Prosedur Pembedahan Spine

Dr. dr. Farhad Bal’afif, SpBS(K)

Bedah Saraf – FKUB / RSUD Dr Saiful Anwar
Malang
 Anatomy
 Spinal cord lies within protective
covering of vertebral column.

 Begins just below foramen magnum

of the skull.

 Ends opposite 2nd lumbar vertebra.

 Below L2 continue as a leash of nerve

roots known as cauda equina.

 Prolongation of the pia matter forms

filum terminale.
Spinal cord structure
 Anatomy of Vertebrae
• Anterior Elements:
• Vertebral body: provide bulk
and height; Sustain
compression loads.
• Middle Elements:
• Pedicles: transfer forces from
posterior to anterior elements.
• Posterior Elements:
• Articular processes and facet
jts, laminae, spinous
processes.
• Lock spine to prevent forward
sliding and twisting; Insertion
sites for muscle
 Causes of spinal cord lesions
congenital; spinal stenosis.
Infection; TB ,abscess.
Trauma; vertebral body fracture or
facet joint dislocation.
Inflammatory; Rheumatoid
arthritis.
Disc and vertebral lesion.
Vascular; epidural & SDH
Tumors.
 Spinal stenosis
75% of cases of spinal
stenosis occur in the
low back ( lumbar
spine).

Causes :
- congenital.
- degenerative.
- trauma.
Other causes of spinal stenosis
aging process (most
common cause ).
herniated discs. (fig)
bone and joint
enlargement.
spondylolisthesis.
bone spurs.
Tx Spinal Stenosis
Initial Tx in most cases is
conservative.
Rest.
Weight loss.
Epidural steroid injections.
Analgesia.
Anti-inflammatory agents.
Muscle relaxant -if needed-
Physiotherapy.
Tx spinal stenosis
Spine surgery:
used when conservative treatment failed.
-laminectomy (removing bone behind the spinal
cord)
-foramenotomy (removing bone around the spinal
nerve).
-discectomy (removing the spinal disc to relieve
pressure).

Complications:
Dural tears.
Infections.
Instability of the spine.
 Infection
Epidural abscess
Usually bacterial
( staphylococcus is
common).
Spread through:
hematogenous

Adjacent focus.
Direct

inoculation.
Risk factor for epidural abscess
• immunodeficiency
• AIDS.
• Alcoholism.
• Chronic renal failure.
• Diabetes mellitus.
• Intravenous drug abuse.
• Malignancy.

• Spinal procedure or surgery.

• Spinal trauma.
 Infection
Infection of spine
Uncommon
Either vertebral
osteomyelitis Or less
commonly intraspinal
infection.
Causative organism :
(staph, Strep, E.coli, TB)
Occasionally due to
unusual organisms like:
Salmonella or brucella.
Tx spinal infections
The goals of treatment are to relieve
spinal cord compression and cure the
infection.
 drain abscess.
 antibiotics or antimicrobial.
 corticosteroid.
 may need urgent surgical decompression by
laminectomy.
 Tumors
Tumors are
classified into 3 types
according to their
site:
-extradural ( between
the meninges and spine
bones)
-intradural
extramedullary
(within meninges)
-intramedullary ( inside
the cord)
 Spinal tumors
Most spinal tumors are extradural (85%)
They may be primary tumors originating in
the spine, or secondary tumors that are the
result of the spread of cancer from other
locations primarily the lung, breast, prostate,
kidney, or thyroid gland.
Any type of tumor may occur in the spine,
including lymphoma, leukemic tumors,
myeloma, and others. A small percentage of
spinal tumors occur within the nerves of the
spinal cord itself, most often consisting of
ependymomas and other gliomas.
 Investigations
Plain X-rays.
Myelography “contrast material is
injected into the thecal sac fluid
surrounding the spinal cord and
nerve root within the spinal canal”
CT.
MRI ( study of choice ).
Tx spinal tumors
The goal of treatment is to reduce or prevent
nerve damage from compression of the spinal
cord, relieve pain and maintain the function.
- Surgical excision is the treatment for
extramedullary tumors.
- Radiation therapy for intramedullary tumors.
The traditional treatment of intramedullary gliomas
has been biopsy followed by radiation therapy.
Radiotherapy is clearly of value in metastatic lesions.
- Chemotherapy can be considered in patients with
progression of disease after radiation therapy.
Spinal cord compression (SCC)
The act of exerting an abnormal amount of pressure
on the spinal cord.
Causes and risk factors :
- Traumatic injury.
- Spinal cord tumors.
- Spinal stenosis.
- Ruptured disks.
- Abscesses.
- Arteriovenous malformations.
- Degenerative diseases, such as arthritis.
 Spinal cord compression

S p in al C ord C om pres s io n in T h re e M a in A re as

T ho rac ic L u m b os a cral C erv ic al

7 0% 2 0% 1 0%
 Clinical presentation
Symptoms vary depending on the cause of the
compression, its location, severity, extent and
rate of development but can include:
- Back pain at the spinal site of compression.
- Pain or burning in other parts of the body.
- Difficulty breathing.
- Weakness in the arms, legs, or both.
- Numbness or tingling in the neck, shoulder, arms,
hands, or legs.
- Loss of coordination or difficulty walking.
- Loss of fine motor skills.
- Loss of sexual function.
- Loss of bladder or bowel control.
- Paralysis.
 Clinical presentation
Cauda equina syndrome;
is a serious condition caused by compression
of the nerves in the lower portion of the
spinal canal .
is considered a surgical emergency because if
left untreated it can lead to permanent loss of
bowel and bladder control and paralysis of
the legs.
 Investigation
X ray.
CT scan.
MRI.
Myelogram.
Biopsy.
Bone scan.
Blood and spinal fluid
studies.
Tx spinal cord compression
Acute cord compression is a 'surgical'
emergency.
In those with malignant disease radiotherapy
may be treatment of choice.
In general, tumor, infection and disc disease
produces anterior compression.
Surgical decompression should be achieved
through an anterior approach.
 Spinal trauma
Spinal cord trauma is damage to the spinal cord. It
may result from direct injury to the cord itself or
indirectly from damage to surrounding bones, tissues,
or blood vessels.
Symptoms:
- Symptoms vary depending on the location of the
injury.
- Spinal cord injury causes weakness and sensory loss
at and below the point of the injury.
- we can divide spinal trauma into 3 levels according to
its location in the spinal cord ( cervical - thoracic –
Lumbosacral ).
 Cervical injuries
- When spinal cord injuries occur near the neck,
symptoms can affect both the arms and the legs:

Breathing difficulties (from paralysis of the breathing

muscles).
Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
Numbness.
Sensory changes.
Spasticity (increased muscle tone).
Pain.
Weakness, paralysis.
 Thoracic injuries
- When spinalinjuries occur at chest level,
symptoms can affect the legs:

Breathing difficulties (from paralysis of the breathing

muscles)
Loss of normal bowel and bladder control (may include
constipation, incontinence, bladder spasms).
Numbness.
Sensory changes.
Spasticity (increased muscle tone).
Pain.
Weakness, paralysis.
Injuries to the cervical or high-thoracic spinal cord may
also result in blood pressure problems, abnormal
sweating, and trouble maintaining normal body
temperature.
 Lumbosacral injuries
- When spinal injuries occur at the lower-back
level, varying degrees of symptoms can affect
the legs:

Loss of normal bowel and bladder control (may

include constipation, incontinence, bladder spasms).
Numbness.
Pain.
Sensory changes.
Spasticity (increased muscle tone).
Weakness and paralysis.
 Investigations
A CT scan or MRI of the spine may show the
location and extent of the damage and reveal
problems such as blood clots (hematomas).
Myelogram (an x-ray of the spine after
injection of dye) may be necessary in rare
cases.
Somatosensory evoked potential (SSEP)
testing or magnetic stimulation may show if
nerve signals can pass through the spinal
cord.
Spine x-rays may show fracture or damage to
the bones of the spine.
Tx Spinal trauma
ABC
Spine Immobilization to prevent further injury to
the spinal cord.
In cervical injuries higher than C5, intubation and
respiratory support are usually needed.
Corticosteroids, rest, analgesics and muscle relaxant.
Surgery (decompression laminectomy ).
Extensive physical therapy and other rehabilitation
interventions are often required after the acute
injury has healed.
THE INITIAL EXAMINATION AND
TREATMENT

EXTRICATION :
GOOD WELL TRAINED TEAM WORK
PREVENT FURTHER INJURIES
SCOOP STRETCHER IS SAFEST

TRANSPORT :
ONCE STABILIZED REFER TO LEVEL 1 TRAUMA CENTRE
TRENDELENBURG POSITION
LONG JOURNEY CONSIDER : NGT, IV LINE, URINARY
CATETHER

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THE IN-HOSPITAL MANAGEMENT

EVALUATION OF A, B & C
PaO2 > 100 mmHg and PaCO2 < 45 mmHg
MAINTAIN BP > 90 mmHg
TREAT NEUROGENIC SHOCK !

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 Disc prolapse
Rupture of the disc or
prolapse as it is usually
called, can press on the
spinal cord and its nerve
roots leading to pain,
numbness and weakness
and may also affect the
control of bowel and
urinary bladder.
Dx: X-ray, CT scan or MRI.
Tx Disc Prolapse
Initial Tx in most cases is conservative.
Rest.
Analgesia.
Anti-inflammatory agents.
Muscle relaxant -if needed-.
Physiotherapy.
Tx Disc Prolapse
 laminectomy, involves excision of a portion of
the lamina and removal of the protruding disk.
spinal fusion, may be necessary to overcome
segmental instability.
Laminectomy and spinal fusion are
sometimes performed concurrently to stabilize
the spine.
Microdiskectomy, can also be used to remove
fragments of nucleus pulposus.
Chemonucleolysis: Injection of the enzyme
chymopapain into the herniated disk produces a
loss of water and proteoglycans from the disk,
thereby reducing both the disk’s size and the
pressure in the nerve root.
 Spondylolisthesis
Spondylolisthesis
is a condition in
which the there is a
defect in a portion of
the spine, causing
vertebra to slip to one
side of the body.
Tx Spondylolisthesis
Non-surgical treatment may include one or a
combination of:
- NSAID’s (e.g. ibuprofen, COX-2 inhibitors)
- Oral steroids
- Physical therapy
- Manual manipulation (e.g. chiropractic
manipulation).

Spinal fusion surgery.

MANAGEMENT PRINCIPLES
Early compression → minimal symptom / sign
MRI is very sensitive for soft tissue
Early Dx and Tx → better result
Prevent secondary damage
Suspected of spinal cord / root compression should
reffered to neurosurgeon as early as possible
 SURGICAL MANAGEMENT
Indications :
- compression syndrome (acute/chronic)
- progressif neurologic deficit
- instability
- debridement
Approaches :
- anterior
- posterior
- endoscopic
Persiapan
Dewasa : Hb > 10 gr %, anak2: Hb> 12 g%
FH normal dan lab lain normal
Daerah yg akan dioperasi harus bersih ( mandi)
 inform concent
ADRENALIN
KULIT
KOMBINASI DENGAN LIDOKAIN
CARA MENYUNTIK : SUBKUTAN
DOSIS MAKSIMAL : ADRENALIN 0,25 MG
LIDOKAIN 4 MG/KG/KALI
CARA MEMBUAT
1 AMPUL = 1 CC = 1/1000
1 CC + 9 CC AQUA = 10 CC  1/10.000
10 CC (1/10.000)  DIAMBIL 1 CC + 9 CC AQUA = 10 CC
ADRENALIN 1/100.000
5 CC LIDOKAIN 2% + 5 CC AQUA + 10 CC ADRENALIN
1/100.000  ADR 1/200.000, LIDOKAIN 0,5%
SPINE INSTRUMENT (LAMINECTOMY)

Handvat mess no. 4 (Scalp blade and handle) : 1 buah

Handvat mess no. 7 (Scalp blade and handle) : 1 buah
Nald voeder (Needle holder) : 2 buah
Gunting metzembaum (Metzemboum scissor) : 1 buah
Gunting benang (Surgical scissor ) : 1 buah
Gunting mayo/kasar (Surgical scissor straight) : 1 buah
Pincet anatomis (Tissue forceps) : 2 buah
Pinset chirurgis (Dissecting forceps) : 2 buah
Disinfeksi klem (washing and dressing forcep) : 1 buah
Canule suction : 2 buah
Bipolar / monopolar couter : 1 set
Duk klem (towel klem) : 5 buah
Klem pean cantik (nissen) : 1 buah
Langenbeck : 2 buah
Gelpi ( Spesial retractors) : 2 buah
Sprider (Laminectomy retractors) : 1 buah
Dissector : 2 buah
Kop / Chissel (Dissector) : 2 buah
Nerve Hook : 2 buah
Nerve root exploration : 1 buah
Caspar rongeur straight/upwards/downwards : 3 buah
Kerrison bone punch no.2/3/4 : 3 buah
Knable tang : 1 buah
Bone cutting : 1 buah
 Spine set

Spine Surg set

Spine set
Spine set
Spine set
Optek operasi HNP
Posisi
Desinfeksi
Batasi daerah operasi dengan kain steril
Sayatan kulit sesuai lokasi
Rawat perdarahan kulit
Pasang peregang kulit (SPREIDER) tajam, tumpul
Spinosus dipisahkan dari otot
Dilakukan laminotomi , laminectomi , disectomi
sesuaikebutuhan
Perdarahan dirawat
TUTUP
Posisi
Posisi
posisi
disinfeksi
LAMINECTOMY
“Discectomy”
Mikrodiskektomi
Laminotomi
Laminektomi
CANAL STENOSIS
`
 SURGICAL TREATMENT
TUMOR IDEM (17 – 4 -2007)
Laminectomy Vertebra Th2 – 5 + total eksisi intradural
ekstramedular tumor
ekstradural tumor at vertebra Th3,4
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SUB AXIAL CERVICAL SPINE INJURIES

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SUB AXIAL CERVICAL SPINE INJURIES

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SUB AXIAL CERVICAL SPINE INJURIES

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