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Wendt K, Nau C, Jug M, Pape HC, Kdolsky R, Thomas S, Bloemers F, Komadina R. ESTES recommendation on thoracolumbar spine fractures : January 2023. Eur J Trauma Emerg Surg 2023:10.1007/s00068-023-02247-3. [PMID: 37052627 DOI: 10.1007/s00068-023-02247-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 02/08/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Klaus Wendt
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Christoph Nau
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Marko Jug
- University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | | | - Richard Kdolsky
- University Clinic for Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Frank Bloemers
- Amsterdam University Medical Centre, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Radko Komadina
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
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Kwon H, Park JY. The Role and Future of Endoscopic Spine Surgery: A Narrative Review. Neurospine 2023; 20:43-55. [PMID: 37016853 PMCID: PMC10080412 DOI: 10.14245/ns.2346236.118] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
Many types of surgeries are changing from conventional to minimally invasive techniques. Techniques in spine surgery have also changed, with endoscopic spine surgery (ESS) becoming a major surgical technique. Although ESS has advantages such as less soft tissue dissection and normal structure damage, reduced blood loss, less epidural scarring, reduced hospital stay, and earlier functional recovery, it is not possible to replace all spine surgery techniques with ESS. ESS was first used for discectomy in the lumbar spine, but the range of ESS has expanded to cover the entire spine, including the cervical and thoracic spine. With improvements in ESS instruments (optics, endoscope, endoscopic drill and shaver, irrigation pump, and multiportal endoscopic), limitations of ESS have gradually decreased, and it is possible to apply ESS to more spine pathologies. ESS currently incorporates new technologies, such as navigation, augmented and virtual reality, robotics, and 3-dimentional and ultraresolution visualization, to innovate and improve outcomes. In this article, we review the history and current status of ESS, and discuss future goals and possibilities for ESS through comparisons with conventional surgical techniques.
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Affiliation(s)
- Hyungjoo Kwon
- Department of Neurosurgery, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Nakanishi K, Uchino K, Watanabe S, Hayashi N, Iba H, Hasegawa T. Video-Assisted Thoracoscopic Surgery for Re-Collapse of Vertebrae after Percutaneous Vertebral Augmentation (PVA). Spine Surg Relat Res 2020; 5:28-33. [PMID: 33575492 PMCID: PMC7870326 DOI: 10.22603/ssrr.2020-0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 05/27/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Due to the increase in osteoporosis accompanying the aging society in Japan, osteoporotic vertebral fractures (OVFs) are increasing. Percutaneous vertebral augmentation (PVA) has been widely used for OVFs because it reduces pain immediately with less invasiveness. Re-collapse of vertebral body after PVA is a rare, but important, complication. Once the re-collapse has occurred, patients should undergo an additional invasive salvage surgery. METHODS We treated 5 patients with re-collapse after PVA in our hospital. For re-collapse after PVA, we performed anterior column reconstruction with video-assisted thoracoscopic surgery (VATS), posterior fixation with percutaneous pedicle screws (PPSs) and minimally invasive spine stabilization (MISt). RESULTS The mean postoperative follow-up was at 62.8 months. At the final follow-up, the patients were free of low back pain, and bony union was achieved in all cases. The postoperative correction loss was 6 degrees. Perioperative complications included aspiration pneumonia in one patient and bone fracture of an adjacent vertebral body in two patients. There were no reoperation cases. CONCLUSIONS We perform minimally invasive combined anterior and posterior surgery with VATS for re-collapse after PVA. This procedure is useful in elderly patients with less reserve capacity.
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Affiliation(s)
- Kazuo Nakanishi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Kazuya Uchino
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Seiya Watanabe
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Norito Hayashi
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Iba
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
| | - Toru Hasegawa
- Department of Orthopedics, Traumatology and Spine Surgery, Kawasaki Medical School, Okayama, Japan
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Zidan I, Khedr W, Fayed AA, Farhoud A. Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome. J Korean Neurosurg Soc 2018; 62:61-70. [PMID: 30486621 PMCID: PMC6328794 DOI: 10.3340/jkns.2017.0271] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 03/21/2018] [Indexed: 11/27/2022] Open
Abstract
Objective Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy.
Methods Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months.
Results The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected.
Conclusion The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior load-bearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.
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Affiliation(s)
- Ihab Zidan
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Wael Khedr
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Abdelaziz Fayed
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Farhoud
- Department of Neurosurgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Minimally Invasive Endoscopic Approach to the Cervicothoracic Junction for Vertebral Osteomyelitis. Case Rep Orthop 2018; 2017:2495041. [PMID: 29375921 PMCID: PMC5742434 DOI: 10.1155/2017/2495041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 10/17/2017] [Accepted: 10/17/2017] [Indexed: 11/17/2022] Open
Abstract
The selection of an anterior, lateral, or posterior approach to the cervicothoracic junction for surgical treatment of vertebral osteomyelitis is still a matter of debate. These ordinary approaches generally require an extensile exposure. This article describes a less invasive approach case of a vertebral osteomyelitis of T2/3 using a video-assisted operating technique of thoracic surgery (VATS). A 78-year-old female underwent anterior debridement and interbody fusion with bone graft at T2/3 using a lateral surgical approach through a right thoracotomy with VATS. The VATS through two small skin incisions in the axillary region provides a good view without requiring elevation of the scapula with extensile muscle dissection and rib resection. There was no complication without partial lobectomy due to pleural adhesion during the perioperative period. Currently, at 1 year after operation, the patient has no back pain with neurologically normal findings and no inflammation findings (CRP was 0.01 mg/dl). Although the operating field of the upper thoracic level in the lateral approach is generally deep and narrow, the VATS provides a good view and allows us to perform adequate debridement and bone fusion at the T2/3 level with a less invasive approach than those previously described anterior or laterally or posterior approach.
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Viezens L, Reer P, Strahl A, Weiser L, Schroeder M, Beyerlein J, Schaefer C. Safety and Efficacy of Single-Stage versus 2-Stage Spinal Fusion via Posterior Instrumentation and Anterior Thoracoscopy: A Retrospective Matched-Pair Cohort Study with 247 Consecutive Patients. World Neurosurg 2017; 109:e739-e747. [PMID: 29079258 DOI: 10.1016/j.wneu.2017.10.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Posterior-anterior spondylodesis is often used to stabilize the spine in various pathologies. The anterior procedure is often performed via thoracoscopy. It is unclear whether the anterior procedure should be performed immediately after posterior instrumentation or after the patient has convalesced. This retrospective study compared perioperative safety and morbidity in 1-stage versus 2-stage posterior-anterior fusion surgery with a thoracoscopic anterior approach. METHODS All consecutive patients who underwent surgery for posterior-anterior spinal stabilization from 2006 to 2013 were included. American Society of Anesthesiologists score, preoperative and postoperative laboratory values, operation duration, blood loss, intensive care unit stay, pain, postoperative hospital stay, perioperative complications, and preoperative and postoperative Eastern Cooperative Oncology Group and Frankel scores were assessed. A subset of the cohort was selected by propensity score matching to eliminate possible selection bias. RESULTS There were 247 patients who underwent 1-stage (n = 104) or 2-stage (n = 143) stabilization with thoracoscopic fusion. Spinal pathologies were fracture, malignancy, pyogenic spondylodiscitis, degenerative spinal disorders, and failed previous surgery. One-stage and 2-stage procedures were similar in terms of preoperative, surgical, and postoperative variables, including complication rates, except that the 1-stage procedure was associated with greater pain 2 days after surgery and shorter hospital stay. The propensity score-matched cohort of 64 pairs yielded similar results with only 1-stage patients showing elevated visual analog scale score on postoperative day 2 (3.8 vs. 2.4, P = 0.043). CONCLUSIONS One-stage stabilization was as safe as 2-stage stabilization and associated with shorter hospitalization. Greater pain after the 1-stage procedure, which resolved 30 days after surgery, reflects the fact that 2-stage patients already had pain relief when they underwent thoracoscopy.
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Affiliation(s)
- Lennart Viezens
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma, Hand, and Reconstructive Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Trauma, Orthopaedic, and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany.
| | - Phillip Reer
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Strahl
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Weiser
- Department of Trauma, Orthopaedic, and Plastic Surgery, University Medical Center Goettingen, Goettingen, Germany
| | - Malte Schroeder
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Spine Surgery, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
| | - Joerg Beyerlein
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Spine Surgery, Albertinen Hospital Hamburg, Hamburg, Germany
| | - Christian Schaefer
- Department of Orthopaedics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Spine Surgery, Klinikum Bad Bramstedt, Bad Bramstedt, Germany
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Kalra RRS, Schmidt MH. The Role of a Miniopen Thoracoscopic-assisted Approach in the Management of Burst Fractures Involving the Thoracolumbar Junction. Neurosurg Clin N Am 2017; 28:139-145. [PMID: 27886875 DOI: 10.1016/j.nec.2016.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Thoracoscopic spinal surgery is a minimally invasive open endoscopic approach to the anterior thoracolumbar spine for decompression and stabilization. It offers an alternative to open thoracotomy for thoracolumbar burst fractures, anterior spinal cord decompression, and spinal reconstruction with interbody and anterolateral plate instrumentation for restoration of biomechanical stability and alignment. Posterior instrumentation may not sufficiently stabilize a significantly disrupted anterior load-bearing spinal column, and the high access morbidity of open procedures is of significant concern. The adoption by spine surgeons of minimally invasive thoracoscopic techniques used by thoracic surgeons has expanded to include treatment of most anterior thoracolumbar disorders.
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Affiliation(s)
- Ricky Raj S Kalra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA.
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Mobbs RJ, Phan K. History of Retractor Technologies for Percutaneous Pedicle Screw Fixation Systems. Orthop Surg 2017; 8:3-10. [PMID: 27028375 DOI: 10.1111/os.12216] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 11/30/2015] [Indexed: 01/07/2023] Open
Abstract
Minimally invasive techniques aimed at minimizing surgery-associated risk and morbidity of spinal surgery have increased in popularity in recent years. Their potential advantages include reduced length of hospital stay, blood loss, and requirement for post-operative analgesia and earlier return to work. One such minimally invasive technique is the use of percutaneous pedicle screw fixation, which is paramount for promoting rigid and stable constructs and fusion in the context of trauma, tumors, deformity and degenerative disease. Percutaneous pedicle screw insertion can be an intimidating prospect for surgeons who have only been trained in open techniques. One of the ongoing challenges of this percutaneous system is to provide the surgeon with adequate access to the pedicle entry anatomy and adequate tactile or visual feedback concerning the position and anatomy of the rod and set-screw construct. This review article discusses the history and evolution of percutaneous pedicle screw retractor technologies and outlines the advances over the last decade in the rapidly expanding field of minimal access surgery for posterior pedicle screw based spinal stabilization. As indications for percutaneous pedicle screw techniques expand, the nuances of the minimally invasive surgery techniques and associated technologies will also multiply. It is important that experienced surgeons have access to tools that can improve access with a greater degree of ease, simplicity and safety. We here discuss the technical challenges of percutaneous pedicle screw retractor technologies and a variety of systems with a focus on the pros and cons of various retractor systems.
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Affiliation(s)
- Ralph J Mobbs
- NeuroSpine Surgery Research Group, Sydney, Australia.,NeuroSpine Clinic, Prince of Wales Private Hospital, Sydney, Australia.,Department of Neurosurgery, University of New South Wales (UNSW), Randwick, Australia
| | - Kevin Phan
- NeuroSpine Surgery Research Group, Sydney, Australia.,NeuroSpine Clinic, Prince of Wales Private Hospital, Sydney, Australia.,Department of Neurosurgery, University of New South Wales (UNSW), Randwick, Australia
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Abstract
Thoracolumbar spine fractures are common injuries that can result in significant disability, deformity and neurological deficit. Controversies exist regarding the appropriate radiological investigations, the indications for surgical management and the timing, approach and type of surgery. This review provides an overview of the epidemiology, biomechanical principles, radiological and clinical evaluation, classification and management principles. Literature review of all relevant articles published in PubMed covering thoracolumbar spine fractures with or without neurologic deficit was performed. The search terms used were thoracolumbar, thoracic, lumbar, fracture, trauma and management. All relevant articles and abstracts covering thoracolumbar spine fractures with and without neurologic deficit were reviewed. Biomechanically the thoracolumbar spine is predisposed to a higher incidence of spinal injuries. Computed tomography provides adequate bony detail for assessing spinal stability while magnetic resonance imaging shows injuries to soft tissues (posterior ligamentous complex [PLC]) and neurological structures. Different classification systems exist and the most recent is the AO spine knowledge forum classification of thoracolumbar trauma. Treatment includes both nonoperative and operative methods and selected based on the degree of bony injury, neurological involvement, presence of associated injuries and the integrity of the PLC. Significant advances in imaging have helped in the better understanding of thoracolumbar fractures, including information on canal morphology and injury to soft tissue structures. The ideal classification that is simple, comprehensive and guides management is still elusive. Involvement of three columns, progressive neurological deficit, significant kyphosis and canal compromise with neurological deficit are accepted indications for surgical stabilization through anterior, posterior or combined approaches.
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Affiliation(s)
- S Rajasekaran
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India,Address for correspondence: Dr. S. Rajasekaran, Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, 313, Mettupalayam Road, Coimbatore - 641 043, Tamil Nadu, India. E-mail:
| | - Rishi Mugesh Kanna
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Ajoy Prasad Shetty
- Department of Orthopaedics, Traumatology and Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Joaquim AF, Patel AA. Thoracolumbar spine trauma: Evaluation and surgical decision-making. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2014; 4:3-9. [PMID: 24381449 PMCID: PMC3872658 DOI: 10.4103/0974-8237.121616] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction: Thoracolumbar spine trauma is the most common site of spinal cord injury, with clinical and epidemiological importance. Materials and Methods: We performed a comprehensive literature review on the management and treatment of TLST. Results: Currently, computed tomography is frequently used as the primary diagnostic test in TLST, with magnetic resonance imaging used in addition to assess disc, ligamentous, and neurological injury. The Thoracolumbar Injury Classification System is a new injury severity score created to help the decision-making process between conservative versus surgical treatment. When decision for surgery is made, early procedures are feasible, safe, can improve outcomes, and reduce healthcare costs. Surgical treatment is individualized based on the injury characteristics and surgeon's experience, as there is no evidence-based for the superiority of one technique over the other. Conclusions: The correct management of TLST involves multiple steps, such as a precise diagnosis, classification, and treatment. The TLICS can improve care and communication between spine surgeons, resulting in a more standardized treatment.
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Affiliation(s)
- Andrei F Joaquim
- Department of Neurology, State University of Campinas, Campinas, Sao Paulo, Brazil
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Northwestern University, Chicago, Illinois, USA
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König MA, Milz S, Bayley E, Boszczyk BM. The direct anterior approach to the thoracolumbar junction: an anatomical feasibility study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:2265-71. [PMID: 24633718 DOI: 10.1007/s00586-014-3255-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 02/18/2014] [Accepted: 02/18/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION The thoracolumbar junction (TJ) is traditionally exposed by lateral or posterior approaches. This usually requires splitting of the diaphragm, or extensile removal of the posterior elements. A circumferential exposure (i.e. simultaneous anterior and bilateral exposure) of the vertebral body is not possible. Direct anterior access would allow circumferential exposure of the vertebral body, with adjacent disc levels, and would avoid splitting the diaphragm or extensive removal of the posterior bony structures. MATERIALS AND METHODS Twelve Thiel cadavers (8 f/4 m) were dissected to access T12 or L1 via a midline laparotomy. Supra- and infragastric laparatomy techniques were investigated. Six cadavers were used to reach T12 through the lesser omentum, six to reach L1 through the greater omentum. RESULTS T12 after bluntly dissecting the lesser omentum, the lesser gastric curvature and the caudate lobe of the liver were utilised as landmarks. A small retroperitoneal incision was performed to mobilise the aorta allowing exposure of the T12 vertebra and its adjacent discs. Discectomy, corpectomy and insertion of an anterior column support were possible. The L1 level can be reached through the greater omentum by mobilising the pancreas as a single retroperitoneal structure, leaving the aorta and celiac trunk as landmarks. Retraction of the great vessels is necessary to expose L1 with its adjacent discs. Implantation of an anterior column support was possible utilising this approach. CONCLUSION Direct anterior access to the TJ is feasible in a reproducible manner. This approach would avoid splitting the diaphragm, or dissection of the erector spinae muscles, and is likely to be less invasive than standard lateral or posterior approaches. This technique may offer a significant time reduction to surgery, especially in exposing the spine. Anterior column support can easily be performed, offering a better avoidance of kyphotic deformities.
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Affiliation(s)
- M A König
- The Centre for Spinal Studies and Surgery, Queens Medical Centre Campus, Nottingham University Hospitals, NHS Trust, Derby Road, Nottingham, NG7 2UH, UK,
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12
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Barbagallo GMV, Piccini M, Gasbarrini A, Milone P, Albanese V. Subphrenic hematoma after thoracoscopic discectomy: description of a very rare adverse event and review of the literature on complications. J Neurosurg Spine 2013; 19:436-44. [DOI: 10.3171/2013.7.spine13193] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a very rare and previously unreported complication of thoracoscopic discectomy. Endoscopic spine surgery has evolved as a safe and effective treatment, and thoracoscopic discectomy, in particular, provides several advantages over open approaches, although it can be associated with intraoperative or postoperative complications. The most frequently observed adverse events are intercostal neuralgia, retained disc fragments, durotomies, atelectasis, extensive bleeding, and emergency conversion to open thoracotomy for vascular injuries. Even rare complications, such as chylorrhea or brain hemorrhagic infarction, have been reported. Nonetheless, a literature review did not reveal any case of postoperative intraabdominal hematoma following thoracoscopic discectomy. A 43-year-old woman, with no history of hematological or vascular disorders or thoracic surgery, underwent a right-sided thoracoscopic discectomy for T11–12 disc herniation. No apparent surgical technique–related complications were encountered, but intermittently repeated difficulties with single-lung ventilation occurred. The resultant dysventilation allowed partial right lung reexpansion, along with increased abdominal pressure. The latter induced an upward ballooning of the right diaphragm with consequent obstruction of the surgical field of view, requiring constant and continuous pressure applied to the thoracic surface of the diaphragm via a metal fan retractor and thus counteracting the increased abdominal pressure. Postoperatively, a large subdiaphragmatic hematoma originating from a bleeding right inferior phrenic artery was diagnosed and required urgent endovascular occlusion. The patient made an uneventful recovery with conservative treatment. A very rare and previously unreported complication—that is, early subdiaphragmatic hematoma after thoracoscopic discectomy—is described here. The authors submit that conversion to an open approach is safer when persistent anesthesia-related complications are encountered in thoracoscopic discectomy.
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Affiliation(s)
- Giuseppe M. V. Barbagallo
- 1Neurosurgery and Radiology Departments, Policlinico “G. Rodolico” University Hospital, Catania; and
| | - Mario Piccini
- 1Neurosurgery and Radiology Departments, Policlinico “G. Rodolico” University Hospital, Catania; and
| | | | - Pietro Milone
- 1Neurosurgery and Radiology Departments, Policlinico “G. Rodolico” University Hospital, Catania; and
| | - Vincenzo Albanese
- 1Neurosurgery and Radiology Departments, Policlinico “G. Rodolico” University Hospital, Catania; and
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Pizanis A, Holstein JH, Vossen F, Burkhardt M, Pohlemann T. Compression and contact area of anterior strut grafts in spinal instrumentation: a biomechanical study. BMC Musculoskelet Disord 2013; 14:254. [PMID: 23971712 PMCID: PMC3766234 DOI: 10.1186/1471-2474-14-254] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Accepted: 08/21/2013] [Indexed: 11/18/2022] Open
Abstract
Background Anterior bone grafts are used as struts to reconstruct the anterior column of the spine in kyphosis or following injury. An incomplete fusion can lead to later correction losses and compromise further healing. Despite the different stabilizing techniques that have evolved, from posterior or anterior fixating implants to combined anterior/posterior instrumentation, graft pseudarthrosis rates remain an important concern. Furthermore, the need for additional anterior implant fixation is still controversial. In this bench-top study, we focused on the graft-bone interface under various conditions, using two simulated spinal injury models and common surgical fixation techniques to investigate the effect of implant-mediated compression and contact on the anterior graft. Methods Calf spines were stabilised with posterior internal fixators. The wooden blocks as substitutes for strut grafts were impacted using a “pressfit” technique and pressure-sensitive films placed at the interface between the vertebral bone and the graft to record the compression force and the contact area with various stabilization techniques. Compression was achieved either with posterior internal fixator alone or with an additional anterior implant. The importance of concomitant ligament damage was also considered using two simulated injury models: pure compression Magerl/AO fracture type A or rotation/translation fracture type C models. Results In type A injury models, 1 mm-oversized grafts for impaction grafting provided good compression and fair contact areas that were both markedly increased by the use of additional compressing anterior rods or by shortening the posterior fixator construct. Anterior instrumentation by itself had similar effects. For type C injuries, dramatic differences were observed between the techniques, as there was a net decrease in compression and an inadequate contact on the graft occurred in this model. Under these circumstances, both compression and the contact area on graft could only be maintained at high levels with the use of additional anterior rods. Conclusions Under experimental conditions, we observed that ligamentous injury following type C fracture has a negative influence on the compression and contact area of anterior interbody bone grafts when only an internal fixator is used for stabilization. Because of the loss of tension banding effects in type C injuries, an additional anterior compressing implant can be beneficial to restore both compression to and contact on the strut graft.
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Affiliation(s)
- Antonius Pizanis
- Department for Trauma-, Hand- and Reconstructive Surgery, University Medical Centre of the Saarland, Homburg, Saar, D 66421, Germany.
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Pneumaticos SG, Triantafyllopoulos GK, Giannoudis PV. Advances made in the treatment of thoracolumbar fractures: current trends and future directions. Injury 2013; 44:703-12. [PMID: 23287553 DOI: 10.1016/j.injury.2012.12.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/03/2012] [Indexed: 02/02/2023]
Abstract
Thoracolumbar fractures are common injuries after blunt trauma and are accompanied with significant morbidity, including neurologic deficit. Parallel to the evolution of initial management during the past few years, efforts have been concentrated on determining clear indications for surgical treatment, as there is no agreement over superiority of conservative or operative treatment. Various classification systems have been used for identifying those injuries requiring surgical intervention. Moreover, novel trends in surgical techniques, including minimal invasive surgery, implants and rehabilitation protocols have provided new, promising aspects regarding the treatment and outcomes of thoracolumbar fractures. The present review focuses on these recent advances.
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Affiliation(s)
- Spyros G Pneumaticos
- Academic Department of Trauma and Orthopaedics, School of Medicine, University of Athens, Greece.
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Beisse R, Verdú-López F. [Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 1: general aspects and treatment of fractures]. Neurocirugia (Astur) 2013; 25:8-19. [PMID: 23578820 DOI: 10.1016/j.neucir.2013.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has greatly evolved since it appeared less than 20 years ago. Nowadays, it is indicated in a large number of processes and injuries. The aim of this article, in its 2 parts, is to review the current status of VATS in treatment of the thoracic and lumbar spine in its entire spectrum. DEVELOPMENT After reviewing the current literature, we develop each of the large groups of indications where VATS is used, one by one. This first part contains a description of general thoracoscopic surgical technique including the necessary prerequisites, transdiaphragmatic approach, techniques and instrumentation used in spine reconstruction, as well as a review of treatment and specific techniques in the management of spinal fractures. CONCLUSIONS Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of fractures and deformities, as well as the reconstruction of injured spinal segments and decompression of the spinal canal in any etiological processes if the lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by the growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in morbidity of the approach and subsequent patient recovery.
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Affiliation(s)
- Rudolf Beisse
- Wirbelsäulenzentrum Starnberger See Benedictus Krankenhaus, Tutzing, Alemania
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Fang T, Dong J, Zhou X, McGuire RA, Li X. Comparison of mini-open anterior corpectomy and posterior total en bloc spondylectomy for solitary metastases of the thoracolumbar spine. J Neurosurg Spine 2012; 17:271-9. [PMID: 22881038 DOI: 10.3171/2012.7.spine111086] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The object of this study was to compare the mini-open anterior corpectomy procedure with posterior total en bloc spondylectomy (TES) in treating patients with solitary metastases of the thoracolumbar spine.
Methods
From 2004 to 2010, 41 patients with solitary metastases of the thoracolumbar spine were treated in our hospital using either a mini-open anterior corpectomy or posterior TES. Intraoperative and diagnostic data, including perioperative complications, were collected using retrospective chart review. The surgical outcomes were assessed according to survival status, neurological function, local recurrence, and pain before and after surgery.
Results
Seventeen patients underwent posterior TES and 24 underwent mini-open anterior corpectomy. Mean blood loss (TES, 1721 ± 293 ml; mini-open corpectomy, 1058 ± 263 ml; p < 0.05), and mean operative time (TES, 403 ± 55 minutes; mini-open corpectomy, 175 ± 38 minutes; p < 0.05) were recorded and calculated. Neurological improvement by at least 1 American Spinal Injury Association Impairment Scale grade was noted in 35 (97.2%) of the 36 cases with preoperative deficits. After the operation, 68.4% of nonambulatory patients became ambulatory again, including 84.6% after mini-open corpectomy and 33.3% after posterior TES (p > 0.05). The visual analog scale scores of the patients were significantly reduced after both procedures, with no difference between the procedures (p > 0.05). The local tumor recurrence rate of the TES group was significantly lower than that of the mini-open corpectomy group (p < 0.05), while the postoperative survival rates within 2 years after surgery were similar. The complication rate in the mini-open corpectomy group (29.2%) was higher than that in the TES group (11.8%), but this difference was not statistically significant (p = 0.185). There was no hardware failure and no loss of the sagittal Cobb angle in either group. Slight subsidence (< 3 mm) of the mesh cage was observed with a successful fusion in 3 (17.6%) of 17 patients in the TES group. No subsidence of polymethylmethacrylate block/autograft was recorded in the mini-open group.
Conclusions
Mini-open anterior corpectomy can be accomplished with less blood loss, fewer fixation instrumentations, and shorter surgical time than that required for TES, but patients who undergo a mini-open corpectomy might have a greater tendency to experience local recurrence. A mini-open anterior corpectomy has a relatively mild learning curve and involves fewer technical difficulties. With smaller incisions, mini-open anterior corpectomy is an option in treating solitary metastases of the thoracolumbar spine.
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Affiliation(s)
- Taolin Fang
- 1Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; and
| | - Jian Dong
- 1Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; and
| | - Xiaogang Zhou
- 1Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; and
| | - Robert A. McGuire
- 2Department of Orthopedic Surgery, University of Mississippi Medical Center, Jackson, Mississippi
| | - Xilei Li
- 1Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; and
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Pizones J, Izquierdo E, Alvarez P, Sánchez-Mariscal F, Zúñiga L, Chimeno P, Benza E, Castillo E. Impact of magnetic resonance imaging on decision making for thoracolumbar traumatic fracture diagnosis and treatment. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2011; 20 Suppl 3:390-6. [PMID: 21779855 DOI: 10.1007/s00586-011-1913-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 07/05/2011] [Indexed: 01/03/2023]
Abstract
INTRODUCTION The role of magnetic resonance imaging (MRI) has recently been enhanced in the diagnosis of thoracolumbar fractures due to its ability to examine soft tissue injury. MATERIAL AND METHODS We conducted a prospective study to analyze the usefulness of MRI in fracture diagnosis and its influence on treatment decision making. Thirty-three patients were enrolled after suffering an acute traumatic thoracolumbar fracture. Osteoporotic or pathologic fractures were excluded. Fractures were initially classified using X-ray and CT scan following the AO classification. Afterward, a selective MRI protocol was performed with T1 and T2-weighted FS/STIR sequences. Subsequently, fractures were classified according to the TLICS system and reclassified following the AO system. Analysis was performed before and after MRI, focusing on: diagnostic changes, occult fractures and differences in treatment decision making. RESULTS Thirty patients (15 males, 15 females) with an average age of 39.9 years were studied. Forty-one fractures were initially diagnosed using plain X-rays and CT scans, while MRI diagnosed 50 fractures and 9 vertebral contusions. MRI modified our diagnosis in 40% of our patients (discovering 18 occult injuries), the classification of fracture pattern in 24% of the fractures (mostly upgrading type A to type B patterns) and the therapeutic management in 16% of our patients. CONCLUSIONS MRI seems to be a useful tool in the evaluation of thoracolumbar acute fractures, as it allows a better visualization of the posterior complex integrity and of the levels involved, offering additional information compared to traditional diagnostic tools.
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Affiliation(s)
- Javier Pizones
- Spine Unit, Department of Orthopaedic Surgery, Hospital Universitario de Getafe, Carretera de Toledo Km. 12.5, 28905, Madrid, Spain.
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Gonschorek O, Spiegl U, Weiss T, Pätzold R, Hauck S, Bühren V. [Reconstruction after spinal fractures in the thoracolumbar region]. Unfallchirurg 2011; 114:26-34. [PMID: 21243483 DOI: 10.1007/s00113-010-1940-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The morbidity of anterior approaches has significantly influenced the development of therapeutic concepts for the treatment of thoracolumbar spine fractures. Minimally-invasive techniques such as mini-open and endoscopic have enlarged the numbers of anterior reconstruction after spinal fractures in the thoracolumbar region. These minimally-invasive approaches have been facilitated by the development of special implants adapted to the new technique and to the local anatomical requirements.Two multi center studies in Germany (MCSI and II) showed the trend towards minimal invasive procedures and anterior approaches in the German speaking spine centers. Since the first report on thoracoscopic anterior procedures in Germany in 1997 a growing number of spine centers established this method. There is still no evidence based high level literature to substantiate a significant benefit for the patients by anatomical reduction and reconstruction of the anterior spinal column. However, there are some reports on better short outcomes in radiological parameters as well as better clinical results in 5 to 8 year follow-ups.The minimal invasive anterior approach seems to be advantageous for the patients by reducing significantly additive operation morbidity. It has become more important over the last two decades for anterior reconstruction after trauma and posttraumatic malalignment of the thoracolumbar spine.
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Affiliation(s)
- O Gonschorek
- Wirbelsäulenchirurgie, Berufsgenossenschaftliche Unfallklinik, Prof.-Küntscher-Straße 8, Murnau, Germany.
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Cappuccio M, Gasbarrini A, Donthineni R, Beisse R, Boriani S. Thoracoscopic assisted en bloc resection of a spine tumor. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 20 Suppl 2:S202-5. [PMID: 20694849 DOI: 10.1007/s00586-010-1539-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Revised: 06/29/2010] [Accepted: 07/18/2010] [Indexed: 11/30/2022]
Abstract
Spine tumors are fairly common and the management is through a multimodality approach. Lesions of the thoracic and lumbar vertebrae have been treated with such extensive anterior and/or posterior approaches. The authors present a case of a 56-year-old lady with solitary T11 metastases from colonic carcinoma and a case of a 43-year-old lady with T5-T6 high-grade osteogenic sarcoma. The treatment consists of a wide vertebrectomy by posterior approach, after anterior release and sub-pleural dissection using a thoracoscopic approach. A thoracoscopic assisted anterior approach could reduce the duration and the morbidity of a vertebrectomy without affecting oncological management.
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Affiliation(s)
- Michele Cappuccio
- Department of Orthopedics and Traumatology-Spine Surgery, Ospedale Maggiore C.A. Pizzardi, Largo Nigrisoli, 2, 40100 Bologna, Italy.
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