Mini-Open Lateral Corpectomy for Thoracolumbar Junction Lesions

Use of Patient-Specific Interbody Cages Through a Minimally Invasive Lateral Approach for Unstable Lumbar Spondylodiskitis

BACKGROUND AND OBJECTIVES

Patients with diskitis/osteomyelitis who do not respond to medical treatment or develop spinal instability/deformity may warrant surgical intervention. Irregular bony destruction due to the infection can pose a challenge for spinal reconstruction. The authors report a lateral approach using patient-specific interbody cages combined with posterior or lateral instrumentation to achieve spinal reconstruction for spinal instability/deformity from spondylodiskitis.

METHODS

This is a retrospective review of 4 cases undergoing debridement, lateral lumbar interbody fusion using patient-specific interbody cages, and supplemental lateral or posterior instrumentation for spinal instability/deformity after spondylodiskitis. The surgical technique is reported, as are the clinical and imaging outcomes.

RESULTS

Four male patients with a mean age of 69 years comprised this study. One had lateral lumbar interbody fusion at L2/3 and 3 at L4/5. The mean hospital stay was 5.8 days. The mean follow-up was 8.5 months (range 6-12 months). There were no approach-related neurological injuries or complications. The mean visual analog scale back pain scores improved from 9.5 to 1.5, and the mean Oswestry disability index improved from 68.5 to 23 at the end of the follow-up. The mean lumbar lordosis increased from 18° to 51°. The segmental angle increased from 6.5° to 18°. The coronal shift was 2.8 cm preoperatively and 0.9 cm postoperatively. The coronal Cobb angle reduced from 8.8° preoperatively to 2.8° postoperatively. On postoperative computed tomography, all patients had interval development of bridging bone across the surgical level through or around the cage. None of them developed cage migration or subsidence.

CONCLUSION

Patients with irregular bony destruction due to diskitis/osteomyelitis may benefit from patient-specific cages for spinal reconstruction to address spinal instability and deformity.

Single-Position Transpsoas Corpectomy and Posterior Instrumentation in the Thoracolumbar Spine for Different Clinical Scenarios

BACKGROUND

The concept of single-position spine surgery has been gaining momentum because it has proven to reduce operative time, blood loss, and hospital length of stay with similar or better outcomes than traditional dual-position surgery. The latest development in single-position spine surgery techniques combines either open or posterior pedicle screw fixation with transpsoas corpectomy while in the lateral or prone positioning.

OBJECTIVE

To provide, through a multicenter study, the results of our first patients treated by single-position corpectomy.

METHODS

This is a multicenter retrospective study of patients who underwent corpectomy and instrumentation in the lateral or prone position without repositioning between the anterior and posterior techniques. Data regarding demographics, diagnosis, neurological status, surgical details, complications, and radiographic parameters were collected. The minimum follow-up for inclusion was 6 months.

RESULTS

Thirty-four patients were finally included in our study (24 male patients and 10 female patients), with a mean age of 51.2 (SD ± 17.5) years. Three-quarter of cases (n = 27) presented with thoracolumbar fracture as main diagnosis, followed by spinal metastases and primary spinal infection. Lateral positioning was used in 27 cases, and prone positioning was used in 7 cases. The overall rate of complications was 14.7%.

CONCLUSION

This is the first multicenter series of patients who underwent single-position corpectomy and fusion. This technique has shown to be safe and effective to treat a variety of spinal conditions with a relatively low rate of complications. More series are required to validate this technique as a possible standard approach when thoracolumbar corpectomies are indicated.

The Efficiency and Reliability of Minimally Invasive Anterior Corpectomy and Percutaneous Posterior Stabilization for the Treatment of Unstable Thoracolumbar Burst Fractures

OBJECTIVE

The purpose of this study was to evaluate the radiological and clinical outcomes of minimally invasive anterior corpectomy and percutaneous posterior stabilization for treating unstable thoracolumbar burst fractures.

METHODS

Patients with unstable thoracolumbar burst fractures who underwent minimally invasive anterior corpectomy and percutaneous posterior stabilization between 2012 and 2019 at a tertiary hospital were enrolled. Radiological outcomes such as endplate subsidence and fusion status were identified on preoperative and postoperative plain radiographs and computed tomography images. Preoperative and postoperative neurological statuses were evaluated using the American Spinal Injury Association impairment scale. Furthermore, operation-related parameters were analyzed.

RESULTS

In total, 21 patients (mean follow-up period, 21.7 months) were included in this study. Of them, 17 (80.95%) patients exhibited complete fusion according to the Bridwell's criteria at the final follow-up, and only 1 patient exhibited nonunion at the surgical level. Endplate subsidence was observed in 6 (28.57%) patients; however, there were no definite symptoms that would have necessitated a revision surgery. Of 15 patients with preoperative neurological impairment, 7 exhibited neurological improvement during follow-up. None of the patients experienced postoperative neurological deterioration. Regarding operation-related parameters, the mean operative time and intraoperative blood loss were 266.19 ± 51.54 min and 520.71 ± 190.86 ml, respectively. The mean length of hospital stays and days to postoperative ambulation were 12.14 and 4.20 days, respectively.

CONCLUSIONS

Minimally invasive anterolateral corpectomy with percutaneous pedicle screw fixation is a reliable surgical treatment option for unstable thoracolumbar burst fractures.

Technical nuances and approach-related morbidity of anterolateral and posterolateral lumbar corpectomy approaches-a systematic review of the literature

Purpose

Approaches for lumbar corpectomies can be roughly categorized into anterolateral (AL) and posterolateral (PL) approaches. It remains controversial to date whether one approach is superior to the other, and no comparative studies exist for the two approaches for lumbar corpectomies.

Methods

A systematic review of the literature was performed through a MEDLINE/PubMed search. Studies and case reports describing technique plus outcomes and possible complications were included. Thereafter, estimated blood loss (EBL), length of operation (LOO), utilized implants, neurological outcomes, complication rates, and reoperation rates were analyzed.

Results

A total of 64 articles reporting on 702 patients including 513 AL and 189 PL corpectomies were included in this paper. All patients in the PL group were instrumented via the same approach used for corpectomy, while in the AL group the majority (68.3%) of authors described the use of an additional approach for instrumentation. The EBL was higher in the AL group (1393 ± 1341 ml vs. 982 ± 567 ml). The LOO also was higher in the AL group (317 ± 178 min vs. 258 ± 93 min). The complication rate (20.5% vs. 29.1%, p = 0.048) and the revision rate (3.1% vs. 9.5%, p = 0.004) were higher in the PL group. Neurological improvement rates were 43.8% (AL) vs. 39.2% (PL), and deterioration was only noted in the AL group (6.0%), while 50.2% (AL) and 60.8% (PL) showed no change from initial presentation to the last follow-up.

Conclusion

While neurological outcomes of both approaches are comparable, the results of the present review demonstrated lower complication and revision rates in anterolateral corpectomies. Nevertheless, individual patient characteristics must be considered in decision-making.

Radiological Evaluation of Combined Anteroposterior Fusion with Vertebral Body Replacement Using a Minimally Invasive Lateral Approach for Osteoporotic Vertebral Fractures: Verification of Optimal Surgical Procedure

The combined anteroposterior fusion with vertebral body replacement (VBR) using a wide footplate expandable cage with a minimally invasive lateral approach has been widely used for pseudoarthrosis after osteoporotic vertebral fractures. The purpose of this study is to evaluate the radiological results of combined anteroposterior surgery using VBR and to recommend the optimal procedure. Thirty-eight elderly patients were included in this study. The mean preoperative local kyphosis angle was 29.3°, and the mean correction loss angle was 6.3°. Cage subsidence was observed in ten patients (26.3%), and UIV or LIV fracture in twelve patients (31.6%). Patients with cage subsidence were compared to those without cage subsidence to determine the causal factors. The mean number of fixed vertebrae was 5.4 vertebrae with cage subsidence and 7.4 vertebrae without cage subsidence. In addition, to precisely clarify the optimal number of fixed vertebrae, those patients with two above–two below fixation were compared to those with less than two above–two below fixation, which revealed that the correction loss angle was significantly less in two above–two below fixation (p = 0.016). Based on these results, we recommend at least two above–two below fixation with VBR to minimize the correction loss angle and prevent cage subsidence.

Transdiaphragmatic Approach as a Novel Less Invasive Retroperitoneal Approach at Thoracolumbar Junction: Comparison with Conventional Diaphragmatic Incision

Introduction

Lateral corpectomy has been considered a minimally invasive surgery, allowing a “transdiaphragmatic approach” at the thoracolumbar junction. This approach allows for a small diaphragmatic incision directly in the retroperitoneal space and the affected vertebra. However, its effectiveness in comparison to a conventional approach remains unclear. Thus, in this present study, we compared the surgical outcomes between conventional diaphragmatic detachment and the transdiaphragmatic approach in patients with vertebral fracture at the thoracolumbar junction.

Methods

In total, 31 patients with a vertebral fracture at the thoracolumbar junction (T12-L2) were included in this study: 17 underwent a conventional approach, whereas 14 underwent a transdiaphragmatic approach, with a minimum 2-year follow-up. The effectiveness of surgery was evaluated in each category of the Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ).

Results

Operative time and estimated blood loss were determined to be significantly shorter in the transdiaphragmatic than in the conventional approach. Perioperative complications were observed in the conventional approach (one atelectasis and one pleural effusion), while no complication was noted in the transdiaphragmatic approach. There were no significant differences in postoperative quality of life as assessed by JOABPEQ in terms of pain-related disorders, lumbar spine dysfunction, gait disturbance, social life dysfunction, or psychological disorders between the conventional and transdiaphragmatic approaches.

Conclusions

A “transdiaphragmatic approach” using lateral access surgery has been found to be associated with a shorter operative time and less blood loss with fewer complications than the conventional approach. Given that equivalent clinical outcomes were achieved in both conventional and transdiaphragmatic approaches, this “transdiaphragmatic approach” could be useful because of its minimal invasiveness.

Minimally invasive corpectomy and percutaneous transpedicular stabilization in the treatment of patients with unstable injures of the thoracolumbar spine: Results of retrospective case series

Objective:

The objective of this study was to analyze the results of surgical treatment of patients with unstable injuries of the thoracolumbar spine using simultaneous minimally invasive corpectomy and percutaneous transpedicular stabilization.

Materials and Methods:

The retrospective study included 34 patients with isolated single-level unstable injuries of the thoracolumbar spine (5 or more points according to the Thoracolumbar Injury Classification and Severity Score (TLICS), operated on from the moment of injury from 8 to 24 h using the technique of minimally invasive corpectomy and percutaneous transpedicular stabilization simultaneously. The technical features of surgery, clinical data (pain level according to the Visual Analog Scale, quality of life according to the SF-36 questionnaire, subjective satisfaction with the operation according to the MacNab scale, and the presence of complications), and instrumental data (angle of segmental kyphotic deformity and sagittal index to and after surgery). The assessment of clinical data was carried out before surgery, at discharge, after 6 months, and in the long-term period, on average, 30 months after surgery.

Results:

When evaluating the clinical data, a significant decrease in the severity of pain syndrome was found on average from 90 mm to 5.5 mm in the late follow-up (P < 0.001), as well as a significant improvement in the physical and psychological components of health according to the SF-36 questionnaire on average from 28.78 to 39.26 (P < 0.001), from 36.93 to 41.43 (P = 0.006), respectively. In the long-term period, according to the MacNab scale, the patients noted the result of the operation: excellent – 18 (52.9%), good – 13 (38.3%), and satisfactory – 3 (8.8%); no unsatisfactory results were registered. Four (11.8%) perioperative surgical complications were registered, which were successfully treated conservatively. A significant restoration of the sagittal profile with an insignificant change in blood pressure was recorded in the long-term postoperative period. An average follow-up assessment of 30 months according to the American Spinal Injury Association scale showed the presence of E and D degrees in 85.4% of patients.

Conclusion:

Minimally invasive corpectomy with percutaneous transpedicular stabilization in the treatment of patients with unstable injuries of the thoracolumbar spine can effectively eliminate kyphotic deformity and prevent the loss of its reduction with a low number of postoperative surgical complications. The technique has minimal surgical trauma with the possibility of early postoperative rehabilitation and provides a significant stable reduction in vertebrogenic pain syndrome, improvement of neurological deficits, and restoration of the quality of life of patients and in the follow-up.

Mid- and Long-Term Efficacy of Surgical Treatment of L1-2 Vertebral Tuberculosis with Subdiaphragmatic Extraperitoneal Approach

Background

The L1–2 vertebral segment is the most common site of spinal tuberculosis. Traditional thoracoabdominal surgery in this segment risks trauma and complications. This study analyzed the surgical efficacy of the subdiaphragmatic extraperitoneal approach in the treatment of L1–2 spinal tuberculosis.

Material/Methods

Retrospective analysis of 67 patients with L1–2 vertebral tuberculosis who underwent posterior internal fixation was performed: 35 patients underwent the subdiaphragmatic extraperitoneal approach (group A) and 32 underwent the thoracoabdominal approach (group B). Operation time, intraoperative blood loss, postoperative hospital stay, postoperative nerve function recovery, deformity correction, bone graft fusion, lesion healing, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complications were observed.

Results

In group A and group B, intraoperative blood loss was 712.00±64.66 mL and 1104.38±131.34 mL; average operation time was 3.16±0.67 h and 5.16±1.07 h; and postoperative hospital stay was 9.60±2.64 days and 13.69±3.87 days, respectively. At 6 months and 5 years after surgery, neurological function, visual analog scale score, and Cobb angle of all patients were significantly improved compared with those before surgery; ESR and CRP decreased to normal levels; lesions completely cured; and all patients had good bone graft fusion. Pulmonary complications occurred in 2 patients in group A and in 14 patients in group B.

Conclusions

The efficacy of subdiaphragmatic extraperitoneal approach was similar to that of the thoracoabdominal approach for L1–2 spinal tuberculosis, but the former has the advantages of less surgical trauma, shorter operation time, less intraoperative bleeding, and fewer postoperative pulmonary complications.

Mini-open lateral retropleural/retroperitoneal approaches for thoracic and thoracolumbar junction anterior column pathologies

OBJECTIVE

Advancements in less invasive lateral retropleural/retroperitoneal approaches aim to address the limitation of posterolateral approaches and avoid complications associated with anterior open thoracotomy or thoracoabdominal approaches.

METHODS

Consecutive patients treated with a mini-open lateral approach for thoracic or thoracolumbar anterior column pathologies were analyzed in a retrospective case series including clinical and radiographic outcomes. Special attention is given to operative techniques and surgical nuances.

RESULTS

Eleven patients underwent a mini-open lateral retropleural or combined retropleural/retroperitoneal approach for thoracic or thoracolumbar junction lesions. Surgical indications included chronic fracture/deformity (n = 5), acute fracture (n = 2), neoplasm (n = 2), and osteomyelitis (n = 2). The mean length of postoperative hospital stay was 7.2 days (range 2-19 days). All patients ultimately had successful decompression and reconstruction with a mean follow-up of 16.7 months (range 6-29 months). Axial back pain assessed by the visual analog scale improved from a mean score of 8.2 to 2.2. Complications included 1 patient with deep venous thrombosis and pulmonary embolism and 1 with pneumonia. One patient developed increased leg weakness, which subsequently improved. One patient undergoing corpectomy with only lateral plate fixation developed cage subsidence requiring posterior stabilization.

CONCLUSIONS

Mini-open lateral retropleural and retroperitoneal corpectomies can safely achieve anterior column reconstruction and spinal deformity correction for various thoracic and thoracolumbar vertebral pathologies.