The spinous processes on the posterior side of the lumbar and sacral vertebrae form a longitudinal crest, which is located in the middle of the back, and the erector spinae muscles are in the spinal sulcus on both sides, without important blood vessels and nerves. There are psoas and quadratus psoas muscles on both sides of the spine, and in the deep layers of the psoas major muscle, the lumbar plexus passes: the anterolateral aspect of the lumbar vertebrae, and the medial border of the psoas major muscle has the lumbar sympathetic nerve trunk. The left side of the lumbar vertebra is the abdominal aorta and the right side is the inferior vena cava. The abdominal aorta descends to the lower edge of the 4th lumbar vertebra and divides into the left and right common iliac arteries, and a sacral median artery is divided on the back of the bifurcation, which descends along the median line of the lumbar 5 vertebral body and the sacral pelvic surface: 4 pairs of lumbar arteries are divided into 4 pairs of lumbar arteries in the posterior wall of the abdominal aorta, which are transversely shaped outward in front and side of the L1~L4 vertebral body, and are located in the middle of the vertebral body between two adjacent intervertebral discs. The ureter descends anteriorly to the psoas muscle, usually anterior to the left common iliac artery terminus, and to the pelvis on the right side anteriorly to the beginning of the external iliac artery.
Therefore, the posterior approach is the most commonly used and safest approach. The anterior approach to the lumbosacral vertebrae should be clearly revealed by autopsy to avoid accidental injury. It is divided into extraperitoneal and intraperitoneal approaches, the latter of which has a history of abdominal surgery, which will prevent surgical exposure and is prone to intestinal paralysis or intestinal adhesions after surgery, so it is rarely used.
The trail is exposed at the back
(1) The posterior full lamina is exposed
【Indications】The posterior approach can be used for those who need to expose the posterior column, perform laminectomy, enlarged spinal canal or spinal canal exploration, correction of deformity, posterior internal fixation, posterior lumbar interbody fusion (PLIF) surgery and bone grafting.
1. Patients with lumbar instability fracture, dislocation or spinal cord and cauda equina nerve injury, who need posterior or posterolateral spinal subtotal ring decompression and internal fixation.
2. Patients with lumbar vertebral vertebral arch depression fracture compressing spinal cord, cauda equina nerve or sacral vertebral instability fracture accompanied by nerve injury.
3. Lumbar spinal stenosis, lumbar intervertebral disc herniation, degenerative lumbar spine disease, lumbar isthmus fissure or slippage, spinal cord, cauda equina nerve compression and spinal canal or adnexal tumors, etc.
【Anesthesia】General anesthesia, continuous spinal epidural block or local infiltration anesthesia. Because spinal cord and cauda equina nerve injuries are often complicated by spinal surgery, sometimes neurophysiological monitoring is required during surgery. Patients with local anesthesia can remind the surgeon of the sensation and movement of both lower limbs at any time, which can effectively prevent nervous system damage, but it is only suitable for simple laminectomy.
【Position】For total laminectomy for spinal canal exploration, deformity correction or internal fixation surgery, lie prone on the Hall-Relton four-point support frame (Fig. 1), which must be suspended to prevent abdominal compression, reduce intraoperative epidural venous plexus regurgitation and bleeding, and prevent genital pressure and distortion. Imaging equipment is used to monitor the procedure. or in a thorax and knee position (with the trunk and thighs at 90°), with a pillow under the knee and the abdomen suspended without pressure (Figure 2).
Fig.1 Prone position after lumbar and lumbosacral spine surgery (Hall-Relton frame)
Fig.2 Chest and knee lying position, most of the body weight is focused on both knees, small pads must be placed under the knees, and the abdomen is suspended without pressure
【Steps】
1. Incision
In order to help the positioning of the lumbar vertebrae during the operation, the first sacral vertebra must be exposed, and the length of the incision is generally along L3~S1 (Fig. 3), and if necessary, it can extend 1~2 spinous processes to both ends of the distal and proximal ends. In order to facilitate the extraction of the iliac bone from the body, the posterior iliac crest is exposed by sharp separation under the superficial fascia on one side of the original incision, and the incision can be appropriately extended from S1 to the distal end.
Fig.3 Longitudinal incision along the midline through the spinous process, and the length is generally along L3~S1
2. Surgical procedure
The skin and subcutaneous tissue are incised to reveal the spinous process and lumbar dorsal fascia. If total laminectomy is performed, the supraspinous ligament can be cut in the middle and sharply peeled off to both sides, which is conducive to the final suture and preserved the supraspinous ligament; otherwise, the fascia and spinous periosteum are sharply cut on one side of the paraspinous process with a knife from the distal end to the proximal end, and the subperiosteal dissection is performed with a wide periosteal dissection device or Cobb periosteal dissection close to the spinous process and the lamina, and the erector spinae muscles on both sides are pushed to the lateral side to the outer edge of the facet joint, and the tamponade is tightly packed with dry gauze to compress and stop bleeding. Then, use a lamina retractor to retract the erector spinae muscles to the sides, exposing the lamina. If bleeding occurs, it can be stopped by electrocoagulation. A periosteal dissection device is used to further remove the remaining soft tissue on the spinous process, lamina, and joint capsule.
【Precautions】
1. The erector spinae muscle fibers are composed of three columns, the medial column is attached to the spinous process, and there are many oblique short muscle bundles in its deep layer, and its muscle fibers are obliquely inward from the transverse process of the vertebra and end at the spinous process of the superior vertebrae. Therefore, when dissecting the erector spinae muscles, it is necessary to move from the distal to the proximal side (Fig. 4), otherwise, it is easy to stray into the interfascicles and increase bleeding during separation.
Fig.4 When exfoliating the erector spinae muscle, it is necessary to distal to the proximal subperiosteal
2. Use a wide periosteal dissection device for subperiosteal dissection, which is not easy to enter the spinal canal by mistake. If spina bifida occult is present, it should be done with caution. If there is a history of laminectomy in the past, it is advisable to expose the distal and proximal normal lamina of the defective lamina segment before further exposing the defect to prevent accidental entry into the spinal canal.
3. In order to preserve the joint capsule of the intervertebral joints, it is not advisable to use a bone knife to perform spinous process and subperiosteal dissection of the lamina to avoid injury.
(2) The posterior hemivertebral lamina is exposed
【Indications】Lumbar intervertebral disc herniation, nerve entrapment syndrome of lumbosacral nerve root and lumbar spinal stenosis, etc., who undergo targeted decompression, and need to undergo ligamentum flavum, hemilaminectomy or fenestration.
Contraindications: Bilateral lumbar disc herniation or central lumbar disc herniation, bilateral sciatica, central lumbar spinal stenosis, or transdural removal of herniated disc and spinal canal exploration require total laminectomy.
【Anesthesia】Local anesthesia, epidural block or general anesthesia can be used.
【Body position】Lateral decubitus position, with the affected side on top, and the lumbar pillow is conducive to widening the laminar space (Fig. 5), exposing the ligamentum flavum, and can also be taken in the prone position.
Fig.5 Lateral decubitus position
【Steps】
1. Incision
A longitudinal incision is made along the midline through the spinous process, and the general length is L3~S1 spinous process. If the lumbar discectomy is performed by fenestration, a small incision of 5 cm can be made to expose the half of the lamina, after the positioning is correct.
2. Surgical procedure
Cut the skin and subcutaneous tissue, expose the spinous process and lumbar dorsal fascia, use a knife or electric knife to sharply cut the fascia and spinous periosteum from the affected side close to the supraspinous ligament of the midline of the spinous process from the distal end to the proximal end, and use a wide periosteal stripper to closely adhere to the spinous process and half of the vertebral lamina for subperiosteal dissection, reach the outside of the intervertebral joint capsule, push the erector spinae muscle to the outside, and compress the hemostasis with dry gauze. Then remove the tamponade gauze. The left hand index finger extends into the deep surface of the erector spinae muscle along the spinous process and vertebral plate, and the right hand holds the half of the lamina retractor along the left hand to guide the sharp teeth of the retractor into the outside of the intervertebral joint to retract the erector spinae muscle. Further removal of residual soft tissue on the lamina, spinous processes, and intervertebral joint capsule.
【Precautions】
In order to prevent the wrong positioning of the intervertebral space, it is necessary to reveal that there is no ligamentum flavum between S1, S1 and 2, and that the ligamentum flavum space between L5 and S1 is wide. L5 is more backward than L4, and striking S1 with a periosteal dissection device has a different response than L5. The above points can be used to facilitate correct positioning, and if necessary, the incision can be extended to fully reveal or with the help of a C-arm machine.
The anterior route is extraperitoneal to expose the vertebral body surgical pathway
(1) Transverse flank incision
【Indications】Exposure of L4, 5 and L5 and S1 vertebral bodies on one side. Tuberculosis lesion removal, anterior lateral decompression, interbody fusion, and lumbar scoliosis correction can be performed.
【Contraindications】
1. The L2 disease vertebrae is not well exposed and should not be used.
2. Patients with lumbar tuberculosis and abscess of both psoas muscles need to undergo contralateral surgery in stages.
【Anesthesia】Continuous epidural block or general anesthesia.
【Body position】Take the supine position, and the affected side is raised so that the back is 60° with the operating table. It can also be taken in the lateral decubitus position, with the back at 90° with the operating table, which is conducive to exposing the side of the vertebral body, so that the abdominal cavity content and its own gravity can be moved to the opposite side, and the surgical field is clear. The contralateral lumbar is cushioned with a lumbar plate or a soft pillow to increase the distance between the iliac ribs to help expose the diseased vertebrae.
【Steps】
1. Incision
The incision arises from the midaxillary line, below the costal margin and from the midpoint of the iliac crest. If L2, 3 or L3 and 4 vertebrae are exposed, they should terminate 3 cm above the umbilicus or 2 cm below the umbilicus, transversely or obliquely, respectively at the outer edge of the rectus abdominis muscle (Fig. 6), and extend to the midline if necessary. To expose the foramen or posterior vertebral body, the anterior end of the incision can be shortened and extended dorsally. L3 or above may be exposed, and renal incision may also be done. Small incisions can also be used, and X-rays must be taken to locate the incision landmarks before surgery (Fig. 7(1)).
Fig.6 Transflank transverse incision (incision with solid line or dotted line showing different lumbar vertebral planes)
2. Surgical procedure
Incision of the skin and subcutaneous tissue, external oblique muscle, internal oblique muscle, transverse abdominis muscle, and transverse fascia abdominis can be incised, generally reaching the outer edge of the rectus abdominis muscle. Wrap the thumb or index finger in saline gauze and gently push the peritoneum along with the ureter from the lateral abdominal wall to the midline to the vertebral body. If necessary, the anterior and posterior layers of the rectus abdominis sheath can be incised, and the rectus abdominis muscle can be retracted or cut inward. The peritoneal fold is blunt medially free directly to the vertebral body. The iliac crest is stretched apart from the costal rim with a thoracic retractor to widen the surgical field for operation.
Fig.7. Locating the incision marker
(1) Preoperative X-ray positioning incision landmark, which can be exposed by transverse small incision;(2) Taking the left approach as an example, the left side of the upper abdomen of the flat umbilical cord is 4~6cm
【Precautions】When the muscles of the abdominal wall are cut to reach the transverse abdominis muscle, the peritoneum should be prevented. To prevent injury to the ureter, it is necessary to prevent accidental injury when the abdominal aorta, inferior vena cava, common iliac arteries, veins, and external iliac arteries and veins are exposed. When the L5 and S1 intervertebral spaces are exposed, the lumbar ascending vein and iliac vein should be found first, and then ligated and cut off respectively to prevent bleeding.
(2) Median incision next to the lower abdomen
【Indications】L4, 5, L5, and S1 are exposed, and extraperitoneal anterior lumbar disc nucleus pulposus extraction, interbody fusion (ALIF), anterior bone plate fixation or artificial disc replacement are performed.
【Contraindications】
1. Patients with lumbar intervertebral disc herniation, dead bone type and lumbar spinal stenosis.
2. Those who have had a history of abdominal surgery in the past and have poor healing.
【Anesthesia】Continuous epidural block or general anesthesia.
【Position】Lie on your back, with pillows in the popliteal fossa on both sides, so that the hip and knee joints are flexed at 30°.
【Steps】
1. Incision
Taking the left approach as an example, the flat umbilicus or the supraumbilical abdomen is 4~6 cm to the left side until the pubic symphysis, and is 7~8 cm long (Fig. 7(2)).
2. Surgical procedure
Incision of the skin and subcutaneous tissue, longitudinal incision of the anterior rectus abdominis sheath at the outer edge of the rectus abdominis sheath, retraction of the rectus abdominis muscle to the midline, longitudinal incision of the posterior sheath to expose, noting that there is no posterior sheath below the semi-annular line. The middle finger is wrapped with saline gauze to bluntly separate the abdominal wall from the lateral peritoneum, pushing the peritoneum to the opposite side, revealing the diseased vertebrae.
【Precautions】
1. The left approach is safer, because the left abdominal aorta and iliac artery are less prone to accidental injury than the right vein.
2. The peritoneum of the free abdominal wall is more prone to tearing than the lateral peritoneum, especially the peritoneum of multiparous women is thinner and easy to break.
3. The intervertebral disc must be positioned correctly.
4. Keep the catheter before surgery to empty the bladder.
(3) Transabdominal median incision
【Indications】L3~L5 tuberculosis with both psoas abscess or lumbosacral tuberculosis with presacral abscess, lumbar interbody fusion or lumbar spine tumor, etc.
【Contraindications】
1. Tuberculosis above L3.
2. Patients with only one psoas abscess.
3. Previous history of major abdominal surgery.
【Anesthesia】Continuous epidural block or general anesthesia.
【Position】Lie on your back, with pillows in the popliteal fossa on both sides, so that the hip and knee joints are flexed at 30°.
【Steps】
1. Incision
From 5 cm in the middle of the umbilicus, go around the left side of the umbilicus to the middle of the umbilicus to reach the pubic symphysis (Fig. 8). A transverse abdominal incision (Fig. 9) can also be made to expose the median peritoneum through the median line alba.
Fig.8 From the median incision of the abdomen 5 cm, from the median of the umbilicus, around the left side of the umbilicus to the median of the umbilicus against the pubic symphysis
Fig.9 Transverse abdominal incision
2. Surgical procedure
The skin and subcutaneous tissue are incised, and the white line of the median abdomen below the semi-ring line is incised before the subumbilicus to expose the peritoneum. The rectus abdominis muscle is retracted to both sides, the peritoneum is gently and bluntly separated, and then the white line above the semi-annular line is cut upward, and the anterior sheath of the rectus abdominis muscle is cut around the left side of the umbilicus, and the left rectus abdominis muscle is retracted outward. Cut the posterior sheath and gently separate the peritoneum, continuing to cut the linea alba upwards. If there is a tear in the peritoneum, part of the posterior sheath can be cut off and repaired and sutured together with the peritoneum. In order to expose both psoas major muscles and the lower lumbar vertebrae, blunt separation of the anterior peritoneum on both sides, and the posterior peritoneum through the lateral peritoneal fold until the left extraperitoneal is exposed. If a transverse abdominal incision is made, the paramedian or transmidal abdominal access to the extraperitoneum may be maintained. When the lower lumbar spine needs to be fully exposed, the rectus abdominis muscle can be transected and entered into the peritoneum.
【Precautions】
1. The paraumbilical peritoneum is the most likely to tear, especially for multiparous women and obese patients, so it should be carefully separated.
2. Keep the urinary catheter before surgery to keep the bladder empty.
(4) L4, 5 and S1 vertebrae are exposed through the abdominal pathway
【Indications】
1. L4, 5 and L5, S1 tuberculosis lesion removal.
2. Recurrent and persistent low back pain, including intervertebral disc degeneration, intervertebral instability, lumbar spondylolisthesis, low back pain after total laminectomy and posterior fusion failure, etc.
Contraindications: Those with a history of abdominal surgery or intestinal adhesions in the past.
【Anesthesia】Continuous epidural block or general anesthesia.
【Position】Lie on your back, with your head down and your feet high.
【Steps】
1. Incision
A median incision is made in the left lower quadrant from the umbilical plane to the suprapubic bone.
2. Surgical procedure
Incision of the skin and subcutaneous tissue, incision of the anterior rectus abdominis sheath, lateral retraction of the rectus abdominis muscle, incision of the posterior sheath and peritoneum. Push the omentum, small intestine, and colon protector up and to the left and right sides with saline gauze pads, respectively, and expose the posterior peritoneum with an automatic retractor in the abdominal cavity. The posterior peritoneum is incised longitudinally, the posterior peritoneum is turned outward, and the periphery is sutured with the anterior peritoneum for several stitches to prevent pus from contaminating the abdominal cavity. The bladder and uterus are pulled downwards to expose the common iliac arteries, veins, and sacral promontory. Ligation severed the median sacral arteries and veins, revealing the L5 and S1 intervertebral discs.
【Precautions】
1. Clean the enema early in the morning before surgery and keep the urinary catheter.
2. The bifurcation of the common iliac artery and vein should prevent blood vessel tearing.
3. Lumbosacral anterior approach surgery may damage the sympathetic nerve and cause impotence or semen regurgitation or reduced range, so damage to the sympathetic nerve and parasympathetic nerve should be avoided.
4. Transperitoneal route, postoperative intestinal adhesions are easy to occur, should be used with caution.
bibliography
[1] Lei Dengqiang, He Yuan, A Hai, Han Xiang, Guan Bingyu.Treatment of single-level lumbar degenerative diseases by posterior translaminar approach lumbar interbody fusion under total endoscopy[J].Journal of Spine Surgery,2024,22(01):12-15+31.
[2] Wang Jinyu.Discussion on the effect of intervertebral foraminoscopy surgery through interlaminar approach in the treatment of lumbar intervertebral disc herniation[J].China Practical Medicine,2024,19(03):56-59.
[3] Shen Shengjun, Xu Shangsheng, Ren Lei, Du Peng, Huo Yongchao, Zhao Yu.Comparison of two surgical combinations in the treatment of lumbosacral tuberculosis[J].Chinese Journal of Orthopedics,2023,31(17):1573-1578.
[4] Tang Zhiyi, Li Shuai, Huang Yunfei, Du Jinpeng, Kong Lingbo, He Baorong.Research progress of anterior surgery for lumbosacral tuberculosis[J].Chinese Journal of Bone and Joint Surgery,2023,16(02):179-184.
[5] Bao Yi, Zhang Chao, Lei Yunkun, Yang Xi, Lu Sheng.Experience in the surgical treatment of lumbosacral tuberculosis[J].Chinese Journal of Orthopaedic Surgery,2021,29(17):1630-1632.
[6] Song Jingang, Cui Yikun, Zhao Bing, Yin Zhenyu, Yang Gangyi, Huang Haifeng.Clinical comparative study on the treatment of lumbosacral tuberculosis by anterior and posterior surgery[J].Journal of Neck and Low Back Pain,2020,41(06):688-692.
[7] Qiu Guixing, Dai Yirong.Orthopedic Surgery:Volume I.Publisher:People's Medical Publishing House.Pub Date:2016/5/1.ISBN:9787117217460.
[8] Qiu Guixing, Dai Yurong.Orthopedic Surgery:Volume II.Publisher:People's Medical Publishing House.Pub Date:2016/5/1.ISBN:9787117217460.
[9] Zhang Hongqi.Spinal tuberculosis simple posterior approach lesion removal interbody bone grafting——Surgical points and skills.Publisher:People's Medical Publishing House.Pub date:2021/5/1.ISBN:9787117313681.
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