VIVA

Spine – Surgical Approach

15 minutes
Case 1
F, 45 y.o with chief complaint pain in her lower back radiating to the right leg. The pain worsen
while the patient sitting and relieve when standing. There was no history of trauma, she works
as buruh gendong at the market
There is no sensoric or motoric deficit.
 Questions
1. Based on anamnesis, physical examination and radiologic
modalities, what is your clinical diagnosis
2. How to perform posterior approach for the lumbar spine
 EXAMINER’S GUIDE

Literature:
Rothman Simeone The Spine
Hoppenfeld Surgical Exposures in Orthopedics
1. Diagnosis : disc herniation of 3rd – 5th lumbar spine without neurologic
deficit
2. The candidate able to describe preparation until step by step of posterior
approach of the lumbar spine
• Prone position with airway and eye protection
• Neck in neutral position not hyperextended
• Arms are positioned at 90 or less of abduction and slightly hanging down
• Ulnar nerves are padded
• Proximal pads support chest distal to axilla slightly above nipple line
• Distal pads support against iliac crest, this position allow abdomen to hang free
• Hips and knee are slight flexed
3. Approach
• Internervous plane : between two paraspinal muscles (erector spinae)
• Landmarks can palpate spinous process (midline incision)
• Superficial dissection incise fat and lumbodorsal fascia to spinous process
• preserve interspinous ligament, detach paraspinal muscles (erector spinae) subperiostally
• dissect down spinous process and lamina to facet joint
• move medial to lateral sparing the facet capsule
• Deep dissection
• remove ligamentum flavum by cutting attachment to edge of lamina
• identify epidural fat and dura using blunt dissection stay lateral to dura and continue to
floor of spinal canal
• Closure : fascia is closed with watertight closure
• closed wound suction drain placed deep to the lumbodorsal fascia if drain is required
Case 2
M, 63 y.o with chief complaint pain in his neck. Patient had difficulty walking up and
downstairs, frequently dropping object in his hand
The patient had difficulties performing toe to heel walk and positive rhomberg test.
There is decrease in sensoric dermatome of C4-C7, slight motoric weakness of C5-C7
and positive finger escape test.
 Questions
1. Based on anamnesis, physical examination and radiologic
modalities, what is your clinical diagnosis
2. How to perform anterior approach for the cervical spine
 EXAMINER’S GUIDE

Literature:
Rothman Simeone The Spine
Hoppenfeld Surgical Exposures in Orthopedics
1. Diagnosis : cervical myelopathy of 5th – 7th cervical spine due to OPLL
2. The candidate able to describe preparation until step by step of
anterior approach of the cervical spine
• Supine position with airway and eye protection
• shoulders/arms pulled caudal to obtain better visualization of C7 in imaging to
identify correct level
Plane
• Superificial  divide platysma which is innervated high up in the neck by the
facial (seventh) cranial nerve
• Middle  sternocleidomastoid (spinal accessory nerve), strap
muscles (segmental innervation from C1, C2, C3)
• Deep  right and left longus colli muscles (segmental branches of cervical
nerves)
• Incision : make transverse skin crease incision at appropriate level,
extend obliquely from the midline to the posterior border of the SCN
• Superficial Dissection
• incise fascia over platysma, spit platysma with finger
• identify anterior border of SCM, incise fascia and retract SCM lateral
• identify and retract strap muscles medially (sternohyoid and sternothyroid)
• identify the carotid pulse and retract carotid sheath lateral
• cut through pretrachial fascia
• localize superior and inferior thyroid arteries and tie off if necessary
• Deep dissection
• split longus colli muscles and anterior longitudinal ligament
• subperiostally disect to expose anterior surface of vertebral body
• retract longus colli muscles and ALL laterally
• identify level with needle in disc space and lateral xray