Approach to Thoracolumbar Spine

- Positioning: - foley and appropriate IV access established; - place patient into left lateral decubitus position (L side up) - break table in the middle; - Incision and Exposure: - incision is made along 10th rib which then curves along anterior abdomen as appropriate (based on size of patient); - 10th rib is identified, the periosteum is incised, and the 10th rib is subperiosteally dissected. - the bone is cut and and is then removed from the costochondral junction; - periosteal bed is opened, exposing the pleural cavity. - using metzenbaum's the pleural cavity is opened widely along the bed of the 10th rib; - the incision is then carried thru the diaphram; - the retroperitoneal fat is identified; - using blunt dissection w/ 2 fingers, the interval between the retroperitoneal fat and the diaphram is dissected around the diaphram to the edge of the spine; - a Finochetti retractor is placed using 2 lap sponges as cushions against the 9th and 11th ribs; - cautery is used to incise the diaphram along the margin of the diaphram costal junction all the way around to the vertebral bodies; - the peritoneum is dissected away from the abdominal muscles and the exernal, internal, and transversalis muscles are incised in line w/ the skin incision;