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Pipsa Ylanko, AOSpine Global Education Manager

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

Lumbotomy (L1-4)
Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Skin Incision

The incision depends on the fracture level, which should be correlated with preoperative imaging.

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: Lumbotomy (L1-L4) enlarge

With this exposure usually three vertebrae can be easily accessed.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The skin is incised on the mark.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Exposure

There are three abdominal wall muscles. The first layer is the external abdominal oblique muscle, the second layer is the internal abdominal oblique muscle, and the third is the transverse abdominal muscle.

The subcutaneous tissue and the fascia of the obliquus externus muscle are dissected.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The first muscle layer is incised with cautery and retracted. The second layer is split and retracted.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The incision should expose the distal 5 cm of the 12th rib. The rib should be exposed subperiosteally with sharp dissection and elevators.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The distal 5 cm of the 12th rib should then be excised; this allows access to the retroperitoneal space.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The transversalis fascia is opened with caution to avoid injury to the peritoneum that lies in the abdominal cavity.

A finger is used to split the muscle and detach it from the peritoneum to facilitate dissection. 

The retroperitoneal fat is a good landmark to detect the retroperitoneal space.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Pitfall: Injured peritoneum
If the peritoneum is injured, organs can be affected or postoperative herniation can occur.

If the peritoneum is violated, it is recommended that it be repaired directly with an absorbable suture and a blunt tapered needle.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The peritoneum has to be shifted away from the lateral abdominal wall until the psoas muscle is exposed. Then, the psoas muscle has to be retracted.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The psoas muscle is mobilized to facilitate posterior retraction. The dissection begins on the anterior border of the psoas muscle over a disc space.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The disc space above and below the fractured vertebra should be exposed initially.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The segmental vessels above and below the fractured vertebra should be isolated, ligated with sutures and clips, and divided.

Next, the segmental vessels over the fractured vertebra should be isolated, ligated, and divided.

For anterior discectomies, these can be spared.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The psoas muscle now can be reflected posteriorly in a subperiosteal manner. The dissection should proceed posteriorly to the level of the pedicles. Take care not to injure the vessels in the neural foramena.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Dissection should now proceed anteriorly on the vertebral bodies above and below the fracture site and the fractured vertebra to the level of the anterior longitudinal ligament with protection of the great vessels anteriorly. The sympathetic chain should be identified and reflected anteriorly along with the periosteum.

Next, the normal vertebral body above and below the fractured vertebra should be exposed.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Pearl: Retraction system
It is helpful to have a table mounted retraction system to gently retract the psoas muscle, abdominal contents, and great vessels/sympathetic chain. 


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

Closure

A retroperitoneal suction drain is optional.

The three abdominal muscle layers are approximated.


Thoracic and lumbar fractures: Lumbotomy (L1-L4) enlarge

The subcutaneous tissues and skin are sutured in a layered fashion.

v1.0 2014-12-99