Updated: 9/12/2017

Transthoracic approach to thoracic spine

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Introduction
  • Allows excellent visualization and access to the anterior thoracic spine
  • Indications
    • fusion of vertebral bodies
    • spinal cord decompression
    • corpectomies or reconstruction of vertebral bodies for cancer
    • scoliotic deformity correction
    • infection in the thoracic spine
    • osteotomies
    • biopsy
Planes
  • No true internervous or intermuscular plane
  • Dissection is intramuscular through
    • latissimus dorsi 
    • serratus anterior
Position & Preparation
  • Anesthesia
    • general anesthesia with endotracheal tube
  • Preparation
    • radiolucent table with ability to flex for added exposure
    • +/- imaging for instrumentation
    • neuromonitoring at discretion of operating surgeon
  • Position
    • lateral decubitus
    • move hard/arm above patient's head
    • pad all pressure points
    • operating surgeon positioned behind patient
  • Side
    • right side
      • upper thoracic spine (T2-9) best approached from right side to avoid heart and aortic arch
    • left side
      • thoracolumbar spine (T10-L2) best approached from left side to avoid liver retraction
Approach
  • Incision  
    • make an incision starting halfway up the medial border of the scapula halfway between the scapula and thoracic spine
    • curve incision down to a point two fingerbreadths below the tip of scapula
    • finish the incision by curving upwards towards the inframammary crease
  • Superficial dissection
    • divide latissimus dorsi in the direction of the incision
    • divide the serratus anterior along the same line to the ribs
    • enter the chest via intercostal space or rib resection
      • ribs resection approach
        • offers greater exposure and bone for autograft
      • intercostal approach
        • considerations
          • use 5th intercostal space for pathology from upper thoracic spine to T10
          • from T10  and lower, use 6th intercostal space
        • technique
          • cut the periosteum on upper border of rib
            • entering on upper border of rib protects intercostal nerve and vessels
          • enter the pleura
          • resect posterior three fourths of the rib for added exposure
          • insert rib spreader
  • Deep dissection
    • deflate lung
    • retract lung anteriorly with moist lap sponge
    • incise pleura over lateral esophagus to allow for retraction of esophagus
    • retract esophagus anteriorly
    • tie off as few intercostal vessels as possible
    • reflect periosteum over spine with elevators to expose involved vertebrae
Dangers
  • Intercostal vessels
    • vulnerable during
      • rib resection when running along undersurface of rib, and
      • exposure of vertebrae within chest
    • avoid injury by entering pleura from above the ribs
  • Lungs 
    • avoid injury by using sharp instruments wisely when within chest
    • expand lungs every 30 minutes to prevent microatelectasis
  • Esophagus
    • avoid injury through adequate retraction of esophagus while working on spine
  • Artery of Adamkiewicz 
    • travels on left side between T9-L2 in 60% of patients
    • must preserve to prevent spinal cord ischemia
 

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