Surgical Approaches
HOW DO I KNOW IF I NEED SURGICAL APPROACHES?
A surgeon should understand the best treatment strategies and practice the full range of surgical approaches. Otherwise, the patient is not getting the full range of treatment options when they get an opinion.
Dr. Jenkins is skilled at all of the approaches below, and selects the procedure and approach based on the needs of the patient, not just because he’s only comfortable with one or two approaches.
Cervical Spine
- Transoral – an anterior approach to the upper 2 levels of the cervical spine, most commonly used to approach conditions that require removal of the odontoid process of the second cervical vertebral body (the “dens”).
- High Retropharyngeal – a different approach to the upper 2-3 levels of the cervical spine from a more lateral approach, allows for a wider exposure than the transoral, and a more extensive degree of resection of disease processes.
- Ventromedial – the standard approach to the cervical spine, an avascular plane can be found that runs between the trachea and esophagus and the carotid sheath to the front of the vertebral bodies. Care must be taken to avoid injury to the carotid and vertebral arteries, the sympathetic plexus, and the recurrent laryngeal nerves.
- Ventrolateral – more lateral than the ventromedial, approach is lateral to the sternocleidomastoid (SCM) muscle.
- Lateral – more directly lateral approach through the side of the neck
- Posterior – laminectomy/laminotomy approach. This includes minimally invasive as well as standard open approaches.
Thoracic Spine
- Posterior – laminectomy/laminotomy approach, including minimally invasive and open approaches.
- Transpedicular – a posterior approach to the thoracic spine that requires removal of the lamina and pedicle and allows access to the lateral vertebral body or disk space.
- Costotransversectomy – a posterior approach to the thoracic spine that requires removal of the lamina, pedicle, medial rib head, and transverse process. This allows access to one-half of the vertebral body and slightly across the midline. It allows for access to most of one side of the disk space.
- Lateral extracavitary – a posterior approach to the thoracic spine that requires removal of the lamina, pedicle, medial rib, and rib head, and transverse process. This allows access to most of the vertebral body from one side. It allows for access across the midline for the disk space. This is the most exposure to the vertebral body from the back, without requiring a thoracotomy.
- Thoracoscopic – Anterior approach similar to the thoracotomy, but with several “port-hole” incisions instead of a single long one, and no rib removal is necessary.
- Thoracotomy – open surgical procedure that involves opening the chest by splitting, and usually removing at least one rib. This requires deflating one lung and often is more painful than some other techniques. It is required when the lung fields are scarred down with prior surgery when long segments are being resected, or if the chest wall is also being removed because of tumor involvement.
- Transdiaphragmatic – a combined thoracotomy and retroperitoneal approach that allows for approaches to the thoracolumbar junction. This requires the removal of the ninth rib and cutting of the diaphragm. The presence of the diaphragm and other vital organs makes minimally invasive approaches to this region more difficult.
Lumbar Spine
- Transperitoneal – anterior approach to disk and vertebral bodies that uses endoscopic or open visualization.
- Retroperitoneal – approach to the lumbar and thoracolumbar spine that goes behind most of the abdominal organs and does not require disturbing the peritoneal sac.
- Direct lateral approaches (XLIF or DLIF) – useful for approaching the disks or vertebral bodies from L1 to L4/5 (the location of the iliac crest prevents access to L5/S1 and sometimes L4/5).
- Lateral extracavitary – a posterior approach to the thoracic spine that requires removal of the lamina, pedicle, medial rib, and rib head, and transverse process. This allows access to most of the vertebral body from one side. It allows for access across the midline for the disk space. This is the most exposure to the vertebral body from the back, without requiring a thoracotomy.
- Transpedicular – a posterior approach to the thoracic spine that requires removal of the lamina, and pedicle and allows access to the lateral vertebral body or disk space.
- Posterior – laminectomy/laminotomy approach, including minimally invasive as well as standard open approaches.