Surgical approaches to the brain and spinal cord

Surgical approaches to the brain and spinal cord

 * trepanation or drilling – the smallest approach
 * used for punctures (abscesses, cysts), puncture biopsy, evacuation chr. subdural
 * in an emergency, it can also be used diagnostically when epidural or acute subdural bleeding is suspected
 * a short incision is made on the skin, subcutaneous tissue and periosteum
 * drill by hand or with a power drill, the diameter of the hole is usually 10 mm
 * percutaneous tap – targeted point tap with a diameter of 2.5-3 mm for puncture and drainage of the ventricular system
 * also for stereotactic performances
 * osteoclastic trepanation(craniectomy) – by widening the hole with bone forceps (we will chip it into the surrounding area, ...)
 * usually during operations in the infratentorial space
 * supratentorially, it is mainly used in traumatology - in acute conditions (epidural or subdural evacuation), comminuted fractures of the calf, ...
 * it is fast
 * osteoplastic trepanation (craniotomy) – the most common method of access to the supratentorial space in planned procedures
 * the skin incision has the shape of a horseshoe and a pedicle with a vascular supply, we make holes and cut through the bone between them either – with a' Gigli saw or a craniotome
 * the most important thing is not to break the dura, we leave the periosteum on the bone (we fold it open like a book)
 * we close the wound by tilting the trepanation plate

Cranioplasty

 * a necessary consequence of osteoclastic trepanation is a bone defect
 * this does not matter during operations in the back of the cranial fossa, because it is covered by a thick layer of muscles
 * on the calf it is a problem (psychological as well - people are afraid of brain injury, ...), they have headaches from frequent fluctuations in pressure, ...
 * it needs to be solved sooner or later with cranioplasty
 * bone sources – rib, flat calf graft (from diploe division), tissue bank graft or synthetic material (acrylate resin)

Hard diaper closure

 * the suture must be waterproof, preferably with an atraumatic continuous suture absorbable material
 * defects are solved by suturing a graft - fascia lata, periosteum, temporal fascia or even muscle
 * with leaks, an epidural pseudocyst can develop and there is a risk of meningitis

Operative approaches to the spine

 * access from the dorsal side – this is where we operate spinal intradural and epidural processes,, lumbar disc herniations, some traumas
 * we remove the paravertebral muscles from the protrusions and arches to the minimum necessary extent, pull them away with a spreader
 * access can be unilateral or bilateral
 * transligamentous approach - via ligg. flava (interarcualia), e.g. for lumbar disc herniation
 * partial hemilaminectomy - we will bear next to ligg. still adjacent lat. edges of arches (lateral to proc. transversus)
 * foraminotomy – we will remove the bony structures of the dorsal wall of the foramen. intervertebrale (intervert. joint)
 * laminectomy – the widest access to the canal, we can bear proc. spinosus with a piece of arcus vertebrae
 * articular processes are preserved
 * for intradural tumor operations, decompression in degenerative canal stenosis, extraction of bone fragments in trauma, etc.
 * if we do not damage the intervertebral joints, the statics of the spine are not significantly disturbed
 * anterior approach – it is used mostly in the neck area, less often in the chest and lumbar region
 * on the cervical spine, this is how we operate on protrusions and osteophytes, extirpation of the meta in the body of the vertebra, in trauma
 * access is between the cervical neurovascular bundle (remains laterally) and trachea with esophagus (medially)

Related Articles

 * Craniocerebral trauma
 * Subdural hematoma *  Acute subdural hematoma *  Chronic subdural hematoma  * Epidural hematoma
 * Surgical instruments
 * Lumbar intervertebral disc herniation * Medulla spinalis