Table Of ContentWolfgang Seeger
Microsurgery of the
Spinal Cord and
Surrounding Structures
Anatomical
and Technical Principles
Springer-Verlag Wien NewY ork
~
Prof. Dr. med. WOLFGANG SEEGER
Medical Director of the Department of General Neurosurgery
and Chairman of Neurosurgery of the Neurosurgical Clinic,
University of Freiburg i. Br., Federal Republic of Germany
With 201 Figures
This work is subject to copyright
All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprint
ing, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data
banks
© 1982 by Springer-Verlag/Wien
Softcover reprint of the hardcover 18t edition 1982
Design: Hans Joachim Boning, Wien
Library of Congress Cataloging in Publication Data. Seeger, Wolfgang, 1929. Microsurgery of the spinal cord and surrounding
structures. Includes bibliographies. 1. Spinal cord-Surgery. 2. Microsurgery. I. Title. RD594.3.S43. 617'.482059.82-643.
ISBN 978-3-7091-3093-3 ISBN 978-3-7091-3091-9 (eBook)
DOI 10.1007/978-3-7091-3091-9
PREFACE ____________________________________________________
~ ~IV
Preface
Like the author's previous publications - "Atlas of the Department of Radiodiagnostics, University of
Topographical Anatomy of the Brain and Surround Freiburg; Prof. Dr. K. Kendel, Director of the Neu
ing Structures" (1978) and "Microsurgery of the rological Clinic, District Hospital Lahr, and his col
Brain" (1980) - this book is based on over ten league Dr. G. Reinshagen; Prof. Dr. J. Dichgans,
years' experience in microsurgery in addition to Director of the Department of General Neurology,
more than ten year's experience in the performance University of Tiibingen; and Prof. Dr. K. Voigt, Di
of macrosurgical operations in the region of the rector of the Department of Neuroradiology, Uni
spine and spinal cord. versity of Tiibingen, for undertaking a considerable
The author is indebted to Prof. G. Ya§argil for en amount of the diagnostic work in the clinical cases
couragement in carrying out intramedullary opera described in this book. Apart from a few excep
tions. Discussions with R. B. Cloward and study of tions, mentioned in the course of the book, myelo
his well-known publications provided important ini grams and recently also computertomograms in
tiatives in relation to the adoption of microsurgical cases of spinal disease were carried out mainly in
dimensions in ventral approaches to the craniospinal these departments. As in the previous volumes, the
junction and to the cervical spine, although the ac topographical anatomical examinations were sup
tual fusion procedures are - just as orthopaedic ported by Prof. Dr. J. Staubesand, Director of the
techniques - dealt with in this volume only very Anatomical Institute I, University of Freiburg, and
briefly. his colleague Dr. F. Platz, as well as by Prof. Dr. N.
In writing this volume, the author again received Bohm, acting Director of the Department of
the most important ideas from discussions with his General Pathology and Pathological Anatomy, Uni
own colleagues; particular thanks are due in this re versity of Freiburg, and his co-workers. The au
spect to Dr. J. Gilsbach and Dr. H.-R. Eggert, Dt. thor's thanks are also due to Mrs. Sheila Brink
B. Bohm, Dr. W. Hassler, and Dr. A. Harders. mann, Diisseldorf, for the translation and to Mrs.
Special thanks are also due to Dr. E. Grobner for Ermy Hilsenbek-Hottek for the typewritten manu
his careful perusal of both German and English script.
texts. The author is indebted to Prof. Dr. U. Tho Finally, particular thanks are also due to Springer
den, Acting Director of the Department of Clinical Verlag Wien/New York, not only for the pleasant
Neurology and Neurophysiology, University of co-operation but also, as with previous volumes, for
Freiburg; Doz. Dr. S. Bockenheimer, Department the willingness to provide for the generous lay-out.
of General Psychiatry with Outpatient Clinic, Uni
versity of Freiburg; Prof. Dr. W. Wenz, Director of Freiburg, March 1982 Wolfgang Seeger
CI= =======================::JI
CONTENTS VII
Contents
Introduction 1
Chapter 1
Operations on the Craniovertebral Junction (Figs. 1 to 32)
Dorsal Approach (Figs. 1 to 9) 2
Ventral (Transoral) Approach (Figs. 10 to 17) 20
Ventrolateral (Para- and Retropharyngeal) Approach (Figs. 18 to 32) 36
Chapter 2
Operations on the Cervical Spine (Figs. 33 to 108)
Dorsal Approach (Figs. 33 to 52) 66
Ventral Approach (Figs. 53 to 93) 106
Ventrolateral Approach in Region of Scalenus Gap and Cervical Pleura (Figs. 94 to 108) 188
Chapter 3
Operations on the Thoracic Spine (Figs. 109 to 148)
Dorsal Approach (Figs. 109 to 135) 218
Ventral (Transpleural) Approach to Thoracic Spine (Figs. 136 to 142) 272
Lateral Approach to Thoracic Spine (Modified Costotransversectomy) (Figs. 143 to 148) 286
Chapter 4
Operations in the Lumbar and Lumbosacral Regions (Figs. 149 to 193)
Dorsal Approach (Figs. 149 to 160) 298
Dorsolateral Approach (Intervertebral Disc Operations) (Figs. 161 to 193) 322
Chapter 5
Appendix (Figs. 194 to 201) 388
References 405
Subject Index 409
1r-----------------------------------------------~IINTRODUCTION
Introduction
Operative interventions on the spinal cord and its eration is a precise diagnosis, and in the cases pre
nerve roots, and operations on nerves and vascular sented the usual diagnostic procedures were used.
structures in the vicinity of the spinal cord can, like During the period of the preparation of this book
operations on the brain, be performed microsurgi computertomography of the spinal column played
cally almost without exception. At present, how an increasing role. Since this could not be suffi
ever, this is still not generally agreed. The most fre ciently allowed for in the case presentations, some
cr
quently performed spinal operation by neurosur typical sections showing some possible sources
geons, the operation for prolapsed lumbar interver of error have been included at the end of the book.
tebral disk, is still usually carried out macrosurgical One special diagnostic point is the localization of
ly. the segment level of the process to be operated on
A warning should be given against the performance immediately before the start of the operation on the
of microsurgical interventions of any kind if there is operating table. The conventional method of deter
no provision for continuity in the wider microsurgi mining the correct level by palpation of the spinous
cal experience of an individual neurosurgeon. As is processes is wrong in principle, since the level of the
the case in brain surgery there are two principles: tip of the spinous process and the aimed-for level of
the instrumental technique including the handling the vertebral body (to which the process demon
of the microscope is different from conventional strated in the myelogram is usually related) are only
techniques and must be constantly practised. sufficiently accurately in line in certain parts of the
the occasionally heard argument, that the visual spinal column. Depending on the segment localiza
field under the microscope is inadequate, is not tion, various procedures had to be developed in or
correct. The lighting is better, and the visualiza der to avoid carrying out unnecessarily extensive
tion of the operative field exposed in depth is not laminectomies or hemilaminectomies, and thus pre
more restricted than with conventional operative vent subsequent disturbances of static function which
techniques. Inadequate knowledge of the topo might otherwise complicate the further course. Op
graphical anatomy can, however, have a more erations in the region of the spinal ganglia are not
serious effect here than with conventional described, since these are rarely performed and the
methods. author has little experience of them.
As in the previous volume special topographical The empirical material on which this work is based
anatomical features are given particular prominence, originates from the Neurochirurgische Klinik der
usually with the help of anatomical models of Universitat Freiburg, with the exception of one spe
operative procedures. These both elucidate the cially mentioned case in which the author carried
principles of the operation and also depict neigh out the operation during his time as Resident at the
bouring structures not visible at the operation site Neurochirurgische Klinik der Universitat Giessen.
itself, either initially or during the subsequent Unless otherwise stated the operations described in
course of the operation. Structures normally de this book were carried out by the author. Opera
picted in a simplified manner in conventional text tions shown without reference to a case of disease
books and other publications have been described in are typical routine operations in which morphology
particular detail, e. g. those encountered in the ven and operative techniques vary only to a small ex
tral approach routes to the craniospinal junction tent, e. g. intervertebral disc operations. In these
and the cervical spine, or in rarely performed oper cases, however, variants and possible errors are pre
ations, such as costotransversectomy or the trans sented in particular detail. As in the earlier books
thoracic approach to the vertebral column. all illustrations were executed by the author with
The precondition for an accurate microsurgical op- Indian ink.
FIG. 1 rl- -----------------------------, 2
Chapter 1
Operations on the Craniovertebral Junction
(Figs. 1 to 32)
A' The same angiogram from ap. The
angioma is lateralized to the right.
Comparison with A indicates that the
angioma forms a semicircular cuff around
the transitional zone Medulla oblongata -
Medulla spinalis, or is lying intraspinally
A" The same angiogram from basal direction.
Feeding arteries from right A. vertebralis
can here be better recognized than in
A and A'
Band B' X-ray and angiograms indicate that a
craniocaudal extension approximately
60 mm long will have to be made to
expose the craniovertebral junction. Skin
and soft tissues at the nape of the neck
must be further opened caudally and
Dorsal approach (Figs. 1 to 9)
cranially in order to accomodate the
width of the opened retractors. At the
Fig. 1. Clinical example of an AVM caudal to the
craniovertebral junction a long skin
obex. Subarachnoid hemorrhage four weeks before
incision must be made Gorresponding to
operation, coma lasting three days followed by
the very wide exposure, to allow the
transitory left hemihypesthesia. No postoperative
soft tissues of the neck to be retracted
deficits
with as little pressure as possible (other
A- A" Preoperative findings
wise there is danger of soft tissue
B - B' Opening of soft tissues
necrosis and postoperative CSF fistula,
A Lateral angiogram of right A. cubitalis
particularly after lengthy operation)
showing the angioma fed by A. verte
bralis and its branches and projecting
Abbreviations:
into Foramen occipitale and the upper
sections of spinal canal as far as ventral c1 A. carotis into
border of spinal canal v 1 A. vertebralis
31 =====----
1..1.,0,11130 - 46
op.10/27-76
angiogram ® to 'it-
10 115 -76 I.!:Y
R
retrador
l=el l:bJ th+ o2fa sk 'I n .I ncision
o=p e2n al. ng meas ure of retractor
retractor
Vertebra .
( Processpro'!llOens
. spln.VIIl
FIG. 2 L...I _____________________________ 14
---1
Fig. 2
A Laminectomy, overview, and presentation of
anatomical model. Topographical relations
between Fossa condyloidea (richly vascularized),
capsule of the atlanto-occipital and atlanto
axial joint, and dura
B Microsurgical site corresponding to anatomical
exposure in A with opened dura
'--======================================:::11 FIG. 2
51_
ticul. atlantepistr.
(atlantoaxialis) lat.
see microsurgical tOP()Jraphy
®
10 m m
retraction of Tonsilla cerebelli
Fossa condyloidea
