Surgical anatomy of minimally invasive lateral approaches to the thoracolumbar junction

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  • 1 Department of Neurosurgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona; and
  • | 2 Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
Open access

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.

ABBREVIATIONS

TL = thoracolumbar.

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.

In Brief

The thoracolumbar junction is a complex anatomical location where multiple structures and tissue planes converge. This study aims to build a conceptual framework for selecting and executing a minimally invasive lateral approach to the thoracolumbar junction for interbody fusion. The main corridors for accessing this region include the retroperitoneal, retrodiaphragmatic, and retropleural approaches. This study provides a framework that surgeons may use to understand appropriate minimally invasive approaches to the thoracolumbar junction.

The thoracolumbar (TL) junction, which spans T11–L2, is a complex anatomical location comprising multiple structural cavities, spaces, and tissue planes. Recent advances in minimally invasive anterolateral retroperitoneal approaches to the lumbar spine have yielded multiple interbody fusion techniques that minimize blood loss and collateral tissue damage.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,24 but few have clearly outlined proper selection and execution of TL junction approaches.

In this study, we provide a systematic guide outlining the selection, relevant anatomy, and step-by-step execution of minimally invasive approaches to the TL junction. The central framework centers on the embryological principle of the extracoelomic space, namely, the shared and contiguous common space comprising the retroperitoneal space in the abdomen and the retropleural space in the thorax, with the diaphragm acting as a septum. Depending on the disc space level and local anatomical configuration of the ribs, an anterolateral approach will likely necessitate work purely within the retroperitoneum or retropleural space, with or without mobilization of the diaphragm. The relevant anatomy and pertinent workflow for approach selection and execution are highlighted, using established anatomical studies, cadaveric dissections, detailed illustrations, and intraoperative photographs.

Methods

Anatomical Dissections and Case Reviews

For the anatomical studies, 9 fresh-frozen adult cadaveric specimens were used. All specimens were free of prior thoracic, retroperitoneal, and abdominal surgeries. Dissections were performed at the cadaveric laboratory at NuVasive, Inc. by the senior author, with the specimens in the lateral decubitus position. Additional clinical cases and associated radiographic and intraoperative media were collected and de-identified for academic presentation in a manner consistent with Health Insurance Portability and Accountability Act guidelines and with an approved active institutional review board protocol. Close attention was given to the relationship between the abdominal and thoracic cavities and their diaphragmatic boundary.

Patient and Cadaver Positioning

We followed previously described protocols for lateral decubitus positioning of patients for a lateral lumbar interbody fusion.1 In brief, the patient is positioned with the side of approach up and the downside iliac crest at the level of the table break. The hips and knees are flexed as much as possible, followed by placement of an axillary roll to decompress the brachial plexus. The patient is taped to the bed, and the head of the table is broken to form an angle of approximately 15°. Breaking the bed is one of the most critical points of emphasis for TL approaches because this action laterally flexes the torso away from the side of the approach (Fig. 1). With lateral flexion, the rib cage elevates, potentially obviating the need to perform additional rib and diaphragm manipulation when approaching the lower TL junction. The patient’s position is adjusted until perfect anteroposterior and lateral radiographs are obtained with the fluoroscope kept in a neutral tilt. The lateral projection of the disc space is then traced on the posterolateral flank for incision planning.

FIG. 1.
FIG. 1.

Patient positioning. The patient is positioned with the approach side facing up and with the downside iliac crest resting at the level of the table break (white arrow). The legs and knees are bent as much as possible, and an axillary roll is placed. The patient is taped to the bed, and the table is broken at approximately 15° to elevate the ribs cranially.

Results

Anatomy of the Abdominal and Thoracic Walls

The soft tissues of the abdominal wall5,6 and chest wall7 are composed of multiple muscle layers; the surgeon must have proper anatomical knowledge and the ability to identify the correct muscle layer to traverse into the appropriate tissue plane. In the anterolateral surface of the abdomen, from the most superficial layer to the deepest, one will first encounter the external oblique muscle that originates from the bottom 6 ribs and runs caudally and medially to insert into the anterior iliac crest, pubis, and linea alba (Fig. 2A). Next, the internal oblique muscle originates inferiorly from the anterior iliac crest and medially from the iliopsoas and TL fascia, and it runs superiorly and medially to insert into the bottom 3 ribs. The deepest muscle layer of the abdominal wall is the transversus abdominis muscle, which shares origins with the internal oblique muscle and runs anteriorly into the linea alba and interdigitates superiorly into the diaphragm muscle fibers. The transversalis fascia running deep to the muscle continues to run over the inferior surface of the diaphragm as the diaphragmatic fascia.

FIG. 2.
FIG. 2.

Anatomical layers of the abdominal and chest walls. A: Surgical illustration demonstrating the tissue layers of the anterolateral surface of the abdomen that are traversed during lateral approaches. B: Surgical illustration demonstrating the tissue layers of the anterolateral surface of the thorax that are traversed during lateral approaches. m., muscle; mm., muscles. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

In the chest wall anatomy, the lower 3 ribs are typically encountered during anterolateral approaches to the TL junction (Fig. 2B). The first superficial muscle in this region is the latissimus dorsi, which originates from the spinous processes of T7–L5 and the posterior iliac crest, forming a cape-like muscle that converges into a tendon that inserts into the floor of the intertubercular groove on the medial aspect of the humerus. Next is the external oblique muscle, previously described, that overlies the bottom portion of the 7th through 12th ribs. Between the ribs runs the external intercostal muscle in an inferoanterior path, followed by the internal intercostal muscle, which runs in an inferoposterior path.8

Beneath the internal intercostal muscle and deep surface of the 11th and 12th ribs is the diaphragm, which runs contiguous with the parietal pleura cranially. Above the 11th rib, the endothoracic fascia is encountered, followed by the parietal pleura.9 At the 11th rib, the endothoracic fascia has previously been described as fusing with the diaphragmatic fascia, a tissue layer that covers the muscle.10 However, from our dissections and experience, the endothoracic fascia typically invests heavily into the medial rib periosteum and becomes easily disrupted when any rib above the 12th is resected, allowing development of the retropleural space between the endothoracic fascia and the parietal pleura.

Anatomy of the Diaphragm

The diaphragm is a musculotendinous layer that forms a concave border above the abdomen, separating it from the thoracic cavity.11 The diaphragm’s inferior surface is covered by the diaphragmatic fascia, a tissue plane continuous with the transversalis fascia; the superior surface is covered by the parietal pleura and pericardium12 (Fig. 3A). The attachments of the diaphragm relevant to the TL junction are along the lateral and posterior margins. The diaphragm attaches anterolaterally to the medial aspects of the 7th and 8th ribs and posterolaterally to the medial surface of the 11th and 12th ribs.

FIG. 3.
FIG. 3.

Structure of the diaphragm and its attachments. A: Cadaveric dissection of the left thoracic wall with a light shining in the thoracic cavity clearly denotes the junction of the thoracic cavity with the abdominal cavity demarcated by the diaphragm (double arrowhead). The parietal pleura lines the cranial surface of the diaphragm and is continuous with the diaphragm along its lateral border. The retroperitoneal space is seen through the division of the diaphragm with the peritoneal membrane (double asterisk). Because the diaphragm is concave toward the abdomen, the retroperitoneum can also be entered by detaching the diaphragm off the medial surface of the 11th and 12th ribs and reflecting it anteriorly. The interface between the diaphragm and a thin layer of endothoracic fascia (double arrowhead) is closely associated with the parietal pleura (asterisk). B: Cadaveric dissection of the left thoracic wall after removal of the 11th and 12th ribs. The diaphragm is retracted anteriorly, revealing the L1 transverse process attachment point of the medial and lateral arcuate ligament (asterisk). The cuff of muscle (black arrowhead) is the remnant of the medial arcuate ligament along its lateral attachment. The medial attachment of the medial arcuate ligament is marked (white arrowhead) at its attachment to the left crus. C: Medical illustration of the medial and lateral diaphragm attachments. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Medially, the diaphragm has 3 attachments relevant to the spinal column: the lateral and medial arcuate ligaments and the midline crura (Fig. 3B). The lateral arcuate ligament is a musculotendinous insertion that spans the quadratus lumborum muscle and inserts into the L1 transverse process medially and the inferior portion of the 12th rib laterally. The medial arcuate ligament spans across the psoas muscle and connects the crus of the diaphragm medially with the L1 transverse process laterally. Classically, L1 is a common attachment point of both arcuate ligaments, as was seen in our specimens bilaterally; however, attachments to L2 and L3 have also been described.13 The crura are long tendinous bands that run longitudinally along the anterolateral aspect of the spine from T12 down to the L2 body on the left and the L3 body on the right.

Anatomy of the Abdominal and Thoracic Cavities and Coelomic and Extracoelomic Spaces

The TL junction runs within the abdominal cavity and the thoracic cavity, with the transitional border denoted by the medial arcuate ligament that typically runs across the lateral surface of the L1 vertebral body. Within both the abdominal and thoracic spaces, 2 separate cavities are defined from different embryological origins: the coelomic cavity, consisting of the peritoneal and pleural spaces, and the extracoelomic cavity, consisting of the retroperitoneal and retropleural spaces.14,15 The coelomic spaces are the potential spaces that exist in between the visceral peritoneum or pleura that lines the abdominal organs and lungs and the parietal peritoneum or pleura that lines the spine, abdominal, and chest wall cavities. The extracoelomic spaces are the retroperitoneal space between the parietal peritoneum and the abdominal wall and the retropleural space between the parietal pleura and the endothoracic fascia.

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).

Discussion

Extracoelomic Approach Selection

An approach to the TL junction can traverse either the coelomic or extracoelomic space. For a coelomic approach, the parietal peritoneum or pleura must be traversed twice, once through its attachment into the cavity wall and once through its coverage on the spine’s lateral surface. During an extracoelomic approach, the parietal membrane is mobilized off the abdominal or thoracic wall and reflected anteriorly off the spine, thus exposing the spine within the extracoelomic space (Fig. 4). In general, we favor an extracoelomic approach because of the additional parietal tissue plane separating the viscera from the plane of dissection and the anatomical continuity of the space within the abdominal and thoracic spaces.

FIG. 4.
FIG. 4.

Illustration of coelomic and extracoelomic cavities seen through the lateral approach. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

The workflow for an extracoelomic TL junction approach proceeds first with identifying the anatomical cavity in which most of the work will occur, followed by recognizing the degree of diaphragmatic manipulation required. A summary of the dominant cavity of the approach and the extent of diaphragmatic manipulation is outlined in Table 1. Typically, the disc spaces from T12 to L2 can be approached within the abdominal cavity, and thus a retroperitoneal approach is preferred. The extent of diaphragmatic involvement is then determined based on the relationship of the lateral ribs to the planned incision overlying the disc space. If minimal ventral vertebral body exposure is needed and the incision is localized near the lower aspect of the 12th rib, a retroperitoneal approach with a cranial oblique angle may be employed. In cases in which significant ventral body exposure is needed, the incision overlies a rib (10th or 11th), or the arcuate ligaments attach caudally to the level of interest, a retroperitoneal retrodiaphragmatic approach with mobilization of the diaphragm is needed. The T11–12 disc space, on the other hand, requires working exclusively within the thoracic cavity through a retropleural corridor. The 3 approaches that can be used are described below.

TABLE 1.

Summary of approach selection

Spinal LevelLocal Anatomical ConsiderationsApproach
T12–L2No ventral vertebral body exposure needed; incision close to bottom of 12th ribRetroperitoneal w/ cranial oblique approach
Significant ventral exposure needed; incision overlies 10th & 11th ribs; arcuate ligament attachments are firm & caudal to level of interestRetroperitoneal w/ diaphragm mobilization (retrodiaphragmatic)
T11–12NoneRetropleural

Retroperitoneal Approach Undermining the Diaphragm for T12–L2

When targeting the T12–L2 disc spaces, the incision can be caudally translated to just below the 12th rib if it is within 5 cm of the caudal border of the 12th rib. We obtain typical retroperitoneal access with electrocautery exposure and divide the external oblique fascia. Then we bluntly dissect the external and internal oblique muscles, splitting the muscle fibers, and the transversalis fascia, before finally using a blunt clamp to puncture and dilate through the transversalis fascia into the retroperitoneal fat (Fig. 5A). We use blunt finger dissection to identify the quadratus lumborum muscle and sweep the peritoneum anteriorly off the psoas muscle.

FIG. 5.
FIG. 5.

Case example of the retroperitoneal approach without diaphragm manipulation. A: Intraoperative photograph of the initial exposure for a standard lateral retroperitoneal approach. After skin incision, 2 blunt Kelly clamps are used to sequentially split and traverse through the lateral abdominal wall muscle fibers. The fibers of the external oblique (black arrowhead), internal oblique (white arrowhead), and transversus abdominis (double black arrowhead) muscles and the retroperitoneal fat (asterisk) are visible. B: An intraoperative anteroposterior radiograph shows a cranial oblique working angle underneath the rib cage to deposit a guidewire into the L1–2 disc space with a small dilator. C: After docking onto the disc space, the retractor can be pivoted cranially, pushing up the T12 rib and achieving a working corridor parallel to the disc space. Figure 5A used with permission from Barrow Neurological Institute, Phoenix, Arizona.

After palpating the psoas muscle, we insert a disc space dilator and guidewire into the T12–L1 or L1–2 disc space at an oblique cranial angle, undermining the 11th and 12th ribs (Fig. 5B). After performing sequential dilation through the psoas, we dock a lateral retractor on the disc space and tilt it to displace the lower ribs cranially, achieving an orthogonal working angle (Fig. 5C). This technique is straightforward at L1–2, but at T12–L1, the arcuate ligaments may impede diaphragm retraction cranially, which requires release of the ligament attachment at the L1 transverse process. This release can be performed bluntly with finger dissection or sharply under direct visualization with a short tube retractor.

Retrodiaphragmatic Approach

When targeting the T12–L2 disc spaces, if the overlying incision is too far away from the caudal border of the 12th rib or if significant ventral exposure of the vertebral body is needed, we release the lateral surface of the diaphragm off of the 11th or 12th rib to access the retroperitoneal space. Typically, the T12–L1 disc space incision overlies the lateral 11th rib, and the L1–2 disc space incision overlies the 12th rib.

The approach is performed by opening the incision and exposing the underlying rib (Fig. 6A). We then most commonly resect a 4- to 5-cm segment of the 11th or 12th rib to reveal the lateral surface of the diaphragm (Fig. 6B). If the ribs are mobile or the intercostal space is large, we can bluntly dissect through the 11–12 intercostal space without rib resection to identify the lateral diaphragmatic surface (Video 1).

VIDEO 1. Surgical video demonstrating the minimally invasive lateral retrodiaphragmatic approach to the T12–L1 disc space. This approach requires partial removal of the 11th rib. Used with permission from Barrow Neurological Institute, Phoenix, Arizona. Click here to view.

FIG. 6.
FIG. 6.

Case example of the retrodiaphragmatic approach. A: An intraoperative image of a left-sided retrodiaphragmatic approach with the 11th rib exposed. B: After removal of the 11th rib, the diaphragm (asterisk) is visible in continuity with the pleura (double asterisk), with a clear border (single arrowhead). A thin layer of endothoracic fascia (double arrowhead) is seen overlying the pleura. C: After retraction of the diaphragm and peritoneum anteriorly, the lateral surface of the psoas muscle (double asterisk) is visible. Also visible is the L1 transverse process (asterisk) attachment point for the lateral (single arrowhead) and medial (double arrowhead) arcuate ligaments. The arrow demarcates the lateral portion of the lateral arcuate ligament at a more superficial depth. Note that to visualize cranial to the L1 transverse process, the arcuate ligament structures need to be divided. D: After dilating through the psoas muscle and docking a lateral retractor over the L1–2 disc space, the left crus of the diaphragm is seen in the ventrolateral aspect of the vertebra (dotted lines). Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

The 12th rib is unique in that it is not as rigid as the other ribs and can be "floating." This mobility sometimes allows for dissection through the intercostal space without rib removal. Next, we use finger dissection to free the diaphragm in the caudal direction and enter the retroperitoneal space through the diaphragmatic fascia, which is the continuation of the transversalis fascia on the inferior surface of the diaphragm. The retroperitoneal space is then developed by blunt finger dissection, and the diaphragm is retracted anteriorly, allowing exposure of the psoas muscle and lateral surface of the spine (Fig. 6C). Typically, access at L1–2 is straightforward, but for T12–L1, the arcuate ligament attachments at L1 need to be divided from a lateral to medial direction. If additional ventral exposure of the vertebral body is necessary, we divide the crus at the ventrolateral portion of the vertebral body (Fig. 6D). Video 1 details the retrodiaphragmatic approach to the T12–L1 disc space.

Retropleural Approach

Typically, the T11–12 disc space or higher is approached exclusively within the thoracic cavity without requiring mobilization of the diaphragm.16 We make an incision and remove a 4- to 5-cm piece of the underlying rib. Typically, the endothoracic fascia is disrupted underneath the removed rib, exposing the pleura as well as the retropleural plane (Fig. 7A). Dissection then proceeds medially, with careful development of the retropleural plane and lysis of any adhesions between the pleura and endothoracic fascia. Having an assistant use a handheld retractor to medially retract the pleura is extremely helpful during the dissection (Fig. 7B). As the exposure extends medially, we encounter the rib head, which can be a marker for the pedicle in relation to the disc space (Fig. 7C). After we expose the lateral surface of the spine, we find where the endothoracic fascia eventually coalesces together with the prevertebral fascia, and we can divide this to expose the bony surface of the vertebrae.

FIG. 7.
FIG. 7.

Case example of the retropleural approach. A: An intraoperative photograph of a right-sided retropleural approach to T11–12. The 11th rib has been resected, opening a corridor through the endothoracic fascia (arrowhead), revealing the pleura (asterisk). The cut end of the 11th rib (double asterisk) is present posteriorly. B: During medial dissection, a handheld retractor is used to pull the pleura ventrally to define its interface (arrowheads) with the endothoracic fascia, and adhesions between the two can be lysed. C: After reaching the lateral surface of the spinal column, the endothoracic fascia coalesces into the rib head periosteum and the prevertebral fascia. The rib head (asterisk) can be used to orient the pedicle, which is immediately deep to the rib head, as well as the disc space, which will be just rostral. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Closure

Mobilization of the diaphragm and its associated attachments does not require direct surgical reapproximation. If the diaphragm muscle belly is incised or opened, a high-caliber suture, such as a 0 Vicryl suture, should be used to close the opening. Additionally, when working in the thoracic space, a chest tube is not needed unless the visceral pleura or lung parenchyma has been transgressed, leading to an air leak.

Conclusions

The extracoelomic approach was first described in 1925 by Fey17 to expose the kidney in urological procedures. In relation to the spine, Francioli18 described a combined abdominal and thoracic extracoelomic approach for sympathectomies in 1951. Subsequently, multiple descriptions of approaches to the TL junction have been circulated.4,16,1921 We sought to highlight crucial anatomical principles and organize a simple framework for surgeons to use when planning and executing a minimally invasive lateral TL junction approach.

The key anatomical concept is that the retroperitoneal space and the retropleural space are continuous compartments of the extracoelomic cavity, separated by the lateral attachments of the diaphragm to the 11th and 12th ribs and the L1 transverse process.3,4 In general, 3 different lateral approaches to the TL junction are available, depending on the level and regional anatomy. 1) For the T12–L2 disc space, the main operative corridor is within the retroperitoneal space. Access to the disc space can sometimes be performed through an oblique cranial approach undermining the 11th or 12th rib. 2) If access to the T12–L2 disc space is required but the rib cage overhang is significant, a retroperitoneal approach with additional mobilization of the diaphragm off its lateral attachments is needed. 3) If access to the T11–12 disc space is required, the approach is performed completely in the chest through a retropleural dissection. For pathologies that require intervention on multiple levels, or if greater exposure across multiple levels is needed, a combination of these techniques can be used.

By using this framework, most approaches to the TL junction can be achieved. However, in rare circumstances, other techniques such as transpleural, transperitoneal, or transdiaphragmatic approaches may be necessary in patients with significant spinal deformity or other anatomical constraints that do not permit the techniques described.

Acknowledgments

We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.

Disclosures

Cadavers and dissection equipment were provided by NuVasive. Dr. Turner and Dr. Uribe are consultants for NuVasive and Misonix.

Author Contributions

Conception and design: Uribe, Xu, Walker, Farber, Turner. Acquisition of data: Xu, Walker, Farber. Analysis and interpretation of data: Xu, Walker, Farber, Godzik. Drafting the article: Xu, Farber. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Statistical analysis: Uribe. Administrative/technical/material support: Uribe, Turner. Study supervision: Uribe, Turner.

Supplemental Information

References

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  • View in gallery

    Patient positioning. The patient is positioned with the approach side facing up and with the downside iliac crest resting at the level of the table break (white arrow). The legs and knees are bent as much as possible, and an axillary roll is placed. The patient is taped to the bed, and the table is broken at approximately 15° to elevate the ribs cranially.

  • View in gallery

    Anatomical layers of the abdominal and chest walls. A: Surgical illustration demonstrating the tissue layers of the anterolateral surface of the abdomen that are traversed during lateral approaches. B: Surgical illustration demonstrating the tissue layers of the anterolateral surface of the thorax that are traversed during lateral approaches. m., muscle; mm., muscles. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

  • View in gallery

    Structure of the diaphragm and its attachments. A: Cadaveric dissection of the left thoracic wall with a light shining in the thoracic cavity clearly denotes the junction of the thoracic cavity with the abdominal cavity demarcated by the diaphragm (double arrowhead). The parietal pleura lines the cranial surface of the diaphragm and is continuous with the diaphragm along its lateral border. The retroperitoneal space is seen through the division of the diaphragm with the peritoneal membrane (double asterisk). Because the diaphragm is concave toward the abdomen, the retroperitoneum can also be entered by detaching the diaphragm off the medial surface of the 11th and 12th ribs and reflecting it anteriorly. The interface between the diaphragm and a thin layer of endothoracic fascia (double arrowhead) is closely associated with the parietal pleura (asterisk). B: Cadaveric dissection of the left thoracic wall after removal of the 11th and 12th ribs. The diaphragm is retracted anteriorly, revealing the L1 transverse process attachment point of the medial and lateral arcuate ligament (asterisk). The cuff of muscle (black arrowhead) is the remnant of the medial arcuate ligament along its lateral attachment. The medial attachment of the medial arcuate ligament is marked (white arrowhead) at its attachment to the left crus. C: Medical illustration of the medial and lateral diaphragm attachments. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

  • View in gallery

    Illustration of coelomic and extracoelomic cavities seen through the lateral approach. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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    Case example of the retroperitoneal approach without diaphragm manipulation. A: Intraoperative photograph of the initial exposure for a standard lateral retroperitoneal approach. After skin incision, 2 blunt Kelly clamps are used to sequentially split and traverse through the lateral abdominal wall muscle fibers. The fibers of the external oblique (black arrowhead), internal oblique (white arrowhead), and transversus abdominis (double black arrowhead) muscles and the retroperitoneal fat (asterisk) are visible. B: An intraoperative anteroposterior radiograph shows a cranial oblique working angle underneath the rib cage to deposit a guidewire into the L1–2 disc space with a small dilator. C: After docking onto the disc space, the retractor can be pivoted cranially, pushing up the T12 rib and achieving a working corridor parallel to the disc space. Figure 5A used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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    Case example of the retrodiaphragmatic approach. A: An intraoperative image of a left-sided retrodiaphragmatic approach with the 11th rib exposed. B: After removal of the 11th rib, the diaphragm (asterisk) is visible in continuity with the pleura (double asterisk), with a clear border (single arrowhead). A thin layer of endothoracic fascia (double arrowhead) is seen overlying the pleura. C: After retraction of the diaphragm and peritoneum anteriorly, the lateral surface of the psoas muscle (double asterisk) is visible. Also visible is the L1 transverse process (asterisk) attachment point for the lateral (single arrowhead) and medial (double arrowhead) arcuate ligaments. The arrow demarcates the lateral portion of the lateral arcuate ligament at a more superficial depth. Note that to visualize cranial to the L1 transverse process, the arcuate ligament structures need to be divided. D: After dilating through the psoas muscle and docking a lateral retractor over the L1–2 disc space, the left crus of the diaphragm is seen in the ventrolateral aspect of the vertebra (dotted lines). Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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    Case example of the retropleural approach. A: An intraoperative photograph of a right-sided retropleural approach to T11–12. The 11th rib has been resected, opening a corridor through the endothoracic fascia (arrowhead), revealing the pleura (asterisk). The cut end of the 11th rib (double asterisk) is present posteriorly. B: During medial dissection, a handheld retractor is used to pull the pleura ventrally to define its interface (arrowheads) with the endothoracic fascia, and adhesions between the two can be lysed. C: After reaching the lateral surface of the spinal column, the endothoracic fascia coalesces into the rib head periosteum and the prevertebral fascia. The rib head (asterisk) can be used to orient the pedicle, which is immediately deep to the rib head, as well as the disc space, which will be just rostral. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

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