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Simpson AK, Lightsey HM, Xiong GX, Crawford AM, Minamide A, Schoenfeld AJ. Spinal endoscopy: evidence, techniques, global trends, and future projections. Spine J 2022; 22:64-74. [PMID: 34271213 DOI: 10.1016/j.spinee.2021.07.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 06/13/2021] [Accepted: 07/06/2021] [Indexed: 02/03/2023]
Abstract
The utilization of indirect visualization during procedures has been increasingly replacing traditional forms of direct visualization across many different surgical specialties. The adoption of arthroscopy, using small cameras placed inside joints, has transformed musculoskeletal care over the last several decades, allowing surgeons to provide the same anatomic solutions with less tissue dissection, resulting in lower requirements for inpatient care, reduced costs, and expedited recovery. For a variety of reasons, spine surgery has lagged behind other specialties in the adoption of indirect visualization. Nonetheless, patient demand for less invasive spine procedures and surgeon drive to provide these solutions and improve care quality has driven global adoption of spinal endoscopy. There are numerous endoscopic platforms and techniques currently utilized, and these systems are rapidly evolving. Additionally, the variance in technology and health system incentives across the globe has generated tremendous regional heterogeneity in the utilization of spinal endoscopic procedures. We present a consolidated review, including the background, evidence, techniques, and trends in spinal endoscopy, so that clinicians can gain a deeper understanding of this rapidly evolving domain of spinal healthcare.
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Affiliation(s)
- Andrew K Simpson
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; Microendoscopic Spine Institute, 75 Francis St, Boston, MA 02115.
| | - Harry M Lightsey
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Grace X Xiong
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Alexander M Crawford
- Harvard Combined Orthopaedic Residency Program, Harvard Medical School, 55 Fruit St., Boston, MA, 02114
| | - Akihito Minamide
- Spine Center, Department of Orthopaedic Surgery, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko City, Tochigi, Japan
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115
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Tannoury C, Beeram I, Singh V, Saade A, Bhale R, Tannoury T. The Role of Minimally Invasive Percutaneous Pedicle Screw Fixation for the Management of Spinal Metastatic Disease. World Neurosurg 2021; 159:e453-e459. [DOI: 10.1016/j.wneu.2021.12.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/17/2021] [Accepted: 12/18/2021] [Indexed: 10/19/2022]
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Evaluation of open and minimally invasive spinal surgery for the treatment of thoracolumbar metastatic epidural spinal cord compression: a systematic review. 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 2021; 30:2906-2914. [PMID: 34052895 DOI: 10.1007/s00586-021-06880-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Metastatic epidural spinal cord compression (MESCC) is a debilitating sequela of cancer that results in pain, disability, and neurologic deficits. Surgical techniques have included open surgical (OS) techniques with anterior and/or posterior decompression and fusion procedures. Further technical evolution has led to minimally invasive spinal (MIS) decompression and fusion. The objective of this study is to compare MIS to OS techniques in the treatment of thoracolumbar MESCC. METHODS A review of the literature was performed using PubMed database. Inclusion criteria included patients 18 years or older, thoracolumbar MESCC, and surgeries with instrumented fusion. A total of 451 articles met the inclusion criteria and further analysis narrowed them down to 81 articles. Variables collected included blood loss, length of stay, operative time, pre- and postoperative Frankel grade, and complications. RESULTS A total of 5726 papers were collected, with a total of 81 papers meeting final inclusion criteria: 26 papers with MIS technique and 55 with OS. A total of 2267 patients were evaluated. They were split into three surgical subtypes of MIS and OS: posterior decompression and fusion, partial corpectomy, and complete corpectomy. Overall, MIS had lower operative time, blood loss, and complications compared to OS. A timeline analysis showed reduction of complication rates in MIS surgery between papers published over a 28-year period. CONCLUSION MESCC carries significant morbidity and mortality. Surgical approaches for palliative treatment should account for this fact. We conclude that MIS techniques offer a viable alternative to traditional OS approaches with lower overall morbidity and complications.
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Choi EH, Chan AY, Gong AD, Hsu Z, Chan AK, Limbo JN, Hong JD, Brown NJ, Lien BV, Davies J, Satyadev N, Acharya N, Yang CY, Lee YP, Golshani K, Bhatia NN, Hsu FPK, Oh MY. Comparison of Minimally Invasive Total versus Subtotal Resection of Spinal Tumors: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 151:e343-e354. [PMID: 33887496 DOI: 10.1016/j.wneu.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/09/2021] [Accepted: 04/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE With the advent of minimally invasive techniques, minimally invasive spine surgery (MISS) has become a realistic option for many spine cases. This study aims to evaluate the operative and clinical outcomes of MISS for total versus subtotal tumor resection from current evidence. METHODS A literature search was performed using the search term (Minimally invasive surgery OR MIS) AND (spine tumor OR spinal tumor). Studies including both minimally invasive total and subtotal resection cases with operative or clinical data were included. RESULTS Seven studies describing 159 spinal tumor cases were included. Compared with total resection, subtotal resection showed no significant differences in surgical time (mean difference (MD), 9.44 minutes; 95% confidence interval [CI], -47.66 to 66.55 minutes; P = 0.37), surgical blood loss (MD, -84.72 mL; 95% CI, -342.82 to 173.39 mL; P = 0.34), length of stay (MD, 1.38 days; 95% CI, -0.95 to 3.71 days; P = 0.17), and complication rate (odds ratio, 9.47; 95% CI, 0.34-263.56; P = 0.12). Pooled analyses with the random-effects model showed that neurologic function improved in 89% of patients undergoing total resection, whereas neurologic function improved in 61% of patients undergoing subtotal resection. CONCLUSIONS Our analyses show that there is no significant difference in operative outcomes between total and subtotal resection. Patients undergoing total resection showed slightly better improvement in neurologic outcomes compared with patients undergoing subtotal resection. Overall, this study suggests that both total and subtotal resection may result in comparable outcomes for patients with spinal tumors. However, maximal safe resection remains the ideal treatment because it provides the greatest chance of long-term benefit.
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Affiliation(s)
- Elliot H Choi
- Department of Neurological Surgery, University of California, Irvine, California, USA; Medical Scientist Training Program, School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Alvin Y Chan
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Andrew D Gong
- Department of Neurological Surgery, University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Zachary Hsu
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Joshua N Limbo
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - John D Hong
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Brian V Lien
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Jordan Davies
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nihal Satyadev
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nischal Acharya
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Chen Yi Yang
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Yu-Po Lee
- Department of Orthopedic Surgery, University of California, Irvine, California, USA
| | - Kiarash Golshani
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Nitin N Bhatia
- Department of Orthopedic Surgery, University of California, Irvine, California, USA
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, California, USA
| | - Michael Y Oh
- Department of Neurological Surgery, University of California, Irvine, California, USA.
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Li J, Wei W, Xu F, Wang Y, Liu Y, Fu C. Clinical Therapy of Metastatic Spinal Tumors. Front Surg 2021; 8:626873. [PMID: 33937314 PMCID: PMC8084350 DOI: 10.3389/fsurg.2021.626873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
Metastatic spinal tumors (MST) have high rates of morbidity and mortality. MST can destroy the vertebral body or compress the nerve roots, resulting in an increased risk of pathological fractures and intractable pain. Here, we elaborately reviewed the currently available therapeutic options for MST according to the following four aspects: surgical management, minimally invasive therapy (MIT), radiation therapy, and systemic therapy. In particular, these aspects were classified and introduced to show their developmental process, clinical effects, advantages, and current limitations. Furthermore, with the improvement of treatment concepts and techniques, we discovered the prevalent trend toward the use of radiation therapy and MIT in clinic therapies. Finally, the future directions of these treatment options were discussed. We hoped that along with future advances and study will lead to the improvement of living standard and present status of treatment in patients with MST.
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Affiliation(s)
- Jie Li
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China.,Key Laboratory of Polymer Ecomaterials, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Changchun, China
| | - Wenjie Wei
- Key Laboratory of Pathobiology, Ministry of Education, School of Basic Medical Sciences, Jilin University, Changchun, China
| | - Feng Xu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yuanyi Wang
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Yadong Liu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
| | - Changfeng Fu
- Department of Spine Surgery, The First Hospital of Jilin University, Changchun, China
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Fiani B, Siddiqi I, Reardon T, Sarhadi K, Newhouse A, Gilliland B, Davati C, Villait A. Thoracic Endoscopic Spine Surgery: A Comprehensive Review. Int J Spine Surg 2020; 14:762-771. [PMID: 33046537 DOI: 10.14444/7109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND From the 1990s, there has been growth in the literature demonstrating the feasibility of minimally invasive approaches for treating diverse spinal disorders. There is still much work to be done in circumnavigating the technical challenges and elucidating relative advantages of endoscopic techniques in spine surgery. In this comprehensive literature review, we discuss the history, advantages, disadvantages, approaches, and technology of, and critically examine peer-reviewed studies specifically addressing, endoscopic thoracic spinal surgery. METHODS Literature review was conducted with the key words "endoscopic," "minimally invasive," and "thoracic spinal surgery," using PubMed, Web of Science, and Google Scholar. RESULTS Review of 241 thorascopic procedures showed a success rate of 98% to 100%, low morbidity, and favorable complication profile. Review of 115 thoracic fixation procedures demonstrated high success rate, and 87% of screw positions were rated "good." Review of 55 full endoscopic uniportal decompressions showed sufficient decompression in most patients. Match pair analysis of 34 patients comparing video-assisted thoracoscopy surgery (VATS) or posterior spinal fusion reported the VATS group had increased operative duration but reduced blood loss. CONCLUSIONS Based on our literature review, there is a high rate of positive outcomes with endoscopic thoracic spine surgery, which reduces tissue dissection, intraoperative blood loss, and epidural fibrosis. However, the technical challenge highlights the importance of further training and innovation in this rapidly evolving field. LEVEL OF EVIDENCE 3. CLINICAL RELEVANCE There is growing evidence demonstrating the success of endoscopic thoracic spinal surgery. Populations that could be helped include the elderly and immunocompromised, who would benefit from decreased hospital stay and enhanced recovery time.
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Affiliation(s)
- Brian Fiani
- Desert Regional Medical Center, Palm Springs, California
| | - Imran Siddiqi
- Western University of Health Sciences College of Osteopathic Medicine, Pomona, California
| | - Taylor Reardon
- University of Pikeville, Kentucky College of Osteopathic Medicine, Pikeville, Kentucky
| | - Kasra Sarhadi
- Miller School of Medicine, University of Miami, Miami, Florida
| | | | | | - Cyrus Davati
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York
| | - Akash Villait
- Midwestern University, Arizona College of Osteopathic Medicine, Glendale, Arizona
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Chang SY, Mok S, Park SC, Kim H, Chang BS. Treatment Strategy for Metastatic Spinal Tumors: A Narrative Review. Asian Spine J 2020; 14:513-525. [PMID: 32791769 PMCID: PMC7435309 DOI: 10.31616/asj.2020.0379] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/29/2022] Open
Abstract
Metastatic spinal tumors are common, and their rising incidence can be attributed to the expanding aging population and increased survival rates among cancer patients. The decision-making process in the treatment of spinal metastasis requires a multidisciplinary approach that includes medical and radiation oncology, surgery, and rehabilitation. Various decision-making systems have been proposed in the literature in order to estimate survival and suggest appropriate treatment options for patients experiencing spinal metastasis. However, recent advances in treatment modalities for spinal metastasis, such as stereotactic radiosurgery and minimally invasive surgical techniques, have reshaped clinical practices concerning patients with spinal metastasis, making a demand for further improvements on current decision-making systems. In this review, recent improvements in treatment modalities and the evolution of decision-making systems for metastatic spinal tumors are discussed.
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Affiliation(s)
- Sam Yeol Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sujung Mok
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Sung Cheol Park
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Hyoungmin Kim
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
| | - Bong-Soon Chang
- Department of Orthopedic Surgery, Seoul National University Hospital, Seoul, Korea
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Gazzeri R, Panagiotopoulos K, Galarza M, Bolognini A, Callovini G. Minimally invasive spinal fixation in an aging population with osteoporosis: clinical and radiological outcomes and safety of expandable screws versus fenestrated screws augmented with polymethylmethacrylate. Neurosurg Focus 2020; 49:E14. [DOI: 10.3171/2020.5.focus20232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 05/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe goal of this study was to compare the clinical and radiological outcomes between fenestrated pedicle screws augmented with cement and expandable pedicle screws in percutaneous vertebral fixation surgical procedures for the treatment of degenerative and traumatic spinal diseases in aging patients with osteoporosis.METHODSThis was a prospective, single-center study. Twenty patients each in the expandable and cement-augmented screw groups were recruited. Clinical outcomes included visual analog scale (VAS), Oswestry Disability Index (ODI), and satisfaction rates. Radiographic outcomes comprised radiological measurements on the vertebral motion segment of the treated levels. Intraoperative data including complications were collected. All patients completed the clinical and radiological outcomes. Outcomes were compared preoperatively and postoperatively.RESULTSAn average shorter operative time was found in procedures in which expandable screws were used versus those in which cement-augmented screws were used (p < 0.001). No differences resulted in perioperative blood loss between the 2 groups. VAS and ODI scores were significantly improved in both groups after surgery. There was no significant difference between the 2 groups with respect to baseline VAS or ODI scores. The satisfaction rate of both groups was more than 85%. Radiographic outcomes also showed no significant difference in segment stability between the 2 groups. No major complications after surgery were seen. There were 4 cases (20%) of approach-related complications, all in fenestrated screw procedures in which asymptomatic cement extravasations were observed. In 1 case the authors detected a radiologically evident osteolysis around a cement-augmented screw 36 months after surgery. In another case they identified a minor loosening of an expandable screw causing local back discomfort at the 3-year follow-up.CONCLUSIONSExpandable pedicle screws and polymethylmethacrylate augmentation of fenestrated screws are both safe and effective techniques to increase the pullout strength of screws placed in osteoporotic spine. In this series, clinical and radiological outcomes were equivalent between the 2 groups. To the authors’ knowledge, this is the first report comparing the cement augmentation technique versus expandable screws in the treatment of aging patients with osteoporosis.
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Affiliation(s)
- Roberto Gazzeri
- 1Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome
- 2Department of Neurosurgery, IRCCS Istituto Nazionale Tumori “Regina Elena,” Rome, Italy; and
| | | | - Marcelo Galarza
- 3Regional Service of Neurosurgery, “Virgen de la Arrixaca” University Hospital, Murcia, Spain
| | - Andrea Bolognini
- 1Department of Neurosurgery, San Giovanni–Addolorata Hospital, Rome
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Telfeian AE, Oyelese A, Fridley J, Doberstein C, Gokaslan ZL. Endoscopic surgical treatment for symptomatic spinal metastases in long-term cancer survivors. JOURNAL OF SPINE SURGERY 2020; 6:372-382. [PMID: 32656374 DOI: 10.21037/jss.2019.10.14] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background To evaluate the feasibility of awake transforaminal endoscopic surgery in the management of symptomatic spinal metastases. Methods Transforaminal endoscopic spine procedures were performed by 1 surgeon in 325 patients over a period of 4 years from 2014 to 2018. Four of these patients suffered from radicular pain secondary to nerve compression from metastatic spine disease and are the basis of our analysis. Data was evaluated retrospectively in these patients with a minimum follow up of 1 year. Results All 4 patients treated with transforaminal endoscopic spine surgery for decompression of their metastatic spine disease had successful resolution of their symptoms without any perioperative complications and only brief recovery periods required. Conclusions Awake endoscopic surgery for the treatment of symptomatic metastatic spine disease is an effective outpatient surgical option for the treatment of patients suffering from radicular pain due to nerve compression from metastatic spine disease.
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Affiliation(s)
- Albert E Telfeian
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Adetokunbo Oyelese
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jared Fridley
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Cody Doberstein
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
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Laratta JL, Weegens R, Malone KT, Chou D, Smith WD. Minimally invasive lateral approaches for the treatment of spinal tumors: single-position surgery without the "flip". JOURNAL OF SPINE SURGERY 2020; 6:62-71. [PMID: 32309646 DOI: 10.21037/jss.2019.12.12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Although primary tumors of the spine and neural elements are rare, metastatic disease to the spine is quite common. Traditionally, surgical treatment for spinal tumor patients involves open decompression with or without stabilization. The single-position minimally invasive (MIS) lateral approach, which has been recently described over the recent decade, allows simultaneous access to the anterior and posterior columns with the patient positioned in the lateral decubitus position. Herein, we review the application of single-position MIS lateral surgery for the treatment of spinal neoplasm. The aim was to review the evolution, operative technique, outcomes, and complications associated with MIS lateral approaches for spinal tumors. The history of spinal tumor diagnosis and management are reviewed and discussed as well as the author's experience and literature regarding spinal tumor treatment outcome and surgical complications, with particular attention to single-position, MIS lateral approaches. In addition, the author's surgical technique is outlined in detail for thoracic, thoracolumbar and lumbar tumors. Furthermore, there are specific indications and complications associated with the surgical treatment of spinal tumors, and the MIS, single-position lateral approach, when applied appropriately, allows for concurrent access to the anterior and posterior column while mitigating the complications associated with traditional, open posterior-based approaches. In the treatment of spinal neoplasms, the goals of surgery are dictated by a number of tumor-specific and patient-specific factors. Therefore, operative treatment of tumors in the future may be a consolidation of historical surgical techniques and MIS, single-position lateral approaches. Regardless, multidisciplinary management is imperative for the individualized treatment of the patient and optimization of outcome.
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Affiliation(s)
- Joseph L Laratta
- Norton Leatherman Spine Center, Louisville, KY, USA.,University of Louisville Medical Center, Louisville, KY, USA
| | - Ryan Weegens
- University of Louisville Medical Center, Louisville, KY, USA
| | - Kyle T Malone
- Clinical Resources, NuVasive, Inc., San Diego, CA, USA
| | - Dean Chou
- University of California San Francisco, San Francisco, CA, USA
| | - William D Smith
- Western Regional Center for Brain and Spine Surgery, Las Vegas, NV, USA.,University Medical Center of Southern Nevada, Las Vegas, NV, USA
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Spiessberger A, Arvind V, Gruter B, Cho SK. Thoracolumbar corpectomy/spondylectomy for spinal metastasis: a pooled analysis comparing the outcome of seven different surgical approaches. 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 2019; 29:248-256. [DOI: 10.1007/s00586-019-06179-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 08/15/2019] [Accepted: 10/05/2019] [Indexed: 01/16/2023]
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Hem S, Beltrame S, Rasmussen J, Vecchi E, Landriel F, Yampolsky C. [Usefulness of minimally invasive spine surgery for the management of thoracolumbar spinal metastases]. Surg Neurol Int 2019; 10:S1-S11. [PMID: 31123635 PMCID: PMC6416751 DOI: 10.4103/sni.sni_288_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Indexed: 11/10/2022] Open
Abstract
Objetivo: Describir los resultados quirúrgicos y evolución de pacientes con metástasis espinales toraco-lumbares operadas con técnica mínimamente invasiva (MISS) utilizando para la decisión terapéutica la evaluación: Neurológica, Oncológica, Mecánica y Sistémica (NOMS). Material y Métodos: Se incluyeron en forma prospectiva pacientes con metástasis espinales toraco-lumbares operados con técnica MISS por el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires entre Junio de 2014 y Junio de 2017. Se utilizó en todos los casos el algoritmo de evaluación NOMS para la decisión terapéutica. Se analizaron los resultados quirúrgicos postoperatorios como el Karnofsky performance status, dolor (VAS – visual analog scale), Frankel, pérdida sanguínea, necesidad de transfusiones, complicaciones, uso de opioides y días de internación. Se consideró como estadísticamente significativo una P < 0.05. Resultados: Durante el período de estudio 26 pacientes cumplieron los criterios de inclusión, de los cuales 13 fueron mujeres. La edad promedio fue 57 (27-83) años. El origen más frecuente de las lesiones fue cáncer de mama (27%). El síntoma más constante fue el dolor (96%), aunque 12 pacientes manifestaron inicialmente mielopatía (46%). Se observaron grados avanzados de invasión del canal con requerimiento de descompresión en el 65% de los casos. Acorde al Spinal Instability Neoplastic Score, 23 pacientes (89%) presentaron lesiones potencialmente inestables o inestables, requiriendo estabilización. Se evidenció una mejoría estadísticamente significativa del VAS en el 77% y del Frankel en el 67% de los casos tras la cirugía. No hubo necesidad de transfusiones. Se registró sólo una complicación quirúrgica leve (4%). La media de internación fue de 5.5 días. Conclusión: En nuestra serie y utilizando como algoritmo terapéutico el NOMS, la cirugía MISS resultó efectiva tanto para la descompresión como para la estabilización espinal, con baja tasa de complicaciones y rápida recuperación postoperatoria.
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Affiliation(s)
- Santiago Hem
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
| | - Sofía Beltrame
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
| | - Jorge Rasmussen
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
| | - Eduardo Vecchi
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
| | - Federico Landriel
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
| | - Claudio Yampolsky
- Departamento de Neurocirugía, Hospital Italiano de Buenos Aires, Peron, CABA, Argentina
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Pennington Z, Ahmed AK, Molina CA, Ehresman J, Laufer I, Sciubba DM. Minimally invasive versus conventional spine surgery for vertebral metastases: a systematic review of the evidence. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:103. [PMID: 29707552 DOI: 10.21037/atm.2018.01.28] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
One of the major determinants of surgical candidacy in patients with symptomatic spinal metastases is the ability of the patient to tolerate the procedure-associated morbidity. In other pathologies, minimally invasive (MIS) procedures have been suggested to have lower intra-operative morbidity while providing similar outcomes. We conducted a systematic review of the PubMed library searching for articles that directly compared the operative and post-operative outcomes of patients treated for symptomatic spinal metastases. Inclusion criteria were articles reporting two or more cases of patients >18 years old treated with MIS or open approaches for spinal metastases. Studies reporting results in spinal metastases patients that could not be disentangled from other pathologies were excluded. Our search returned 1,568 articles, of which 9 articles met the criteria for inclusion. All articles were level III evidence. Patients treated with MIS approaches tended to have lower intraoperative blood loss, shorter operative times, shorter inpatient stays, and fewer complications relative to patients undergoing surgeries with conventional approaches. Patients in the MIS and open groups had similar pain improvement, neurological improvement, and functional outcomes. Recent advances in MIS techniques may reduce surgical morbidity while providing similar symptomatic improvement in patients treated for spinal metastases. As a result, MIS techniques may expand the pool of patients with spinal metastases who are candidates for operative management.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Camilo A Molina
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jeffrey Ehresman
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Ilya Laufer
- Weill Cornell Medical College, New York, NY, USA.,Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daniel M Sciubba
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Singh S, Sardhara JC, Khatri D, Joseph J, Parab AN, Bhaisora KS, Das KK, Mehrotra A, Srivastava AK, Behari S. Technical pearls and surgical outcome of early transitional period experience in minimally invasive lumbar discectomy: A prospective study. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2018; 9:122-129. [PMID: 30008531 PMCID: PMC6024740 DOI: 10.4103/jcvjs.jcvjs_47_18] [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] [Indexed: 11/29/2022] Open
Abstract
Background: There is growing indications of minimally invasive spine surgery. The inherent attitude and institutive learning curve limit transition from standard open surgery to minimally invasive surgery demanding understanding of new instruments and correlative anatomy. Materials and Methods: In this prospective study, 80 patients operated for lumbar disc prolapse were included in the study (between January 2016 and March 2018). Fifty patients (Group A) operated by various minimally invasive spine surgery (MISS) techniques for herniated disc disease were compared with randomly selected 30 patients (Group B) operated between the same time interval by standard open approach. Surgical outcome with Oswestry Disability Index (ODI) and patient satisfaction score was calculated in pre- and postoperative periods. Results: Mean preoperative ODI score in Group A was 31.52 ± 7.5 standard deviation (SD) (range: 6“46; interquartile range [IQR]: 8; median: 32.11) and postoperative ODI score was 9.20 ± 87.8 SD (range: 0“38; IQR: 11; median: 6.67). Mean preoperative ODI score in Group B was 26.47 ± 4.9 SD (range: 18“38; IQR: 4; median: 25) and postoperative ODI score was 12.27 ± 8.4 SD (range: 3“34; IQR: 12; median: 10.0). None of the patients was unsatisfied in either group. On comparing the patient satisfaction score among two groups, no significant difference (P = 0.27) was found. Discussion: On comparing the change in ODI and preoperative ODI among both groups, we found a significant difference between the groups. It is worth shifting from open to MISS accepting small learning curve. The satisfaction score of MISS in early transition period is similar to open procedure. Conclusion: The MISS is safe and effective procedure even in transition period for the central and paracentral prolapsed lumbar intervertebral disc treatment. The results are comparable, and patient satisfaction and symptomatic relief are not compromised.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Deepak Khatri
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jeena Joseph
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Abhijit N Parab
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh S Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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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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Sulaiman OA, Garces J, Mathkour M, Scullen T, Jones RB, Arrington T, Bui CJ. Mini-Open Thoracolumbar Corpectomy: Perioperative Outcomes and Hospital Cost Analysis Compared with Open Corpectomy. World Neurosurg 2017; 99:295-301. [DOI: 10.1016/j.wneu.2016.11.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 11/12/2016] [Accepted: 11/15/2016] [Indexed: 11/29/2022]
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Ravindra VM, Brock A, Awad AW, Kalra R, Schmidt MH. The role of the mini-open thoracoscopic-assisted approach in the management of metastatic spine disease at the thoracolumbar junction. Neurosurg Focus 2017; 41:E16. [PMID: 27476840 DOI: 10.3171/2016.5.focus16162] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective Treatment advances have resulted in improved survival for many cancer types, and this, in turn, has led to an increased incidence of metastatic disease, specifically to the vertebral column. Surgical decompression and stabilization prior to radiation therapy have been shown to improve functional outcomes, but anterior access to the thoracolumbar junction may involve open thoracotomy, which can cause significant morbidity. The authors describe the treatment of 12 patients in whom a mini-open thoracoscopic-assisted approach (mini-open TAA) to the thoracolumbar junction was used to treat metastatic disease, with an analysis of outcomes. Methods The authors reviewed a retrospective cohort of patients treated for thoracolumbar junction metastatic disease with mini-open TAA between 2004 and 2016. Data collection included operative time, estimated blood loss, length of stay, follow-up duration, and pre- and postoperative visual analog scale scores and Frankel grades. Results Twelve patients underwent a mini-open TAA procedure for metastatic disease at the thoracolumbar junction. The mean age of patients was 59 years (range 53-77 years), mean estimated blood loss was 613 ml, and the mean duration of the mini-open TAA procedure was 234 minutes (3.8 hours). The median length of stay in the hospital was 7.5 days (range 5-21 days). All 12 patients had significant improvement in their postoperative pain scores in comparison with their preoperative pain scores (p < 0.001). No patients suffered from worsening neurological function after surgery, and of 7 patients who presented with neurological dysfunction, 6 (86%) had an improvement in their Frankel grade after surgery. No patients experienced delayed hardware failure requiring reoperation over a mean follow-up of 10 months (range 1-45 months). Conclusions The mini-open TAA to the thoracolumbar junction for metastatic disease is a durable procedure that has a reduced morbidity rate compared with traditional open thoracotomy for ventral decompression and fusion. It compares well with traditional and novel posterior approaches to the thoracolumbar junction. The authors found a significant improvement in preoperative pain and neurological symptoms that supports greater use of the mini-open TAA for the treatment of complex metastatic disease at the thoracolumbar junction.
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Affiliation(s)
- Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Andrea Brock
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Al-Wala Awad
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Ricky Kalra
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Meic H Schmidt
- Department of Neurosurgery, Clinical Neurosciences Center and Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
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Choi D, Bilsky M, Fehlings M, Fisher C, Gokaslan Z. Spine Oncology—Metastatic Spine Tumors. Neurosurgery 2017; 80:S131-S137. [DOI: 10.1093/neuros/nyw084] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 11/07/2016] [Indexed: 01/24/2023] Open
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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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When Less Is More: The indications for MIS Techniques and Separation Surgery in Metastatic Spine Disease. Spine (Phila Pa 1976) 2016; 41 Suppl 20:S246-S253. [PMID: 27753784 PMCID: PMC5551976 DOI: 10.1097/brs.0000000000001824] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE The aim of this study was to review the techniques, indications, and outcomes of minimally invasive surgery (MIS) and separation surgery with subsequent radiosurgery in the treatment of patients with metastatic spine disease. SUMMARY OF BACKGROUND DATA The utilization of MIS techniques in patients with spine metastases is a growing area within spinal oncology. Separation surgery represents a novel paradigm where radiosurgery provides long-term control after tumor is surgically separated from the neural elements. METHODS PubMed, Embase, and CINAHL databases were systematically queried for literature reporting MIS techniques or separation surgery in patients with metastatic spine disease. PRISMA guidelines were followed. RESULTS Of the initial 983 articles found, 29 met inclusion criteria. Twenty-five articles discussed MIS techniques and were grouped according to the primary objective: percutaneous stabilization (8), tubular retractors (4), mini-open approach (8), and thoracoscopy/endoscopy (5). The remaining 4 studies reported separation surgery. Indications were similar across all studies and included patients with instability, refractory pain, or neurologic compromise. Intraoperative variables, outcomes, and complications were similar in MIS studies compared to traditional approaches, and some MIS studies showed a statistically significant improvement in outcomes. Studies of mini-open techniques had the strongest evidence for superiority. CONCLUSIONS Low-quality evidence currently exists for MIS techniques and separation surgery in the treatment of metastatic spine disease. Given the early promising results, the next iteration of research should include higher-quality studies with sufficient power, and will be able to provide higher-level evidence on the outcomes of MIS approaches and separation surgery. LEVEL OF EVIDENCE N/A.
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21
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Thoracoscopic Vertebrectomy for Thoracolumbar Junction Fractures and Tumors: Surgical Technique and Evaluation of the Learning Curve. Clin Spine Surg 2016; 29:E344-50. [PMID: 27137153 DOI: 10.1097/bsd.0b013e318286fa99] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE The authors evaluated the surgical technique and learning curve for video-assisted thoracoscopic surgery (VATS) for treating thoracolumbar junction burst fractures and bony tumors by examining surgical data and outcome for the first 30 VATS procedures performed by a single surgeon at a training institution. SUMMARY OF BACKGROUND DATA VATS is commonly used in the treatment of early-stage lung cancer. Widespread use of this technique among neurosurgeons is limited by the lack of cases and the steep learning curve. METHODS This study was a retrospective case series of the first 30 T12 and L1 thoracoscopic vertebrectomies from 2003 to 2008. The sample was limited to 1 surgeon and 1 region of the spine to minimize the potential variation so that a learning curve could be assessed. Surgical data and outcomes were analyzed. Estimated blood loss and operation time were analyzed using a linear generalized estimating equation model with a first-order autoregression correlation structure. RESULTS The average operative time for thoracoscopic corpectomy was 270±65 minutes (range, 160-416 min). Operating room time decreased significantly after the first 3 operations. The authors observed a stable linear decrease in operating time over the course of the study. The average blood loss during the thoracoscopic procedure was 433±330 mL (range, 100-1500 mL) and did not change as the series progressed. Complications and conversions to open procedures occurred in 2 patients and were evenly distributed throughout the series. CONCLUSIONS Thoracoscopic vertebrectomy at the thoracolumbar junction has a relatively long learning curve. In this series, operating room time improved dramatically after the first 3 cases but continued to improve subsequently. The learning curve can be accomplished without an increase in blood loss, complications, rate of conversion to open procedures, or frequency of misplaced instrumentation.
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22
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Moussazadeh N, Rubin DG, McLaughlin L, Lis E, Bilsky MH, Laufer I. Short-segment percutaneous pedicle screw fixation with cement augmentation for tumor-induced spinal instability. Spine J 2015; 15:1609-17. [PMID: 25828478 DOI: 10.1016/j.spinee.2015.03.037] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 02/19/2015] [Accepted: 03/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Pathologic vertebral compression fractures (VCFs) represent a major source of morbidity and diminished quality of life in the spinal oncology population. Procedures with low morbidity that effectively treat patients with pathologic fractures are especially important in the cancer population where life expectancy is limited. Vertebroplasty and kyphoplasty are often not effective for mechanically unstable pathologic fractures extending into the pedicle and facet joints. Combination of cement augmentation and percutaneous instrumented stabilization represents a minimally invasive treatment option that does not delay radiation and systemic therapy. PURPOSE The objective of the study was to evaluate the safety and efficacy of cement-augmented short-segment percutaneous posterolateral instrumentation for tumor-associated VCF with pedicle and joint involvement. METHODS Forty-four consecutive patients underwent cement-augmented percutaneous spinal fixation for unstable tumors between 2011 and 2014. Retrospective analysis of prospectively collected data, including visual analog pain scale (VAS) response score and procedural complications, was performed. RESULTS Patients with a median composite Spinal Instability Neoplastic Scale score of 10 (range=8-15) were treated with constructs spanning one to four disk spaces (median of two spaces, constituting 84% of all cases). The proportion of patients with severe pain decreased from 86% preoperatively to 0%; 65% of patients reported no referable instability pain postoperatively. There was one adjacent-level fracture responsive to kyphoplasty, and one case of asymptomatic screw pullout. Two patients subsequently required decompression in the setting of disease progression despite radiation; there was no perioperative morbidity. CONCLUSIONS Percutaneous cement-augmented posterolateral spinal fixation is a safe and effective option for palliation of appropriately selected mechanically unstable VCF that extends into pedicle and/or joint.
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Affiliation(s)
- Nelson Moussazadeh
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E. 68th St, New York, NY 10065, USA
| | - David G Rubin
- Legacy Spine & Neurological Associates, 5800 W. 10th St, Little Rock, AR, USA
| | - Lily McLaughlin
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Eric Lis
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA
| | - Mark H Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E. 68th St, New York, NY 10065, USA
| | - Ilya Laufer
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA; Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E. 68th St, New York, NY 10065, USA.
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Rao PJ, Thayaparan GK, Fairhall JM, Mobbs RJ. Minimally invasive percutaneous fixation techniques for metastatic spinal disease. Orthop Surg 2015; 6:187-95. [PMID: 25179352 DOI: 10.1111/os.12114] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 06/08/2014] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE Surgical treatment of spinal metastasis is generally a palliative procedure. Although minimally invasive surgical (MIS) techniques are supposedly less morbid than open techniques, there is a lack of stratification of MIS techniques based on anticipated longevity. A simple stratification into three percutaneous surgical techniques based on modified Tokuhashi score is here proposed. METHODS Patients recommended for spinal surgery for metastatic spinal disease between 2009 and 2012 and operated on by the senior author (RJM) were retrospectively reviewed. One of three MIS techniques was offered based on estimated survival using a modified Tokuhashi score. Technique #1 is suitable for patients with predicted short longevity (<6 months). Using a mini-open midline or paramedian decompression and percutaneous screw fixation, the goal here is for rapid mobilization and minimization of hospitalization. Technique #2 is suitable for patients with predicted medium longevity (6-12 months). They are suitable for decompression and/or cement vertebral body replacement and a two levels stabilization. Technique #3 is suitable for patients with predicted long term survival survival (>12 months). In these patients, the primary goal of surgery is a wide local or marginal resection of tumor, decompression of the neurological elements and a robust stabilization construct. They are suitable for an open 360°decompression, vertebral body reconstruction and a multilevel stabilization. RESULTS The study included eight patients with a mean age of 59 years (range, 36-72 years). Mean modified Tokuhashi score was 10 (range, 7-13) with three patients in the short term, two in the medium term and three in the long term survival category. Mean blood loss was 700 mL (range, 100-1200 mL), mean operating time 280 min (range, 120-360 min) and length of stay in the hospital was on average 13 days (range, 3-30 days). CONCLUSION The authors present three minimally invasive technique options for the management of spinal metastatic disease corresponding to three clinical prognostic categories. In this small series, MIS techniques resulted in speedy recovery, minimal morbidity and no mortality.
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Affiliation(s)
- Prashanth J Rao
- Neurospine Clinic, Prince of Wales Hospital, Sydney, Australia; University of New South Wales, Sydney, Australia
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Miscusi M, Polli FM, Forcato S, Ricciardi L, Frati A, Cimatti M, De Martino L, Ramieri A, Raco A. Comparison of minimally invasive surgery with standard open surgery for vertebral thoracic metastases causing acute myelopathy in patients with short- or mid-term life expectancy: surgical technique and early clinical results. J Neurosurg Spine 2015; 22:518-25. [PMID: 25723122 DOI: 10.3171/2014.10.spine131201] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECT Spinal metastasis is common in patients with cancer. About 70% of symptomatic lesions are found in the thoracic region of the spine, and cord compression presents as the initial symptom in 5%-10% of patients. Minimally invasive spine surgery (MISS) has recently been advocated as a useful approach for spinal metastases, with the aim of decreasing the morbidity associated with more traditional open spine surgery; furthermore, the recovery time is reduced after MISS, such that postoperative chemotherapy and radiotherapy can begin sooner. METHODS Two series of oncological patients, who presented with acute myelopathy due to vertebral thoracic metastases, were compared in this study. Patients with complete paraplegia for more than 24 hours and with a modified Bauer score greater than 2 were excluded from the study. The first group (n = 23) comprised patients who were prospectively enrolled from May 2010 to September 2013, and who were treated with minimally invasive laminotomy/laminectomy and percutaneous stabilization. The second group (n = 19) comprised patients from whom data were retrospectively collected before May 2010, and who had been treated with laminectomy and stabilization with traditional open surgery. Patient groups were similar regarding general characteristics and neurological impairment. Results were analyzed in terms of neurological recovery (American Spinal Injury Association grade), complications, pain relief (visual analog scale), and quality of life (European Organisation for Research and Treatment of Cancer [EORTC] QLQ-C30 and EORTC QLQ-BM22 scales) at the 30-day follow-up. Operation time, postoperative duration of bed rest, duration of hospitalization, intraoperative blood loss, and the need and length of postoperative opioid administration were also evaluated. RESULTS There were no significant differences between the 2 groups in terms of neurological recovery and complications. Nevertheless, the MISS group showed a clear and significant improvement in terms of blood loss, operation time, and bed rest length, which is associated with a more rapid functional recovery and discharge from the hospital. Postoperative pain and the need for opioid administration were also significantly less pronounced in the MISS group. Results from the EORTC QLQ-C30 and QLQ-BM22 scales showed a more pronounced improvement in quality of life at follow-up in the MISS group. CONCLUSIONS In the authors' opinion, MISS techniques should be considered the first choice for the treatment for patients with spinal metastasis and myelopathy. MISS is as safe and effective for spinal cord decompression and spine fixation as traditional surgery, and it also reduces the impact of surgery in critical patients. However, further studies are needed to confirm these findings.
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Affiliation(s)
- Massimo Miscusi
- Department of Medico-Surgical Sciences and Biotechnologies, and
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Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To determine the risk profile and complications associated with anterior vertebral body breach by Kirschner (K)-wire during percutaneous pedicle screw insertion. SUMMARY OF BACKGROUND DATA Percutaneous techniques and indications are rapidly expanding with numerous studies now supporting the use of percutaneous pedicle screw stabilization as an adjunct for multiple pathologies such as degenerative, tumor, and trauma. With regards to complication rates, little has been documented. MATERIALS AND METHODS A total of 525 consecutive percutaneous pedicle screws were retrospectively reviewed and the rate of anterior vertebral body breach was recorded, including any potential adverse clinical outcomes. RESULTS Of 525 percutaneous pedicle screw insertions, there were 7 anterior breaches recorded. We rated the breaches as a minor breach (<5 mm; n=3), moderate breach (5-25 mm; n=2), and major breach (>25 mm; n=2). Two patients had a postoperative ileus with a retroperitoneal hematoma on postoperative computed tomography scan. No patient required reoperation or blood transfusion. CONCLUSIONS The indications for minimally invasive spinal fusion have expanded to include conditions such as degenerative, trauma, deformity, infection, and neoplasia. Although the rate of anterior K-wire breach is low, the technique requires the acquisition of a new set of skills including the safe passage of a K-wire, and knowledge of potential complications that may ensue.
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Saigal R, Wadhwa R, Mummaneni PV, Chou D. Minimally Invasive Extracavitary Transpedicular Corpectomy for the Management of Spinal Tumors. Neurosurg Clin N Am 2014; 25:305-15. [DOI: 10.1016/j.nec.2013.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Park MS, Deukmedjian AR, Uribe JS. Minimally invasive anterolateral corpectomy for spinal tumors. Neurosurg Clin N Am 2014; 25:317-25. [PMID: 24703449 DOI: 10.1016/j.nec.2013.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Traditional open anterior and posterior approaches for the thoracic and thoracolumbar spine are associated with approach-related morbidity and limited surgical access to the level of abnormality. This article describes the minimally invasive anterolateral corpectomy for the treatment of spinal tumors, and reviews the current literature.
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Affiliation(s)
- Michael S Park
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606, USA.
| | - Armen R Deukmedjian
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606, USA
| | - Juan S Uribe
- Department of Neurosurgery & Brain Repair, Morsani College of Medicine, University of South Florida, 2 Tampa General Circle, 7th Floor, Tampa, FL 33606, USA
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Verdú-López F, Beisse R. [Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 2: treatment of the thoracic disc hernia, spinal deformities, spinal tumors, infections and miscellaneous]. Neurocirugia (Astur) 2014; 25:62-72. [PMID: 24456908 DOI: 10.1016/j.neucir.2013.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Revised: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has evolved greatly since it appeared less than 20 years ago. It is currently used in a large number of processes and injuries. The aim of this article, in its two parts, is to review the current status of VATS of the thoracic and lumbar spine in its entire spectrum. DEVELOPMENT After reviewing the current literature, we developed each of the large groups of indications where VATS takes place, one by one. This second part reviews and discusses the management, treatment and specific thoracoscopic technique in thoracic disc herniation, spinal deformities, tumour pathology, infections of the spine and other possible indications for VATS. 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 spinal deformities, spinal tumours, infections and other pathological processes, as well as the reconstruction of injured spinal segments and decompression of the spinal canal if lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in regard to 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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Kaloostian PE, Yurter A, Zadnik PL, Sciubba DM, Gokaslan ZL. Current paradigms for metastatic spinal disease: an evidence-based review. Ann Surg Oncol 2013; 21:248-62. [PMID: 24145995 DOI: 10.1245/s10434-013-3324-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Management of metastatic spine disease is quite complex. Advances in research have allowed surgeons and physicians to better provide chemotherapeutic agents that have proven more efficacious. Additionally, the advancement of surgical techniques and radiosurgical implementation has altered drastically the treatment paradigm for metastatic spinal disease. Nevertheless, the physician-patient relationship, including extensive discussion with the neurosurgeon, medicine team, oncologists, radiation oncologists, and psychologists, are all critical in the evaluation process and in delivering the best possible care to our patients. The future remains bright for continued improvement in the surgical and nonsurgical management of our patients with metastatic spine disease. METHODS We include an evidence-based review of decision making strategies when attempting to determine most efficacious treatment options. Surgical treatments discussed include conventional debulking versus en bloc resection, conventional RT, and radiosurgical techniques, and minimally invasive approaches toward treating metastatic spinal disease. CONCLUSIONS Surgical oncology is a diverse field in medicine and has undergone a significant paradigm shift over the past few decades. This shift in both medical and surgical management of patients with primarily metastatic tumors has largely been due to the more complete understanding of tumor biology as well as due to advances in surgical approaches and instrumentation. Furthermore, radiation oncology has seen significant advances with stereotactic radiosurgery and intensity-modulated radiation therapy contributing to a decline in surgical treatment of metastatic spinal disease. We analyze the entire spectrum of treating patients with metastatic spinal disease, from methods of diagnosis to the variety of treatment options available in the published literature.
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Affiliation(s)
- P E Kaloostian
- Department of Neurosurgery, The Johns Hopkins Hospital, Baltimore, MD, USA
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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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Case report: Curetting osteoid osteoma of the spine using combined video-assisted thoracoscopic surgery and navigation. Clin Orthop Relat Res 2013; 471:680-5. [PMID: 23212772 PMCID: PMC3549152 DOI: 10.1007/s11999-012-2725-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 11/19/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND A spinal osteoid osteoma is a rare benign tumor. The usual treatment involves complete curettage including the nidus. In the thoracic spine, conventional open surgical treatment usually carries relatively high surgical risks because of the close anatomic relationship to the spinal cord, nerve roots, and thoracic vessels, and pulmonary complications and postoperative pain. CASE REPORT We report the case of a 16-year-old girl with a symptomatic osteoid osteoma at the T9 level whose lesion was currettaged using video-assisted thoracoscopic surgery (VATS) guided by a navigation system (VATS-NAV). There were no complications and the patient had immediate relief of the characteristic pain after surgery and was asymptomatic at 5 months' followup. LITERATURE REVIEW Progressive advances in the technology of spinal surgery have evolved to offer greater safety and less morbidity for patients. The advent of minimally invasive surgery has expanded the indications for VATS for anterior spinal disorders. Spinal navigation systems have become useful tools allowing localization and excision of the nidus of osteoid osteomas with minimal bone resection and without radiation exposure. CLINICAL RELEVANCE The VATS-NAV combination in our patient allowed accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability.
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Thoracoscopic maneuvers for chest wall resection and reconstruction. J Thorac Cardiovasc Surg 2012; 144:S52-7. [DOI: 10.1016/j.jtcvs.2012.06.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 03/31/2012] [Accepted: 06/05/2012] [Indexed: 11/19/2022]
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Minimally invasive thoracic corpectomy: surgical strategies for malignancy, trauma, and complex spinal pathologies. Minim Invasive Surg 2012; 2012:213791. [PMID: 22888418 PMCID: PMC3409553 DOI: 10.1155/2012/213791] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Accepted: 06/07/2012] [Indexed: 11/17/2022] Open
Abstract
The rapid expansion of minimally invasive techniques for corpectomy in the thoracic spine provides promise to redefine treatment options in this region. Techniques have evolved permitting anterior, lateral, posterolateral, and midline posterior corpectomy in a minimally invasive fashion. We review the numerous techniques that have been described, including thoracoscopy, tubular retraction, and various instrumentation techniques. Minimally invasive techniques are compared to their open predecessors from a technical and complication standpoint. Advantages and disadvantages of different approaches are also considered, with an emphasis on surgical strategies and nuance.
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Rocco G, Serra L, Mehrabi-Kermani F, Setola S. Video-assisted paraspinal approach for the stabilization of the complex spine. Interact Cardiovasc Thorac Surg 2012; 15:585-7. [PMID: 22791788 DOI: 10.1093/icvts/ivs303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Access to complex conditions of the thoracic spine and of the posterior mediastinum offers significant challenges, especially if the surgeon wishes to comply with the principles of minimal invasiveness. We report a successful vertical, paraspinal incision along with the subperiosteal removal of the overlying 2-cm rib segments combined with video assistance through single-access video-assisted thoracic surgery to perform a total T6 and partial T7 corpectomy for a metastatic multiple myeloma in a 50-year old man. This approach appears to provide excellent exposure and minimal morbidity when a reliable approach to the complex spine is needed.
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Affiliation(s)
- Gaetano Rocco
- Department of Thoracic Surgery, National Cancer Institute, Pascale Foundation, Naples, Italy.
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Abstract
Minimally invasive spine surgery (MISS) techniques were developed to address morbidities associated with open spinal surgery approaches. MISS was initially applied for indications such as the microendoscopic decompression of stenosis (MEDS)-an operation that has become widely implemented in modern spine surgery practice. Minimally invasive surgery for MEDS is an excellent example of how an MISS technique has improved outcomes compared with the use of traditional open surgical procedures. In parallel with reports of surgeon experience, accumulating clinical evidence suggests that MISS is favoured over open surgery, and one could argue that the role of MISS techniques will continue to expand. As the field of minimally invasive surgery has developed, MISS has been implemented for the treatment of increasingly difficult and complex pathologies, including trauma, spinal malignancies and spinal deformity in adults. In this Review, we present the accumulating evidence in support of minimally invasive techniques for established MISS indications, such as lumbar stenosis, and discuss the need for additional level I and level II data to demonstrate the benefit of MISS over traditional open surgery. The expanding utility of MISS techniques to address an increasingly broad range of spinal pathologies is also highlighted.
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Milchteim C, Yu WD, Ho A, O'Brien JR. Anatomical parameters of subaxial percutaneous transfacet screw fixation based on the analysis of 50 computed tomography scans: Clinical article. J Neurosurg Spine 2012; 16:573-8. [PMID: 22519926 DOI: 10.3171/2012.3.spine11449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cervical transfacet screw placement has been described in the literature. Although the technique shows promise for percutaneous application, parameters for screw placement have not been well delineated. This study used reconstructed CT scans with imaging software to assess the feasibility of percutaneous transfacet screw placement, analyzing potential entry angles, transfacet lengths, and sex differences at each subaxial level. METHODS Fifty consecutive cervical CT scans (obtained in 26 males and 24 females [mean age 41.5 years]) were reformatted using OsiriX software, and transfacet lengths, entry angles, and potential occipital clearance were analyzed at all subaxial levels. Statistical analyses were used to determine the differences, if any, between transfacet lengths, entry angle, and occipital clearance across individual cervical levels. Repeatability was quantified by calculating the intraclass correlation coefficient and Cohen kappa value. RESULTS A total of 200 transfacet lengths and 200 entry angles in 50 patients were analyzed. The mean transfacet lengths were 17.9 ± 2.6, 17.6 ± 3.2, 16.3 ± 3.6, and 13.1 ± 2.2 mm at C3-4, C4-5, C5-6, and C6-7, respectively, with mean entry angles at 52.7° ± 7.8°, 56.5° ± 8.0°, 55.0° ± 8.8°, and 53.0° ± 8.7°, respectively. Analysis of variance revealed a significant difference between the mean transfacet lengths, while post hoc analysis revealed significantly larger transfacet lengths in the upper 2 cervical levels (C3-4 and C4-5) than in the lower 2 cervical levels (C5-6 and C6-7). Analysis of variance demonstrated no significant difference between the entry angles. Males had significantly larger transfacet lengths at C5-6 (17.4 vs 15.1 mm) and C6-7 (13.7 vs 12.4 mm) than females. The occiput would have blocked percutaneous screw placement in 86%, 78%, 54%, and 20% of the cases at C3-4, C4-5, C5-6, and C6-7, respectively. Transfacet lengths may accommodate longer screws in the upper cervical spine, but potential screw sizes decrease in the lower subaxial levels. A transfacet entry angle of approximately 50° or greater was associated with a higher incidence of occipital clearance. Additionally, the occiput may pose a significant obstruction to percutaneous transfacet fixation in upper subaxial levels. Interrater reliability was poor for screw angle and length measurements, but was satisfactory in intrarater analysis in 6 of 8 measurements. There was moderate to good agreement of occipital clearance in all but one measurement. CONCLUSIONS Cervical transfacet screw placement is possible from C-3 to C-7. Because occipital clearance can be difficult at C3-4 and C6-7, the use of curved or flexible instruments may be necessary to obtain the appropriate screw trajectory. Screw lengths varied with spinal level and the sex of the patient.
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Affiliation(s)
- Charles Milchteim
- Department of Orthopaedic Surgery, George Washington University, Washington, DC, USA
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Minimally invasive surgery compared to open spinal fusion for the treatment of degenerative lumbar spine pathologies. J Clin Neurosci 2012; 19:829-35. [PMID: 22459184 DOI: 10.1016/j.jocn.2011.10.004] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Revised: 10/04/2011] [Accepted: 10/09/2011] [Indexed: 01/04/2023]
Abstract
This clinical study prospectively compares the results of open surgery to minimally invasive fusion for degenerative lumbar spine pathologies. Eighty-two patients were studied (41 minimally invasive surgery [MIS] spinal fusion, 41 open surgical equivalent) under a single surgeon (R. J. Mobbs). The two groups were compared using the Oswestry Disability Index, the Short Form-12 version 1, the Visual Analogue Scale score, the Patient Satisfaction Index, length of hospital stay, time to mobilise, postoperative medication and complications. The MIS cohort was found to have significantly less postoperative pain, and to have met the expectations of a significantly greater proportion of patients than conventional open surgery. The patients who underwent the MIS approach also had significantly shorter length of stay, time to mobilisation, lower opioid use and total complication rates. In our study MIS provided similar efficacy to the conventional open technique, and proved to be superior with regard to patient satisfaction, length of hospital stay, time to mobilise and complication rates.
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Abuzayed B, Tuna Y, Gazioglu N. Thoracoscopic anatomy and approaches of the anterior thoracic spine: cadaver study. Surg Radiol Anat 2012; 34:539-49. [PMID: 22374583 DOI: 10.1007/s00276-012-0949-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 02/17/2012] [Indexed: 12/23/2022]
Abstract
PURPOSE [corrected] In spite of the extensive case studies considering thoracoscopic approaches to the anterior thoracic spine, the literature lacks studies of the thoracoscopic anatomic dissection and approaches. In this article, the authors present their study of thoracoscopic anatomy of the anterior spine with illustrated step-wise dissection and approaches for sympathectomy, discectomy and corpectomy. MATERIALS AND METHODS Four adult cadavers with no history of disease, local trauma or surgery were studied and bilateral thoracoscopic anterior spinal approaches were performed. Thoracoscopic dissections were done in the Department of Anatomy, using Karl Storz 30°, 5 mm and 30 cm rod lens rigid endoscope (Karl Storz and Co., Tuttlingen, Germany). As surgical instrumentation, Karl Storz Rosenthal endoscopic surgical set and 15 mm portals were used for all approaches. RESULTS For sympathectomy, the cadaver is positioned supine and the port locations are in the third and fifth intercostal spaces in the anterior axillary line. The stellate ganglion is cephalad to the second rib, and the T2 and T3 ganglia are divided just superior to T2 ganglia and inferior to T3. For discectomy, the cadaver is positioned in the lateral decubitus position. The working portal is positioned directly over the affected disc in the posterior axillary line. The camera portal is positioned in the middle axillary line; 2-3 intercostal spaces caudal to the working portal. The rib head is removed and the lateral surface of the pedicle and neural foramen are exposed. The pedicle and the floor of the spinal canal are resected to decompress the ventral aspect of the spinal canal. For corpectomy, the position of the cadaver and ports are as same as for discectomy. The adjacent segmental vessels are divided first, and the discs above and below the targeted corpus are removed. The ipsilateral pedicle is then removed to decompress the anterior spinal cord, followed by median corpectomy. CONCLUSIONS Thoracoscopic approaches are minimally invasive procedures and they can be used safely in patients who need anterior exposure to the thoracic spine for the treatment of a spectrum of diseases. Knowledge of the normal anatomy and thoracoscopic cadaver dissection are essential steps in improving the learning curve.
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Affiliation(s)
- Bashar Abuzayed
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
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Taghva A, Hoh DJ, Lauryssen CL. Advances in the management of spinal cord and spinal column injuries. HANDBOOK OF CLINICAL NEUROLOGY 2012; 109:105-30. [PMID: 23098709 DOI: 10.1016/b978-0-444-52137-8.00007-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Spinal cord injury (SCI) is a significant public problem, with recent data suggesting that over 1 million people in the U.S.A. alone are affected by paralysis resulting from SCI. Recent advances in prehospital care have improved survival as well as reduced incidence and severity of SCI following spine trauma. Furthermore, increased understanding of the secondary mechanisms of injury following SCI has provided improvements in critical care and acute management in patients suffering from SCI, thus limiting morbidity following injury. In addition, improved technology and biomechanical understanding of the mechanisms of spine trauma have allowed further advances in available techniques for spinal decompression and stabilization. In this chapter we review the most recent data and salient literature regarding SCI and address current controversies, including the use of pharmacological adjuncts in the setting of acute SCI. We will also attempt to provide a reader with basic understanding of the classifications of SCI and spinal column injury. Finally, we review advances in spinal column stabilization including improvements in instrumented fusion and minimally invasive surgery.
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Affiliation(s)
- Alexander Taghva
- Department of Neurological Surgery, University of Southern California, Los Angeles, CA, USA.
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Smith ZA, Yang I, Gorgulho A, Raphael D, De Salles AAF, Khoo LT. Emerging techniques in the minimally invasive treatment and management of thoracic spine tumors. J Neurooncol 2011; 107:443-55. [DOI: 10.1007/s11060-011-0755-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2011] [Accepted: 10/24/2011] [Indexed: 10/15/2022]
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Krisht KM, Mumert ML, Schmidt MH. Management considerations and strategies to avoid complications associated with the thoracoscopic approach for corpectomy. Neurosurg Focus 2011; 31:E14. [PMID: 21961858 DOI: 10.3171/2011.8.focus11133] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The thoracoscopic approach to the anterior spine is a practical and valuable means of approaching ventral spinal lesions but demands advanced technical skills and fine hand-eye coordination that is usually acquired with experience. A mutual understanding of all the ventilatory and surgical steps allows for an organized orchestration between the anesthesiologist and surgeon, which ultimately helps minimize potential complications. Despite a concerted effort by all involved to avoid risks, thoracoscopic surgery is associated with complications for which the surgical team should be cognizant. In this paper, the authors detail the operative technique of vertebral corpectomy and interbody fusion via the thoracoscopic approach for the treatment of ventral spinal pathology involving the thoracic and lower lumbar spine, discuss complications known to occur with the thoracoscopic approach, and present means to help avoid them.
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Affiliation(s)
- Khaled M Krisht
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah 84132, USA
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A systematic review of the current role of minimally invasive spine surgery in the management of metastatic spine disease. Int J Surg Oncol 2011; 2011:598148. [PMID: 22312514 PMCID: PMC3263667 DOI: 10.1155/2011/598148] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Accepted: 03/30/2011] [Indexed: 02/08/2023] Open
Abstract
Although increasingly aggressive decompression and resection methods have resulted in improved outcomes for patients with metastatic spine disease, these aggressive surgeries are not feasible for patients with numerous comorbid conditions. Such patients stand to benefit from management via minimally invasive spine surgery (MIS), given its association with decreased perioperative morbidity. We performed a systematic review of literature with the goal of evaluating the clinical efficacy and safety of MIS in the setting of metastatic spine disease. Results suggest that MIS is an efficacious means of achieving neurological improvement and alleviating pain. In addition, data suggests that MIS offers decreased blood loss, operative time, and complication rates in comparison to standard open spine surgery. However, due to the paucity of studies and low class of available evidence, the ability to draw comprehensive conclusions is limited. Future investigations should be conducted comparing standard surgery versus MIS in a prospective fashion.
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Mobbs RJ, Sivabalan P, Li J. Technique, challenges and indications for percutaneous pedicle screw fixation. J Clin Neurosci 2011; 18:741-9. [PMID: 21514165 DOI: 10.1016/j.jocn.2010.09.019] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 01/27/2023]
Abstract
Minimally invasive techniques in spinal surgery are increasing in popularity due to numerous potential advantages, including reduced length of stay, blood loss and requirements for post-operative analgesia as well as earlier return to work. This review discusses guidelines for safe implantation of percutaneous pedicle screws using an image intensifier technique. As indications for percutaneous pedicle screw techniques expand, the nuances of the minimally invasive surgery technique will also expand. It is paramount that experienced surgeons share their collective knowledge to assist surgeons at their early attempts of these complex, and potentially dangerous, procedures. Technical challenges of percutaneous pedicle screw fixation techniques are also discussed including: small pedicle cannulation, percutaneous rod insertion for multilevel constructs, incision selection for multilevel constructs, changing direction with percutaneous pedicle screw placement, L5/S1 screw head proximity and sclerotic pedicles with difficult Jamshidi placement. We discuss potential indications for minimally invasive fusion techniques for complex spinal surgery and support these with descriptions of illustrative patients.
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Affiliation(s)
- Ralph J Mobbs
- Department of Neurosurgery, Prince of Wales Private Hospital, Sydney Spine Clinic, Randwick, New South Wales 2031, Australia.
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Di X, Sui A, Hakim R, Wang M, Warnke JP. Endoscopic minimally invasive neurosurgery: emerging techniques and expanding role through an extensive review of the literature and our own experience - part II: extraendoscopic neurosurgery. Pediatr Neurosurg 2011; 47:327-36. [PMID: 22456199 DOI: 10.1159/000336019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/15/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The field of minimally invasive neurosurgery has grown dramatically especially in the last decades. This has been possible, in the most part, due to the advancements in technology especially in tools such as the endoscope. The contemporary classification scheme for endoscopic procedures needs to advance as well. METHODS The present classification scheme for neuroendoscopic procedures has become confusing because it mainly describes the use of the endoscope as an assisting device to the microscope. The authors propose an update to the current classification that reflects the independence of the endoscope as a tool in minimally invasive neurosurgery. RESULTS The proposed classification groups the procedures as 'intraendoscopic' neurosurgery or 'extraendoscopic' neurosurgery (XEN) in relation to the 'axis' of the endoscope. A review of the literature for the XEN group together with exemplary cases is presented. CONCLUSION We presented our proposed classification for the endoscope-only surgical procedures. The XEN group is expanded in this article.
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Affiliation(s)
- Xiao Di
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
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Uribe JS, Dakwar E, Le TV, Christian G, Serrano S, Smith WD. Minimally invasive surgery treatment for thoracic spine tumor removal: a mini-open, lateral approach. Spine (Phila Pa 1976) 2010; 35:S347-54. [PMID: 21160399 DOI: 10.1097/brs.0b013e3182022d0f] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective registry. OBJECTIVE The objective of this study is to examine procedural and long-term outcomes of a mini-open, lateral approach for tumor removal in the thoracic spine. SUMMARY OF BACKGROUND DATA The majority of spinal tumors present as metastatic tumors in the thoracic spine. Conventional surgical treatments have been associated with high rates of approach-related morbidities as well as difficult working windows for complete tumor excision. Recent advances in minimally invasive techniques, particularly mini-open (minimally invasive, not endoscopic) approaches, help to reduce the morbidities of conventional procedures with comparable outcomes. METHODS Twenty-one consecutively treated patients at 2 institutions were treated between 2007 and 2009. Treatment variables, including operating time, estimated blood loss, length of hospital stay, and complications were collected, as were outcome measures, including the visual analog scale for pain and the Oswestry disability index. RESULTS Twenty-one patients with thoracic spinal tumors were successfully treated with a minimally invasive lateral approach. Operating time, estimated blood loss, and length of hospital stay were 117 minutes, 291 mL, and 2.9 days, respectively. One (4.8%) perioperative complication occurred (pneumonia). Mean follow-up was 21 months. Two patients had residual tumor at last follow-up. Two patients died during the study as the result of other metastases (spine tumor was secondary). Visual analog scale improved from 7.7 to 2.9 and Oswestry disability index improved from 52.7% to 24.9% from preoperative to the last follow-up. CONCLUSION The mini-open lateral approach described here can be performed safely and without many of the morbidities and difficulties associated with conventional and endoscopic procedures. Proper training in minimally invasive techniques and the use of direct-visualization minimally invasive retractors are required to safely and reproducibly treat these complex indications.
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Affiliation(s)
- Juan S Uribe
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA.
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Abstract
STUDY DESIGN Case report and review of the literature. OBJECTIVE We report a case of splenic rupture in association with thoracoscopic spine surgery. SUMMARY OF BACKGROUND DATA Complications of thoracoscopic spine surgery have been reported in the literature, including pleural effusion, pneumothorax, chyle thorax, intercostal neuralgia, cerebrospinal fluid fistula, lung injury, and great vessel injury. Although it has been reported to have occurred with other endoscopic procedures, splenic rupture has not been reported in association with thoracoscopic spine surgery. METHODS A 60-year-old man with a T12 spine lesion underwent T12 corpectomy and fusion using a thoracoscopic approach. Intraoperatively, he became hemodynamically unstable, and postoperative abdominal computed tomography was consistent with splenic rupture. RESULTS He underwent emergent splenectomy and has made a good recovery. CONCLUSION This case describes how retraction on the diaphragm during thoracoscopic spine surgery can lead to splenic injury. A high index of suspicion should be maintained in cases in which hemodynamic instability is identified despite a clean surgical field.
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Blood transfusions after thoracoscopic anterior thoracolumbar vertebrectomy. Acta Neurochir (Wien) 2010; 152:597-603. [PMID: 19907918 DOI: 10.1007/s00701-009-0549-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Accepted: 10/12/2009] [Indexed: 10/20/2022]
Abstract
PURPOSE Anterior vertebral body reconstruction (AVBR) for trauma or tumor involves corpectomy and placement of hardware to reconstitute the anterior weight-bearing stability of the spine. We report our clinical experience with thoracoscopic techniques for AVBR. METHODS We retrospectively analyzed patients who underwent thoracoscopic AVBR surgery for expandable cage placement. We report pathological condition, patient age, vertebral body level, operative time, estimated blood loss (EBL), and need for blood transfusion. RESULTS Twenty-one expandable cages were placed thoracoscopically in 15 fractures and six tumors. In fracture cases, mean age, operative time, EBL, and transfusion rate were 36.7 years, 4.9 h, 543 mL, and 7% (1/15), respectively. In tumor cases, mean age, operative time, EBL, and transfusion rate were 61.9 years, 4.9 h, 758 mL, and 17% (1/6), respectively. CONCLUSIONS Thoracoscopic AVBR with expandable cages can be accomplished safely with acceptable operative times and blood loss and low transfusion rates.
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