Authors of section

Authors (on behalf of the AOSpine Knowledge Forum Tumor)

Ilya Laufer, JJ Verlaan

General Editor

Luiz Vialle

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Minimally invasive lumbotomy in L2-L4

1. Approach

A left sided lumbotomy can be used to perform a decompression of levels L2-L4.

The left-sided approach is more common and therefore described below.

A right sided approach is in general possible, but very rarely used.

2. Incision site

The exact incision site will depend on the location of the involved level. The disc space L5/S1 cannot be reached with this approach.

A self-retaining retractor system is necessary to allow the exposure of the spine.

It is necessary to confirm the correct level of the approach with fluoroscopy.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

3. Application

The less invasive lumbotomy is ideal for plating. The less invasive retroperitoneal approach is excellent for vertebral body replacement.

4. Preparation

Under fluoroscopic control, the involved vertebra or injured disc and the adjacent segments are marked on the skin.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

If bisegmental stabilization is to be performed, the incision runs from the posterior edge of the lower end plate of the vertebral body above the involved level to the anterior edge of the upper endplate of the involved vertebra.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

If a monosegmental stabilization is to be performed, the incision runs from the midpoint of the posterior wall of the vertebral body above the involved level to the midpoint of the anterior wall of the vertebral body below the involved level.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The skin is incised on the mark.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

5. Exposure

There are three abdominal wall muscles. The first layer is the external abdominal oblique muscle, the second layer is the internal abdominal oblique muscle, and the third is the transverse abdominal muscle.

The subcutaneous tissue and the fascia of the obliquus externus muscle are dissected.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The first muscle layer is incised with cautery and retracted. The second layer is split and retracted.

The transversalis fascia is opened with caution to avoid injury to the peritoneum, which lies in the abdominal cavity.

A finger is used to split the muscle and detach it from the peritoneum to facilitate dissection.

The retroperitoneal fat is a good landmark to detect the retroperitoneal space.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

Pitfall: Injured peritoneum

If the peritoneum is injured, organs can be affected or postoperative herniation can occur.

If the peritoneum is violated, it is recommended that it be repaired directly with an absorbable suture and a blunt tapered needle.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The peritoneum must be shifted away from the lateral abdominal wall until the psoas muscle is exposed.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The psoas muscle is exposed to facilitate posterior retraction.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The psoas muscle is anteriorly released and retracted posteriorly towards the spinal canal to expose the spine.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

A self-retaining retractor system is necessary to allow the exposure of the spine.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

6. Further dissection

The segmental vessels above and below the involved vertebra can be isolated, ligated with sutures and clips, and divided.

Next, the segmental vessels over the involved vertebra can be isolated, ligated, and divided.

For anterior discectomies, these can be spared.

It is mandatory to have a table mounted retraction system to gently retract the psoas muscle, abdominal contents, and great vessels/sympathetic chain.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

7. Closure

A retroperitoneal drain is inserted.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)

The wound is then closed in layers.

For patients undergoing metastatic spine tumor surgery, intrawound vancomycin can be applied to decrease the risk of postoperative wound complications.

For patients undergoing revision metastatic spine tumor surgery, plastic surgery should perform the soft tissue reconstruction to decrease the risk of wound complications.

Thoracic and lumbar pathologies: Minimally invasive lumbotomy (L2-L4)