Surgical Anatomy of the Diaphragm in the Anterolateral Approach to the Spine

Baaj, Ali A.; Papadimitriou, Kyriakos; Amin, Anubhav G.; Kretzer, Ryan M.; Wolinsky, Jean Paul; Gokaslan, Ziya L.

doi:10.1097/bsd.0b013e3182a18125

Cited by 19 publications

(7 citation statements)

References 12 publications

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“…Critically, the retroperitoneal space and the retropleural space are continuous with each other, separated only by the diaphragm, which is continuous with the parietal pleura. 3,4 If the diaphragm's lateral attachments to the 11th and 12th ribs are freed, and the diaphragm as well as the continuous parietal pleura are mobilized, both extracoelomic cavities would be connected as one (Fig. 3C).…”

Section: Anatomy Of the Abdominal And Thoracic Cavities And Coelomic And Extracoelomic Spacesmentioning

confidence: 99%

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Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

Walker

Farber

et al. 2022

Journal of Neurosurgery: Spine

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OBJECTIVE The thoracolumbar (TL) junction spanning T11 to L2 is difficult to access because of the convergence of multiple anatomical structures and tissue planes. Earlier studies have described different approaches and anatomical structures relevant to the TL junction. This anatomical study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the spine for interbody fusion at any level of the TL junction with appropriate adjustments for local anatomical variations. METHODS The authors reviewed anatomical dissections from 9 fresh-frozen cadaveric specimens as well as clinical case examples to denote key anatomical relationships and considerations for approach selection. RESULTS The retroperitoneal and retropleural spaces reside within the same extracoelomic cavity and are separated from each other by the lateral attachments of the diaphragm to the rib and the L1 transverse process. If the lateral diaphragmatic attachments are dissected and the diaphragm is retracted anteriorly, the retroperitoneal and retropleural spaces will be in direct continuity, allowing full access to the TL junction. The T12–L2 disc spaces can be reached by a conventional lateral retroperitoneal exposure with the rostral displacement of the 11th and 12th ribs. With caudally displaced ribs, or to expose T12–L1 disc spaces, the diaphragm can be freed from its lateral attachments to perform a retrodiaphragmatic approach. The T11–12 disc space can be accessed purely through a retropleural approach without significant mobilization of the diaphragm. CONCLUSIONS The entirety of the TL junction can be accessed through a minimally invasive extracoelomic approach, with or without manipulation of the diaphragm. Approach selection is determined by the region of interest, degree of diaphragmatic mobilization required, and rib anatomy.

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Section: Anatomy Of the Abdominal And Thoracic Cavities And Coelomic And Extracoelomic Spacesmentioning

confidence: 99%

“…1,2 However, many spine and exposure surgeons do not apply these techniques to the TL junction. Multiple studies have described relevant anatomy and outcomes data, [2][3][4] but few have clearly outlined proper selection and execution of TL junction approaches.…”

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confidence: 99%

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

Walker

Farber

et al. 2022

Journal of Neurosurgery: Spine

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“…The point of intersection of the insertion of the arcuate ligaments corresponds to the transverse process of L1. 2,[6][7][8][9] Initially, to access the thoracolumbar junction, the extracelomic space must be preserved, developing a retropleural plane and mobilizing the diaphragm of its costal and lumbar insertions. Dissection of the costal muscle layer begins above the desired space.…”

Section: Surgical Techniquementioning

confidence: 99%

“…Understanding the anatomy of the thoracolumbar junction (T1L1) is complex and challenging to spine surgeons, highlighting the presence of the diaphragm -a structure that divides the thoracic and abdominal cavities anatomically. 2,[6][7][8] The use of an expandable tubular device, capable of creating a corridor for the direct visualization of the antero-lateral portion of the spine in the thoracolumbar junction, thus avoiding the complications of an open thoracophrenolombotomy seems to be the key to reduce the morbidity related to surgical access and deal with the nuances of the regional anatomy. For this, it is crucial to keep surgical dissection out of the pleural cavity, using an extracavitary plan in order to safely mobilize the diaphragm.² Retropleural access is achieved by creating a plane between the parietal pleura and the internal surface of the rib below the initial incision, with the diaphragm and pleura retracted and dissected by anterior approach, 6 which allows lateral access to the vertebral bodies and discs, as well as to the ventral dural sac for decompression.…”

Section: Introductionmentioning

confidence: 99%

MINIMALLY INVASIVE LATERAL RETROPLEURAL APPROACH TO THE THORACOLUMBAR JUNCTION – REVIEW & EXPERIENCE

Menezes¹,

Fernandes²,

Arruda³

et al. 2020

Coluna/Columna

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Objective To describe the minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine and its viability in several affections of the region, demonstrating its indications, potential advantages, and necessary precautions, with an emphasis on the local anatomy, especially the diaphragm. Methods After a review of the literature, the initial experience of the Service is reported, comparing it to the published results. The surgical technique used is described with emphasis on the surgical anatomy of the diaphragm. Results The minimally invasive lateral retropleural approach to the thoracolumbar junction with the application of an expandable tubular retractor was described step-by-step in this study, with emphasis on the crucial points of technical execution, such as preoperative planning, access to the retropleural plane, and an orthogonal approach for adequate discectomy and/or corpectomy and subsequent implant placement. It can be used in the treatment of deformities, degenerative diseases, trauma, tumors, and infections and it allows for adequate interbody arthrodesis fusion rates associated with a smaller skin incision and less soft tissue damage, blood loss, and postoperative pain. Thus, it results in better postoperative mobility and a shorter hospital stay, which can also be observed in the data from initial experience of this Service. Conclusions The minimally invasive technique for the lateral retropleural approach to the thoracolumbar spine with the application of an expandable tubular retractor was shown to be promising and safe for the treatment of several spinal diseases despite the complex and challenging local anatomy and it presents advantages over the morbidity rates observed in the traditional approach. Level of evidence IV; Case series.

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“…It is important to preserve a 1-cm cuff of the diaphragmatic costal border for reinsertion. 6 Insertion of thoracic pedicle screws using establised landmarks and trajectories should be placed.…”

Section: Figurementioning

confidence: 99%

Principles of Spine Instrumentation

Dahlan

Ompusunggu

Utomo

et al. 2020

AANHS-J

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Introduction : Spinal implants were initially, and are still, used for the supplementation of bony fusion. However, bony fusion operations were initially performed without implants.1 In the US, Wire and screw fixation of the unstable spine techniques remained to use until the pre-World War II years. 20 years after World War II, there were two major breakthroughs in spine surgery: the Harrington system for spine stabilization and deformity correction and the interspinous wiring technique of Rogers. Rogers described the technique of cervical interspinous wiring in the early 1940s. Harrington introduced his instrumentation system in 1962. Discussion : Since then, modifications of both techniques have been devised to increase their security of fixation. The next significant advance in dorsal spinal stabilization was the development of multisegmental spinal instrumentation. Multisegmental instrumentation permits sharing of the load applied to the instrumentation construct with multiple vertebrae, so that decreasing the chance of failure at the metal–bone interface.The Luque segmental wiring technique, developed in the early 1970s, was the first of this class of implants to achieve wide clinical application. Subsequent modifications have been used. Conclusion : Further modifications were the forerunners of more complex, currently used systems of universal spinal instrumentation (USI).

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Surgical Anatomy of the Diaphragm in the Anterolateral Approach to the Spine

Abstract: An understanding of the diaphragmatic-costal and diaphragmatic-spinal attachments is key for the safe and effective implementation of diaphragm mobilization during the lateral and thoracoabdominal approaches to the spine.

Cited by 19 publications

References 12 publications

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

MINIMALLY INVASIVE LATERAL RETROPLEURAL APPROACH TO THE THORACOLUMBAR JUNCTION – REVIEW & EXPERIENCE

Principles of Spine Instrumentation

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