Surgical approaches to the brain and spinal cord

From WikiLectures

Surgical approaches to the brain and spinal cord[edit | edit source]

  • 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
Trepanated skull, Bronze Age
  • 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
    • supratentorial, 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
Craniotomy, whitish dura mater and arachnoid visible
Gigli's saw used in craniotomy

Cranioplasty[edit | edit source]

  • 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[edit | edit source]

  • 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[edit | edit source]

  • 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)

Links[edit | edit source]

Related Articles[edit | edit source]

Resources[edit | edit source]

BENEŠ, Jiří. Studijní materiály [online]. [cit. 2009]. <>.

References[edit | edit source]

  • ZEMAN, Miroslav. Speciální chirurgie. 2. edition. Galén, 2004. 575 pp. ISBN 80-7262-260-9.