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

Mini open approach (L4-S1)
Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Preliminary Remarks

The exact incision site will depend on the level of the fracture. The disc space L1/2 and above cannot be reached with this approach.

The straight anterior approach (retroperitoneal approach) is excellent for corpectomy, spinal canal decompression, and vertebral body replacement. The lumbotomy is ideal for plating.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Skin incision

Under fluoroscopic control, the fractured vertebra or injured disc and the adjacent segments are marked on the skin.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

In the following, alternative options for skin incisions are depicted, depending on surgeon's and patient's preference

Shown are the midline skin incision, the pararectal skin incision, and the transverse skin incision.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

The skin is incised on the mark.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Exposure

After dissection of the subcutaneous tissue, the anterior rectus sheet is incised and the rectus muscle is mobilized to the medial or lateral side, depending on the incision and surgeon's preference.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

The posterior rectus sheet is opened and the peritoneum is exposed.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Next the peritoneum is carefully retracted using a hand.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Depending on the level of the fracture, the great vessels are approached differently.

L4/5
For the L4/5 level, vessels have to be retracted to the opposite side.

L5/S1
For L5/S1, the vertebrae are accessed in between the vessels bifurcation.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Pitfall: Iliolumbar vein
If L4/L5 is approached, the ascending iliolumbar vein should be ligated. Otherwise significant bleeding might occur. 


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Retraction system

A retraction system is mandatory at this point.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

Closure

A retroperitoneal drain is inserted.


Thoracic and lumbar fractures: Mini open retroperitoneal approach (L4-S1) enlarge

The wound is then closed in layers.

v1.0 2014-12-99