Can be done in either prone or a floppy lateral
position about 20 degrees lateral decubitus position.
The bolsters should be so placed so as to allow
adequate chest expansion especially in the prone position.
Incision: Usually longitudinal para spinal incision
is preferred especially when a decompression and interbody fusion is planned, how ever depending on the pathology even a midline
or a transverse para spinous incision may be used.
A curvi linear skin incision centered about four
fingers from midline of the desired vertebrae and curving toward midline caudally and cephalad is made.
A cautery is used to cut the para spinal muscle
and thoracolumbar fascia. A cobbs elevator is used to separate the muscle attachment from the lamina. A sharp periosteal dissection
is carried out to separate the periosteum from the rib.
The Costotransverse joint is incised, the periosteum
of the rib is elevated
Circumferentially with especial care being taken
during the subperiosteal elevation of the anterior periosteum as the pleura lies immediately behind the rib bed.
The neurovascular bundle traverses the lower edge
of the rib after leaving the intervertebral foramen located at the caudal aspect of transverse process, it should be identified
The rib is cut laterally at the angle of rib and
lifted off its bed. This allows the dissection of the parietal pleura and endothoracic fascia under vision. The rib should
be disarticulated from the costovertebral joint. A self-retaining retractor or a rib spreader can be used to improve the exposure.
A sharp dissection at the base of transverse process
leads onto the pedicle and the vertebral body. The exiting nerve root can be identified at the foramen. The nerve can be dissected
medially applying a gentle medial traction. The dural sac will be visible medially.
After the dural sleeve and nerve root is adequately
visualized and protected, the decompression may be carried out removing the pedicle, the lamina, and vertebral body.
While dissecting anterior to the vertebral body
it is imperative to elevate the prevertebral fascia off the body to protect the anterior structures.
The closure can be performed in layers: fascia,
sub cutaneous tissue and skin.
Injury to neurovascular bundles.
Injury to pleura.
Injury to great vessels lying anterior to the
Postoperative atelectasis of lung.