The skin and subcutaneous tissue is infiltrated with a 1:500,000 epinephrine solution to achieve hemostasis.
Two parallel skin incisions are made proximally 2.5 cm lateral to the midline at the level of L4-S1.
Alternatively, a vertical incision is made midline over the spinus processes of L4-S1.
Intramuscular plane must be developed between the multifidus and the longissimus using blunt dissection.
As the plane is developed, one palpates medially the facets while continuing to dissect lateral to them all the way down to the transverse process.
Self-retaining retractors are placed allowing visualization of the part articularis medially and the transverse process laterally.
Distally, dissection is taken down onto the sacral ala. At the S1 level the iliac crest tends to be on the superficial lateral aspect of the approach, allowing for bone graft harvesting if required.
Drains are usually inserted via a separate stab incision.
Once the surgical fixation and decompression have been performed, tight closure of the muscle and fascial layer is performed with continuous or interrupted sutures.
The subcutaneous layers and skin are sutured