles, California Allan Goldstein, Director of Medical Photography, Centinela Hospital, Inglewood, California Contents Foreword by Robert A. Robinson, M.D. ix Preface xi 1 Anterior Cervical Approaches to the Spine 1 2 Transoral Approach to Cl-2 7 3 Anterior Medial Approach to C1,2,3 12 4 Anterior Lateral Approach to the Upper Cervical Spine 20 5 Anterior Medial Approach to the Midcervical Spine 26 6 Lateral Approach to the Cervical Spine (Verbiest) 32 7 Lateral Approach to the Cervical Spine (Hodgson) 39 8 Supraclavicular Approach 43 9 Lincoln Highway Approach to the Cervical Spine 50 10 Cervical-Thoracic Junction 57 11 Transaxillary Approach to the Upper Dorsal Spine 58 Roger C. Breslau 12 Third Rib Resection in the Transthoracic Approach 64 13 Thoracotomy Approach 69 14 The Thoracolumbar Junction 80 15 Tenth Rib: Thoracoabdominal Approach 83 16 Eleventh Rib Approach 89 17 Twelfth Rib Approach 96 18 Anterior Retroperitoneal Flank Approach to L2-5 of the Lumbar Spine 101 19 Anterior Retroperitoneal Flank Approach to L5-S1 112 20 Anterior Extraperitoneal Midline Incision of L2-S 1 117 21 Transperitoneal Midline Approach to L4-S1 123 22 Superior Hypogastric Sympathetic Plexus 130 23 Approach to the Posterior Aspect of Cl-2 133 24 Cervical Foraminotomy: Indications and Technique 140 Peter Dyck 25 Costotransversectomy 148 26 Posterior Approach to the Lower Lumbar Spine 154 27 Lumbar Laminotomy, Foraminotomy, Root Decompression, and Discectomy in the Lateral Position 167 Michael L.J. Apuzzo 28 Bilateral Paraspinous Lumbosacral Approach 176 Index 183 vii Foreword The desire to expose the spine for surgery by anterior approaches at any level between the head and the sacrum is not new. Spinal pathology is often located anterior to the spinal cord and nerve roots in the cervical and thoracic spine, and anterior to the peripheral nerves that emerge from the lumbosacral spine below the first lumbar ver tebra. To treat such pathology one prefers to expose the front of the spine directly and widely enough to eradicate the pathology and to have full control of bleeding throughout the procedure. The posterior elements of the spine are important for mechanical stability of the spine, and therefore for the protection of the neural and vascular structures in the spine that would be threatened by instability. Extensive eradication of pathology posterior to the spinal canal and the intervertebral foraminae, including the transverse processes, may leave no adequate bony bed for the surgical creation of a stabilizing osseous fusion. In such a situation, an anterior fusion procedure is the only viable alternative to a posterior or posterolateral fusion. In situations where it is critically important to obtain a stable fusion, as in tuberculosis of the spine, both an anterior and a posterior fusion operation at the same motion segments is, in almost every instance, a guarantee of a stable osseous fusion. One should know both approaches. The feasibility of anterior spinal surgery for most surgeons depended on develop ments over approximately one hundred years, between 1850 and 1950, in anesthesia and intubation techniques, aseptic surgical techniques, X-ray controlled localization of the skeletal anatomy in the operating room, readily available blood for transfusions and, finally, antibiotics. These developments all came together about 1950 to give impetus to the use of anterior and anterolateral surgical exposures of the spine. The surgeon now has the option of attacking lesions of the spine directly: the anterior ones anteriorly and the posterior ones posteriorly. The purpose of this book by Dr. Robert Watkins and a few colleagues selected for their particular surgical expertise is to describe in simple language and clear illustrations the approaches to the spine by any route at any level. I congratulate Dr. Watkins and his coauthors on what seems to me to be an extremely successful achievement of this purpose. Robert A. Robinson, M.D. lX Preface This volume is designed to meet the need for a practical, well-illustrated guide to the normal anatomy of surgical approaches to the spine-the most fundamental infor mation for spinal surgery. Most of the basic approaches, anterior and posterior, are covered for each level of the spine. The specific pathology and the operative procedure indicated for any particular patient will naturally influence the choice of approach. While we have illustrated only normal anatomy as seen through the surgical incision, we hope to have given the reader a sound basis for choosing the most appropriate surgical approach for various clinical conditions. The illustrations are accompanied by a methodical description of operative tech nique for spinal exposure, emphasizing the critical anatomical landmarks. The bibliog raphy accompanying each chapter is not comprehensive, nor does it necessarily cite the original reports of each technique: rather, we have chosen to include good descrip tive reports of each approach. It is our hope that an improved understanding of surgical anatomy and operative approaches will free the spinal surgeon to implement the optimal treatment plan for each patient. xi Anterior Cervical Approaches 1 to the Spine The significant anatomic landmarks for differentiating the approaches to the cervical spine presented in Table 1.1 are the sternocleidomastoid muscle, the carotid sheath, and the longus coli muscle (Fig. 1B). Categorization is based on the direction of approach relative to these specific structures, as demonstrated in the table. For exam ple, approach no. 1 is medial to the sternocleidomastoid muscle (therefore, retracting it laterally) and medial to the carotid sheath (therefore, retracting it laterally as well). Approach no. 7 is directed lateral to the sternocleidomastoid muscle and lateral to the carotid sheath. A significant aspect of these approaches is whether to approach the carotid sheath medially or laterally. Approaching the carotid sheath medially and retracting laterally often requires sacrifice of vessels coursing from the carotid sheath to the medial musculovisceral column. Nerves running from lateral to medial also must be retracted. Approaching the carotid sheath laterally and retracting it medially, as in the anterolateral approaches,3.4.9.1O.1l produces a more avascular plane, but may also result in a more limited exposure. Both the anterior medial and the anterolateral approaches have common points of dissection and anatomy. The skin incision must be cosmetically acceptable, but efficient (Fig. 1A). Superfi cial landmarks used to place the incision over the appropriate level of the spine are: (1) C3-4, which is 1 cm above the thyroid cartilage; (2) C5-6, which is at the cricoid cartilage.6 Other superficial landmarks to be identified are the angle of the jaw, the sternocleidomastoid muscle, the hyoid bone, the cricoid cartilage, the superior border of the thyroid cartilage, and the insertion to the sternocleidomastoid to the clavicle. For best cosmesis, make a 3-cm transverse incision in a skin crease. A longer transverse incision from midline to anterior border of the sternocleidomastoid muscle will allow adequate exposure for three vertebral bodies and two disc levels. The exact pathology and the technical demands of the operation determine the size of the exposure and the structures that must be transected rather than retracted. After the skin incision has been made, when a well-developed platysma muscle is visible, it is best to open the platysma muscle along the line of its fibers. The platysma muscle should be elevated with Adson pick-ups and opened carefully to avoid damage to underlying veins and the sternocleidomastoid muscle.6 (A well-devel oped platysma muscle should be closed as one individual layer.) Under the platysma is the external jugular vein, which courses on the external surface of the sternocleido mastoid muscle, and the anterior jugular vein, which is in a more anterior medial location over the sternocleidomastoid-strap muscle interval or on the lateral aspect of the strap musculature. The anterior and external jugular veins must be divided and ligated when their presence interferes with the procedure. The sternocleidomastoid 1 2 Robert G. Watkins, M.D. TABLE 1.1 Approaches to the Cervical Spine Sternocleido- mastoid Muscle Carotid Sheath Longus Coli Medial Lateral Medial Lateral Medial Lateral I. Anterior medial CI_31.6.7.8 X X X 2. Anterior Medial X X X Midcervical Spine,·6.7.8 3. Supraclavicular Approach' X X X 4. Anterolateral Approach to X X X CI_32.11 5. Anterolateral Approach to X X X Midcervical Spine9 6. Lateral Approach to X X X Midcervical Spine2 7. Lateral Approach to the X X X Midcervical Spine3 X = direction of the approach. Fig. lA: The approximate skin areas for approaches to specific spi C4-6 nal levels are usually indicated by palpable subcutaneous structures. Cl-2 lies under the angle of the jaw, C3-4 a centimeter above the thyroid cartilage in the region of the hyoid bone, C4-6 at the level of thyroid cartilage, C5-6 at the cricoid cartilage, and C7-T1 in the supraclavicular area. For best cos mesis, make a transvers~ skin inci sion. A transverse incision from midline to anterior border of ster nocleidomastoid muscle .will allow adequate exposure for three verte bral bodies and two disc levels. A vertical incision along the anterior border of the sternocleidomastoid muscle, as seen on the dotted line. may be used for long exposures of the cervical spine. Anterior Cervical Approaches to the Spine 3 Submandibular Gland Anterior Belly of Digastric Muscle Facial Artery and Vein Stylohyoid Mu c1e ----+-ilM L..". ....' - Posterior Belly Omohyoid Muscle of Diga tric Sternohyoid Muscle Mu c1e External Carotid Artery Internal Sternocleidomastoid Muscle -HlH "-'+--- Jugular Vein Vagus Nerve ...- ~-- Ansa Cervicalis Scaleneus Anterior lY'~I""l''''_~ Recurrent Thyroid Cricoid Thoracic Laryngeal Cartilage Cartilage Duct Nerve Fig. 18: The numerous soft tissue structures of the anterior neck; note the relatively avascular area between the superior thyroid artery and the inferior thyroid artery. The standard approach to the anterior aspect of the spine is lateral to the thyroid gland and medial to the carotid artery. must be identified as the initial key to the approach; for anterior medial approaches, the medial border of the sternocleidomastoid; for the lateral approaches, the lateral border of the sternocleidomastoid. The second landmark, the carotid sheath, is first identified by finger palpation of the carotid pulse. The carotid sheath contains the carotid artery, internal jugular vein, the vagus nerve, and sometimes the sympathetic plexus. The third landmark structure is the longus coli muscle, which must be identified under the prevertebral fascia over the spine. Palpate for the spine. Often the anterior tubercle of the transverse process is mistaken for the vertebral body. Inadvertent dissection in this more lateral area can damage the sympathetic plexus and cause bleeding from the longus coli. The more avascular area of the spine is the midline.
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