Executive Editor: Luiz Vialle General Editor: German Ochoa (in memoriam)

Authors: Alex Vaccaro, Frank Kandziora, Michael Fehlings, Rajasekaran Shanmughanathan

Thoracic and lumbar trauma

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Glossary

Right sided thoracotomy (T3-10)
Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Skin Incision

The incision is carried out from postero-superiorly around the angle of the scapula, obliquely sloping to antero-inferiorly.

The length of the incision depends on many factors eg, number, location, and classification of fractures, obesity of the patient, previous thoracic operations, etc. 

It is necessary to confirm the correct level of the approach with fluoroscopy.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The posterior superior end of the incision should be sufficiently high to access the level above the fractured vertebra. This is best checked by image intensifier.

In general, the thoracotomy should be planned to be two levels above the fractured level.

Similarly, the most inferior part of the incision should allow access to the vertebra below the fractured vertebra.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Pearl: Incision above T5
Above T5 the scapula is an obstacle.  Therefore, the skin incision differs slightly and is made two centimeters below the tip of the scapula. This allows the scapula to be released from the subscapularis muscle and lifted to grant access to the appropriate intercostal space.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Exposure

The skin and subcutaneous tissues and overlaying muscles are incised in line, with the incision down to the rib to be exposed.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Sometimes, one rib has to be removed for access to the fractured vertebra. The rib is dissected subperiosteally and then cut from the posterior angle to as far anteriorly as possible avoiding injury to the neurovascular bundle. The rib is saved for subsequent bone grafting. 


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The pleura is then cut to allow entry into the chest without injuring the lung.

A rib spreader can be used to gradually open the created space.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The lung is then retracted anteriorly to expose the spine. It is optimal to have single lung ventilation with selective collapse of the ipsilateral lung tissue to provide exposure to the thoracic vertebral column.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Pearl: Retraction system
It is helpful to have a table mounted retraction system to gently retract the lung and the vascular structures.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The parietal pleura should be opened longitudinally over the spine at the fracture level and a level above and below. It is easiest to begin the dissection at the discs, which will appear as avascular "hills". The "valleys" are the vertebral bodies, and the segmental vessels are in the midline.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The segmental vessels at the fracture level and above and below the fracture level should be isolated and ligated in the mid vertebral body with sutures and/or clips.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

A subperiosteal exposure is then undertaken to the level of the anterior longitudinal ligaments with protection of the great vessels.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Posteriorly, the dissection should expose the heads of the ribs.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Closure

If possible, the parietal pleura should be sutured. 


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Chest drains are usually inserted via a separate stab incision.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

Closure is carried out in layers. Care is taken to avoid including the intercostal nerve in the suture.


Thoracic and lumbar fractures: Right sided thoracotomy (T3-T10) enlarge

The wound is closed.

v1.0 2014-12-99