Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases

Giant calcified thoracic disk herniations: ossification of PLL or autonomous entity?

BACKGROUND

Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of ossified posterior longitudinal ligament (OPLL) with a possible common pathophysiology consisting in the dural violation.

METHODS

Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital, Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed.

RESULTS

There was no mortality, whereas permanent morbidity consisted of 1 case of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL.

CONCLUSIONS

GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.

Single-Stage Posterior Transpedicular Corpectomy and 360-Degree Reconstruction for Thoracic and Lumbar Burst Fractures: Technical Nuances and Outcomes

BACKGROUND

 We evaluate the feasibility of a single-stage posterior corpectomy and circumferential arthrodesis with the aid of spinal navigation for the treatment of traumatic thoracolumbar burst fractures.

METHODS

 This was a single-center, retrospective study. Demographics, clinical, and radiologic data of 19 patients who underwent surgery at our institution for thoracolumbar burst fractures between 2016 and 2019 were collected. All patients enrolled in the present study underwent surgery by means of posterior fixation and transpedicular corpectomy with the aid of an intraoperative image-guided neuronavigation system.

RESULTS

 Postoperative correction of the vertebral height ratio was achieved in all cases, with an average increase of 23.6% (p = 0.0005). No statistical differences (p = 0.9) were found comparing 1- and 3-month postoperative CT scans, in relation to vertebral height ratio. A statistically significant difference was found between the pre- and postoperative kyphotic angles for the thoracolumbar and lumbar segments (p = 0.0018 and 0.005, respectively), but no difference was found between kyphotic angles at the 3-month follow-up. A unilateral approach was performed on 15 patients (79%), while 4 cases (21%) required a bilateral laminectomy. We did not observe any significant intraoperative complication.

CONCLUSION

 Single-stage posterior corpectomy and fixation is a safe and effective approach for thoracic and lumbar burst fractures. It provides excellent 360-degree reconstruction in a single surgical stage with satisfactory results in terms of kyphosis reduction, biomechanical stability, and reduced invasiveness. Spinal navigation represents a fundamental tool to overcome some anatomical limits of the presented technique.

Outcomes of Anterior Decompression and Anterior Instrumentation in Thoracolumbar Burst Fractures-A Prospective Observational Study With Mid-Term Follow-up

OBJECTIVE

To analyze the functional, neurological, and radiological outcomes after anterior surgery in thoracolumbar burst fractures.

DESIGN

Prospective observational study.

SETTING

Tertiary care hospital.

PATIENTS

Thirty-six patients with thoracolumbar burst fractures (T11-L2).

INTERVENTION

Anterior decompression, anterior column reconstruction with mesh cage, and instrumented stabilization.

OUTCOME

Functional (Visual Analog Score, Oswestry Disability Index, and Spinal Cord Independence Measure), neurological (ASIA Impairment Scale), and radiological (kyphosis, anterior vertebral height loss, canal encroachment %) parameters.

RESULTS

Patients were prospectively followed for a mean duration of 5.9 ± 3.2 years (2.4-10 years). Statistically significant improvement was noted in functional outcomes from preop values (P-value < 0.001). 29 patients (80.5%) had improvement in neurology after surgery at the final follow-up with a positive correlation with % change in canal encroachment (r = 0.64, P -0.018). The mean preoperative kyphosis of 29.1 ± 11.9 degrees got corrected to 9.4 ± 3.8 degrees in immediate postop and 15.7 ± 11.8 at the final follow-up(P < 0.001). Preoperative mean canal encroachment of 58.5 ± 15.7% was reduced to 6.5 ± 3.2% postoperatively (P < 0.001). Two patients developed neurological complications (subacute progressive ascending myelopathy), and 5 patients developed pulmonary complications. No pseudarthrosis, implant loosening, or cage migration was noted in any patient.

CONCLUSION

Anterior surgery performed in 36 patients with thoracolumbar burst fractures in our study showed good outcomes. 80.5% of patients improved in neurology after surgery by at least one ASIA Impairment Scale grade. There was statistically significant improvement noted in radiological outcome (Kyphosis and Canal encroachment %) and functional outcome (Visual Analog Score, Oswestry Disability Index, and Spinal Cord Independence Measure score) after surgery in immediate postop and at the final follow-up. Only 13.8% of patients developed pulmonary complications that were managed successfully with chest drain.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Minimally Invasive Lateral Corpectomy of the Thoracolumbar Spine: A Case Series of 20 Patients

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To report our experience with corpectomy of the thoracolumbar (TL) spine through a minimally invasive lateral retropleural or retroperitoneal approach.

METHODS

This is a retrospective case series of 20 consecutive patients who underwent minimally invasive TL corpectomy and spinal reconstruction. Electronic medical records were reviewed for demographic, operative, and clinical outcome data.

RESULTS

Between 2015 and 2019, 20 consecutive cases of minimally invasive TL corpectomy were performed, comprising 12 men (60%) and 8 women (40%) with a mean age of 54.3 years. Indications for surgery were infection (n = 6, 30%), metastatic disease (n = 2, 10%), fracture (n = 6, 30%), and calcified disc herniation (n = 6, 30%). Partial and complete corpectomy was performed in 5 patients (25%) and 15 patients (75%), respectively. Mean operative time and estimated blood loss was 276.2 minutes and 558.4 mL, respectively. Mean length of stay from admission and surgery were 14.6 and 11.4 days, respectively. Mean length of stay from surgery for elective cases was 4.2 days. Mean follow-up time was 330.4 days. Visual analogue scale score improved from 7.7 to 4.5 (P < .01). There were a total of 3 postoperative complications in 2 patients, including 1 mortality for urosepsis. One patient had revision spinal surgery for adjacent segment disease.

CONCLUSIONS

Corpectomy and reconstruction of the TL spine is feasible and safe using a minimally invasive lateral retropleural or retroperitoneal approach. Since this is a relatively new technique, more studies are needed to compare the short- and long-term radiographic and clinical outcomes between minimally invasive versus open corpectomy of the TL spine.

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

Objective:

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

Materials and Methods:

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

Results:

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

Conclusion:

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

Transpedicular Approach for Corpectomy and Circumferential Arthrodesis in Traumatic Lumbar Vertebral Body Burst Fractures: A Retrospective Analysis of Outcome in 35 Patients

Background

Traumatic vertebral burst fractures can be surgically approached via different approaches (anterior/posterior, or combined). Transpedicular approach (TA) is a posterior approach that has the advantage of achieving circumferential arthrodesis via single posterior only approach. The purpose of this study was to analyze our experience with TA in management of traumatic lumbar burst fractures (TLBFs).

Materials and Methods

All consecutive patients with TLBFs managed with TA over 5 years duration were included in this retrospective study. Correction of kyphotic deformity and change in neurological status were analyzed to assess outcome. Cobb's angle and ASIA grade were used for this purpose.

Results

There were 21 males and 14 females. Eight patients had complete (ASIA-A) while 22 had incomplete injury. All patients had a TLICS score >=4. The mean preoperative Cobb's angle was 13.97° that improved to -3.57° postoperatively (mean kyphosis correction-17.54°). None of the patients developed iatrogenic nerve root injury. There was no perioperative mortality. The mean cobb's angle was 1.23° at 39.1 months follow-up. Eight patients developed cage subsidence but none required revision surgery. Postoperatively, 27 (77.1%) patients showed neurological improvement and none deteriorated. The median ASIA score improved from 3 to 5. A fusion rate of 91.4% was observed at last follow-up.

Conclusions

The advantages of TA including sense of familiarity with posterior approach amongst spine surgeons, lesser approach-related morbidity, and results comparable to anterior/combined approaches, make TA an attractive option for managing TLBFs. Although technically difficult, it can be successfully used for circumferential arthrodesis in lumbar region without sacrificing nerve roots.

Combined, Rib-Sparing, Bilateral Approach to the Ventral Mid and Low Thoracic Spine: Study on Comparative Anatomy and Surgical Feasibility

BACKGROUND

Pathologies of the ventral thoracic spine represent a challenge, igniting arguments about which should be the ideal surgical approach to access this area. Anterior transthoracic thoracotomy and a number of posterolateral routes have been developed. Among the latter, costotransversectomy has demonstrated to provide good ventral exposure with a lower, but not negligible, morbidity. The optimal approach should be the one minimizing surgical morbidity on both neural and extraneural structures while optimizing exposure.

METHODS

The authors described the combined, rib-sparing, bilateral approach (CRBA) to the ventral mid/low-thoracic spine. The technique combines a transfacet pedicle partially sparing approach on one side and a transpedicular with transverse process resection on the contralateral one. A laboratory investigation was conducted. The technique was applied in a surgical setting, and a case was reported.

RESULTS

CRBA is rib-sparing, completely extracavitary, and does not require pleural exposure and paraspinal muscle splitting, thus minimizing potential morbidity. The combination of 2 corridors ensures the greatest exposure compared with standard posterolateral approaches. The only blind corner is limited to a small area just in front of the dural sac. A bimanual approach optimizes control during surgical manipulation, even if the area of maneuverability and cross-section areas of surgical corridors are slightly limited compared to traditional costotransversectomy due to the minimally invasive nature of the procedure.

CONCLUSIONS

CRBA represents a safe and effective option to access the ventral mid/low thoracic spine. It provides great exposure and bimanual manipulation of the surgical target, minimizes potential morbidity, and avoids entrance into the thoracic cavity and paraspinal muscle splitting.

[Lateral retropleural and retrodiaphragmatic approach in patients with spine trauma and diseases: a systematic review and meta-analysis]

BACKGROUND

Retropleural and/or retrodiaphragmatic approach is one of the options for anterolateral access to the thoracic spine and thoracolumbar region. This technique has no disadvantages associated with thoracotomy or extensive tissue dissection following posterolateral approaches.

OBJECTIVE

Systematic analysis of foreign and national researches devoted to the possibility, safety and effectiveness of lateral retropleural approach to the thoracic spine and meta-analysis of the most common complications associated with this approach.

MATERIAL AND METHODS

Initial searching revealed 133 abstracts for further study. Inclusion criteria: 1) available full-text version of the manuscript in English or Russian; 2) age of patients over 18 years; 3) description of lateral retropleural or retrodiaphragmatic approach complicated or not complicated by access-associated complications. According to these criteria, we enrolled 10 manuscripts.

RESULTS

Meta-analysis showed high (10.6%) probability of pleural injury associated with surgical approach. Compared to endoscopic transthoracic interventions, the above-mentioned access is characterized by similar or slightly greater blood loss (401.2 ml vs. 100-775 ml) and slightly longer surgery time (200.5 vs. 97.5-186 min) that may be due to small number of interventions and relatively little experience of such operations. The number of patients with approach-related complications is comparable to that for endoscopic transthoracic access (5% vs. 3.7-13.3%). Compared to transthoracic minithoracotomy, this approach is characterized by similar blood loss (401.2 vs. 391 ml), longer surgery time (200.5 vs. 168 min) and similar or lower morbidity (5% vs. 5-13.5%).

CONCLUSION

Minimally invasive anterolateral retropleural and/or retrodiaphragmatic approach to the thoracic spine and thoracolumbar junction for corpectomy and discectomy ensures effective spinal canal decompression and less incidence of complications following open or thoracoscopic thoracic spine surgery. Dissection of parietal pleura should be of special attention because injury of this structure occurs in 10.6% of cases. Skin incision 7.1 cm and rib resection for at least 5 cm may be valuable to prevent plural damage.

Short-segment decompression and fixation for thoracolumbar osteoporotic fractures with neurological deficits

Objective

We assessed our results of short-segment decompression and fixation for osteoporotic thoracolumbar fractures with neurological deficits.

Methods

We evaluated 20 elderly patients (age, 60–89 years; mean, 73.2 years) with osteoporotic thoracolumbar fractures and neurological deficits. They underwent short-segment decompression and fixation and followed up for 40.6 (range, 24–68) months. A visual analog scale (VAS) and the Oswestry Disability Index (ODI) were used to measure back pain and disability. We also analyzed patients’ radiologic findings and neurological status. Perioperative and postoperative complications were recorded.

Results

At the latest follow-up, the average VAS score for back pain and ODI scores had significantly improved. The radiologic assessment showed significant improvements in local kyphosis, anterior vertebral height, and the vertebral wedge angle compared with the original measures. Neurological function also improved in 18 of 20 patients. No major complications occurred perioperatively. Our techniques included preservation of the posterior ligament complex, decortication of facet joints for fusion, no tapping to increase the screw insertional torque, pre-contouring of the rods according to the “adaptive” curve obtained from postural reduction, and postoperative spinal bracing.

Conclusions

Posterior short-segment decompression and fixation could be an effective surgical option for osteoporotic thoracolumbar burst fractures with neurological deficits.

Management of Pediatric Posttraumatic Thoracolumbar Vertebral Body Burst Fractures by Use of Single-Stage Posterior Transpedicular Approach

PURPOSE

The posterior transpedicular approach (PTA) is a posterior approach that has the advantage of achieving circumferential arthrodesis by a single posterior-only approach. The purpose of this study was to analyze our experience with PTA in the management of pediatric traumatic thoracolumbar burst fractures (TTLBFs).

METHODS

Consecutive pediatric patients (age ≤18 years) with TTLBFs treated with PTA for 6 years were included in this retrospective study. Correction of kyphotic deformity and change in neurologic status were analyzed to assess outcome. The Cobb angle and American Spinal Injury Association (ASIA) grade were used for this purpose.

RESULTS

There were 6 male and 8 female patients. Five patients had complete injury (ASIA-A), and 9 had incomplete injury. The mean Thoracolumbar Injury Classification and Severity score was 6.71. The mean preoperative Cobb angle was 14.71° and improved to -3.35° postoperatively (mean kyphosis correction -18.05°). Two of the patients experienced iatrogenic nerve root injury. There was 1 postoperative mortality due to complications unrelated to the surgery. The mean Cobb angle was -0.07° at the 32.2-month follow-up visit. Six patients experienced cage subsidence, but none required revision surgery. Postoperatively, 11 (78.5%) patients showed neurologic improvement, and none experienced deterioration. The average ASIA score improved from 2.5 to 3.78. A fusion rate of 100% (n = 12) was observed at the last follow-up visit.

CONCLUSIONS

The present study demonstrates that PTA is a feasible approach in selected pediatric patients with unstable traumatic thoracolumbar burst fractures, with results comparable with those in the adult population. This study demonstrates in detail the procedure, along with the neurologic and radiologic outcomes of this approach in the pediatric population.

A quantitative analysis of posterolateral approaches to the ventral thoracic spinal canal

BACKGROUND CONTEXT

Various posterolateral approaches exist to access ventral thoracic spinal canal pathologies. Selecting the optimal surgical approach requires sound understanding of the exposure and working angle afforded by each approach.

PURPOSE

The purpose of this study was to quantify exposure of the ventral spinal canal with various posterolateral thoracic spinal approaches and to determine how regional anatomical differences affect measurements.

STUDY DESIGN

This is a quantitative anatomical cadaveric study.

METHODS

Four fresh cadaveric C7-L1 specimens were used with a saline infusion model to mimic in vivo thecal sac dimensions. Using stereotactic navigation, we measured exposure (expressed as percentage of total width) and maximum approach angle of the ventral spinal canal without thecal sac retraction after each surgical condition: laminectomy (L), 50% medial facetectomy (MF), transpedicular (TP), costotransversectomy (CTV), and lateral extracavitary (LE). The thoracic spine was divided into four regions (T1-T2, T3-T6, T7-T10, and T9-T12). A two-sided paired t test was used.

RESULTS

At T1-T2, visualized exposures were 25.8%, 31.5%, 42.3%, 45.1%, and 46.8%, respectively, after each surgical condition. Costotransversectomy and LE did not provide significant increase in exposure compared with the preceding condition. At T3-T6, exposures were 19.1%, 29.6%, 38.7%, 44.4%, and 44.5%, respectively. Only LE did not provide significant increase in exposure compared with the preceding condition. At T7-T10, visualized exposures were 17.9%, 30.6%, 39.9%, 44.9%, and 53.3%, respectively. All successive surgical conditions provided a significant increase in exposure. At T11-T12, visualized exposures were 14.2%, 25.8%, 43.1%, 47.7%, and 52.7%, respectively. Only LE did not provide a significant increase in exposure compared with the preceding condition. Each successive surgical condition provided a significantly increased lateral approach angle compared with the preceding condition, except LE at T1-T2. Maximum approach angle was more favorable at T1-T2 for L, MF, TP, and CTV compared with other thoracic regions.

CONCLUSIONS

Medial facetectomy and TP approaches provide significantly increased exposure of the ventral spinal canal at all thoracic regions. Costotransversectomy provided significantly increased exposure compared with TP at T3-T12. Lateral extracavitary only provided significantly increased exposure compared with CTV at T7-T10. The results of this study can be used preoperatively to determine the optimal approach based on quantitative measurements and region-specific anatomical differences.

Complication avoidance in the resection of spinal meningiomas

BACKGROUND

Surgical resection is considered the treatment of choice for spinal meningiomas and can be safe and effective; however, neurologic and surgical complications occur. This article reviews the factors that may predict susceptibility to this postoperative decline and addresses therapeutic choices, adjunctive therapies, and technologic applications that may help avoid complications.

METHODS

A literature search was conducted for articles related to spinal meningiomas addressing surgical treatment, adjuvant treatment, and technologic applications related to management and minimizing of complications.

RESULTS

There were 16 surgical series identified, comprising 1090 patients with median mortality of 1% (range, 0%-4%), nonneurologic surgical morbidity of 4% (range, 0%-24%), and permanent neurologic deterioration of 6% (range, 0%-21%). Common complications were cerebrospinal fluid leaks and fistulas, venous thromboembolic disease, myocardial infarction, and neurologic deterioration with either transient or permanent neurologic deficits. Predictive risk factors of neurologic decline included pathoanatomic features of lesion calcification, anterior dural attachment, infiltrative tumor, and tumoral adherence to the spinal cord and patient-specific factors of preoperative neurologic and advanced age.

CONCLUSIONS

Alongside surgery, selection of more direct approaches and use of adjuvant radiotherapy in patients with higher grade lesions and recurrent disease may lead to improved outcomes. New technologies, including microsurgical technique, intraoperative electrophysiologic monitoring, intraoperative ultrasound, and ultrasonic aspiration, may improve the safety and limit the complications of resection.

Comparison of minimal access and traditional anterior spinal surgery in managing infectious spondylitis: a minimum 2-year follow-up

BACKGROUND CONTEXT

Traditional anterior spinal surgery (TASS) for the thoracolumbar spine is associated with significant morbidities. To avoid excessive tissue damage, minimal access spinal surgery (MASS) has been developed to treat a variety of anterior spinal disorders at the authors' institution. No previous reports comparing the outcomes of MASS and TASS for the treatment of infectious spondylitis were noted in the literature, to our knowledge.

PURPOSE

The aim of this study was to investigate the outcomes of MASS in managing infectious spondylitis and compare the results to TASS with a minimum follow-up of 2 years.

STUDY DESIGN

A retrospective comparative cohort study in a single center.

PATIENT SAMPLE

Forty patients with thoracic or lumbar infectious spondylitis who underwent anterior spinal surgery were enrolled.

OUTCOME MEASURES

Perioperative data including operative time, estimated blood loss, packed red blood cell transfusion, postoperative tube drainage, need for intensive care, and length of hospital stay. Postoperative complications were classified according to the Clavien-Dindo system. Fusion grade was assessed by plain radiographs on the basis of Burkus criteria.

METHODS

Between January 2002 and June 2010, all enrolled patients were collected via the Spine Operation Registry of the authors' institution. There were 23 MASS patients and 17 TASS patients. The average follow-up was 4.2 years (range, 2-9 years).

RESULTS

The mean estimated blood loss in MASS and TASS groups was 521.7 versus 979.4 mL (p=.007), intraoperative transfusion of packed red blood cells was 0.9 versus 2.7 units (p=.019), the amount of postoperative tube drainage was 235.2 versus 454.3 mL (p=.005), the number of patients requiring postoperative intensive care was 2 versus 7 (p=.023), and length of hospital stay was 15.4 versus 22.9, respectively (p=.043). The overall complication rate in the MASS group was 17% and 59% in the TASS group (p=.007). No major complications occurred in the MASS group, whereas four occurred in the TASS group (p=.026). Bone graft union was achieved in 38 of 39 survival patients (97%), with no difference between the groups. One patient in TASS had a pseudarthrosis and needed a posterior instrumented fusion.

CONCLUSIONS

Minimal access spinal surgery has been suggested to be an effective and safe technique in treating thoracic and lumbar infectious spondylitis. Minimal access spinal surgery did not need endoscopic equipments or complex surgical instruments. Furthermore, in comparison to TASS, MASS resulted in a reduced blood transfusion amount, decreased intensive care unit stay, reduced overall length of stay, and reduced surgical complication rate. Nevertheless, the risks may be increased in performing MASS on patients with multilevel involvement, which could be associated with high vascularity, alternated vascular anatomy, increased soft-tissue edema, and adhesion.

Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications

STUDY DESIGN

Systematic review.

OBJECTIVE

The authors review complications, as reported in the literature, associated with ventral and posterolateral approaches to the thoracic spine.

SUMMARY OF BACKGROUND

The lateral extracavitary, costotransversectomy, and transthoracic thoracotomy techniques allow surgeons to access the ventral thoracic spine for a wide range of spinal disorders including tumor, degeneration, trauma, and infection. Although the transthoracic thoracotomy has been used traditionally to reach the ventral thoracic spine when access to the vertebral body is required, modifications to the various dorsal approaches have enabled surgeons to achieve goals of decompression, reconstruction, and stabilization through a single approach.

METHODS

A systematic Medline search from 1991 to 2011 was performed to identify series reporting clinical data related to these surgical approaches. The morbidity associated with each approach is reviewed and strategies for complications avoidance are discussed.

RESULTS

Four thousand six hundred seventy-seven articles that assessed outcomes of the approaches to the thoracic spine were identified; of these 31 studies that consisted of 774 patients were selected for inclusion. A mean complication rate of 39%, 17%, and 15% for thoracotomy, lateral extracavitary, and costotransversectomy, respectively, was determined. The thoracotomy approach had the highest reoperation (3.5%) and mortality rates (1.5%). The specific complications and neurological outcomes were categorized.

CONCLUSIONS

Outcomes of the surgical approaches to the thoracic spine have been reported with great detail in the literature. There are limited studies comparing the respective advantages and disadvantages and the differences in technique and outcome between these approaches. The present review suggests that in contrast to the historical experience of the laminectomy for thoracic spine disorders, these alternative approaches are safe and rarely associated with neurological deterioration. The differences between these approaches are based on their complication profiles. A thorough understanding of the regional anatomy will help avoid approach-related complications.

The vascular supply to the spinal cord and its relationship to anterior spine surgical approaches

BACKGROUND CONTEXT

The understanding of vascular supply to the spinal cord is important given that the evolution of surgical approaches to the spine may bring along the potential for more frequent complications, especially a rare but devastating complication: that of spinal cord ischemia or infarction. To maximally avoid this complication, the relationship between the spinal cord vascularity and the anterior spine surgical approach needs further study.

PURPOSE

To provide a theoretical basis that will allow the spinal surgeon to take appropriate steps to avoid spinal cord ischemia during anterior spinal surgery through anatomic means.

STUDY DESIGN

Spinal cord vascular casting assessment with cadaveric specimen.

METHODS

Twenty adult cadaveric specimens (11 men and 9 women) were obtained for the latex perfusion and vessel dissection. In addition, nine patients (seven men and two women) underwent superselective angiography of the spinal cord. The segmental arterial anastomosis and radiculomedullary vessels in the thoracolumbar region were shown and reviewed.

RESULTS

There were approximately 21 pairs of segmental arteries in the thoracolumbar region. Adjacent segmental arteries were networked with each other. The latex infusion specimens demonstrated 72 anterior radiculomedullary arteries and 177 posterior radiculomedullary arteries in all 20 samples. The anterior and posterior spinal arteries were also networked with each other at several levels. Superselective spinal angiography was consistent with the latex infusion specimens showing.

CONCLUSIONS

The variety of anatomy of spinal cord arterial networks is shown, and the relation between the blood supply of certain spinal levels and the potential ischemic complications during the anterior surgical approach is discussed. It is hopefully of benefit to surgeons, after fully understanding the anatomy of these spinal vascular supply structures, that there may be even greater avoidance of vascular compromise in these challenging operations.

Lumbar hemangioma masking a plasma cell tumor--case report and review of the literature

BACKGROUND CONTEXT

Vertebral hemangiomata are ubiquitous bone tumors. Often multiple, they are generally benign in nature and slow growing. They typically have a predictable radiographic appearance. Occasionally, hemangiomata may behave in a more aggressive manner, causing pathologic fracture or even symptoms/signs of nerve compression. In such cases, one must be careful not to assume that an atypical hemangioma is responsible. Coexisting, more malignant processes may be present and sometimes may be radiographically undetectable in the setting of acute fracture. This was the case in our patient.

STUDY DESIGN

Case report/university spine surgery center.

METHODS

The patient underwent a corpectomy of her affected vertebra with conversion to a total spondylectomy when intraoperative frozen section was consistent with plasma cell neoplasm. A reconstruction with vertebral body replacement and fusion through anterior and posterior approaches was completed. Subsequently, the literature was reviewed for other cases of atypical hemangiomata to investigate the incidence of coexistent lesions.

RESULTS

This patient presented with pain secondary to an unstable pathologic vertebral body fracture. Surgery to stabilize her spine was elected. Intraoperative recognition of abnormal-appearing tissue led to the diagnosis of a plasma cell neoplasm that was not seen on imaging. Coexistent in the same vertebra was hemangiomatous tissue that was visible on preoperative imaging.

CONCLUSIONS

There are rare reports of aggressively behaving hemangiomata that mainly have occurred in the thoracic spine. There have been no reports of the coexistence of a hemangioma and a plasma cell tumor in the same vertebral level in the setting of acute compression fracture.

Circumferential spinal cord decompression through a posterior midline approach with lateral auxiliary ports for lower thoracic compressive myelopathy

BACKGROUND

The lower thoracic spine is a complicated area within the vertebral column because of its anatomic complexity and inaccessibility. A variety of surgical procedures have been applied to access lower thoracic spinal lesions. When hard compressive pathologies are located on the ventral side of the dura, existing surgical approaches have limitations and often have poor outcomes.

OBJECTIVE

To describe a new operative technique, modified posterior laminectomy, and report the results of 3 consecutive cases.

METHODS

First, posterior decompression was performed by laminectomy. The cutting burr was introduced to make a hole in the lateral vertebral body, and this hole was deepened and extended to make a cavity into the vertebra. Next, ventral dural decompression was performed using a posterior approach with lateral auxiliary ports. A lateral auxiliary port was made about 10 to 12 cm away from the midline and dilated toward the midline in a diagonal fashion. The cutting burr was inserted along the port and used for further drilling out. An opposite port was made, and the same procedure was repeated until both sides were in communication. The compressive lesion was then dissected and removed with minimal retraction of the dural sac. Finally, the corresponding segments were stabilized.

RESULTS

Complete removal of the lesion was achieved in all 3 patients without neurological deterioration or surgery-related complications.

CONCLUSION

Circumferential decompression through a posterior approach with lateral auxiliary ports is simple and easy to apply with posterior laminectomy. This new operative technique is a safe, effective, and less invasive approach to ventral dural compressive lesions in the lower thoracic region.

Biomechanical study comparing a new combined rod-plate system with conventional dual-rod and plate systems

Most anterior spinal instrumentation systems are designed as either a plate or dual-rod system and have corresponding limitations. Dual-rod designs may offer greater adjustability; however, this system also maintains a high profile and lacks a locking design. Plate systems are designed to be stiffer, but the fixed configuration is not adaptable to the variety of vertebral body shapes. The authors designed a new combined rod-plate system (D-rod) to overcome these limitations and compared its biomechanical performance with the conventional dual-rod and plate system. Eighteen pig spinal specimens were divided into 3 groups (6 per group). An L1 corpectomy was performed and fixed with the D-rod (group A; n=6), Z-plate (Sofamor Danek, Memphis, Tennessee) (group B; n=6), or Ventrofix (Synthes, Paoli, Pennsylvania) (group C; n=6) system. T13-L2 range of motion was measured with a 6 degrees of freedom (ie, flexion-extension, lateral bending, and axial rotation) spine simulator under pure moments of 6.0 Nm. The D-rod and Ventrofix specimens were significantly stiffer than the Z-plate specimens (P<.05) based on results obtained from lateral bending and flexion-extension tests. The D-rod and Z-plate specimens were significantly stiffer than the Ventrofix specimens (P<.05) in axial rotation. The D-rod combines the advantages of the plate and dual-rod systems, where the anterior rod exhibits the design of a low-profile locking plate, enhanced stability, and decreased interference of the surrounding vasculature. The posterior rods function in compression and distraction, and the dual-rod system offers greater adjustability and control over screw placement. The results indicate that it may provide adequate stability for anterior thoracolumbar reconstruction.

Paediatric spinal Langerhans cell histiocytosis requiring corpectomy and fusion at C7 and at Th8-Th9 levels

An 11-year-old girl was treated by corpectomy and anterior fusion because of the destruction of the C7 vertebral body. Pathological studies were not conclusive. The outcome was excellent, but 18 months later, she required thoracic corpectomy with anterior fusion owing to the impending kyphotic fracture of the Th8 vertebral body. Langerhans cell histiocytosis was now recognised and chemotherapy was given. 3 years later, the disease appears well controlled with normal shape of both the operated vertebral levels and maintenance of the movements of the adjacent vertebrae.

Treatment of subacute thoracic spine fracture-dislocation by total vertebrectomy and spine shortening: technical note

Vertebral resection with spine shortening has been primarily reported for the treatment of demanding cases of nontraumatic disorders. Recently, this technique has been applied to the treatment of traumatic disorders. The current treatment of vertebral fracture-dislocation when there is partial or total telescoping of the involved vertebrae is a combined anterior-posterior approach with corpectomy, anterior support implant, and further posterior instrumentation. These procedures usually require 2 surgical teams, involve longer operating times and greater risk of surgical complications related to the anterior approach, and commonly entail longer postoperative care before discharge. The authors report on 2 patients with high thoracic fracture-dislocations with telescoping (T-2 and T-4) who were treated in the subacute phase with total spondylectomy (T-3 and T-5, respectively) and spine shortening by using only a posterior approach. Complete recovery of the sagittal balance was achieved with this technique and the postoperative periods were clinically uneventful. One patient presented with asymptomatic hemothorax that did not require drainage. In paraplegic patients with anterior thoracic dislocation fractures in which one vertebral body blocks the reduction of the other, total spondylectomy and spine shortening seem to be a reasonably safe and effective technique.

Lateral Extracavitary vs Costotransversectomy Approaches to the Thoracic Spine

BACKGROUND:

The lateral extracavitary approach (LECA) and costotransversectomy (CTE) are 2 dorsolateral approaches that avoid entrance into the pleural cavity and facilitate ventral decompression. The indications and outcomes of each of these approaches have not been fully defined in the literature.

OBJECTIVE:

To assess the techniques, indications, and complications associated with the LECA and CTE approaches to the thoracic spine.

METHODS:

A retrospective analysis was performed on all patients who underwent LECA and CTE between 2000 and 2009 at our institution.

RESULTS:

A total of 54 patient charts were reviewed (19 LECA, 35 CTE). Indications for operation included disk herniation, trauma, tumor, osteomyelitis, and scoliosis/kyphosis. Osteomyelitis was treated significantly more often with LECA (47%) than with CTE (9%; P = .002). Mean blood loss was 2134 mL and 1556 mL (P = .3) in LECA and CTE, respectively, and hospital stay was 17.2 days for LECA and 9.8 days for CTE (P = .07). Thirteen LECA patients (68%) and 19 CTE patients (54%; P = 1.0) had preoperative or postoperative complications.

CONCLUSION:

LECA was used more often to treat complex pathologies such as osteomyelitis and trended toward significance for more frequent use in extensive procedures involving 1- or 2-level corpectomies. As can be expected, CTE was associated with slightly less blood loss and a shorter hospital stay compared with the more extensive LECA operation. Adverse outcomes occurred with similar frequency for CTE and LECA.

The anterior stand-alone approach (ASAA) during the acute phase of spondylodiscitis: results in 40 consecutively treated patients

PURPOSE

Spondylodiscitis mainly affects the anterior part of the spine. In this paper, we retrospectively analyze our experience with the anterior stand-alone approach (ASAA) in the treatment of spinal infections.

METHODS

Forty consecutive patients with severe spondylodiscitis underwent the ASAA during the acute infective phase. Treatment consisted of disease debridement, vertebral body reconstruction using titanium expandable prostheses and anterior fixation.

RESULTS

There was neither mortality nor major morbidity. Successful arthrodesis was achieved in 39 out of 40 patients who remained disease free throughout the follow-up period. Six months after treatment, one patient experienced pseudarthrosis and required supplemented posterior spinal fixation for vertebral instability. However, adequate arthrodesis was eventually obtained even in this patient.

CONCLUSIONS

ASAA with spine reconstruction using synthetic materials during the acute infection phase was safe and effective. The infections were rapidly defeated, the patients were allowed to stand up early after the procedure and the length of hospital stay was significantly reduced.

The transpedicular approach compared with the anterior approach: an analysis of 80 thoracolumbar corpectomies

Object

Whereas standard anterior approaches for thoracolumbar corpectomies have commonly been used, the transpedicular technique is increasingly used to perform corpectomies from a posterior approach. The authors conducted a study to analyze whether there was a difference in outcomes by comparing transpedicular corpectomies to standard anterior thoracolumbar corpectomies.

Methods

The senior author performed thoracolumbar corpectomies in 80 patients between 2004 and 2008. The authors reviewed medical records and follow-up data, consisting of clinic visits, radiographs, or telephone interviews. Neurological outcome, complications, operative times, revision surgery rates, and estimated blood loss (EBL) were evaluated.

Results

Thirty-four patients underwent transpedicular corpectomies, and 46 patients underwent anterior thoracolumbar approaches. Single-level transpedicular corpectomies appear to be comparable to anterior-only corpectomies in terms of EBL, operative time, and complication rates. There was a higher complication rate, increased EBL, and longer operative time with anterior-posterior corpectomies compared with transpedicular corpectomies. Patients undergoing transpedicular corpectomies had a greater recovery of neurological function than those in whom anterior-approach corpectomies were performed.

Conclusions

The transpedicular corpectomy appears to have a comparable morbidity rate to anterior-only corpectomies, but its morbidity rate is lower than that of anterior-posterior corpectomies.

Posterior approach to ventrally located spinal meningiomas

For the resection of anteriorly located meningiomas, various approaches have been used. Posterior approach is less invasive and demanding; however, it has been associated with increased risk of spinal cord injury. We evaluated ten consecutive patients that underwent surgery for spinal meningiomas. All patients were preoperative assessed by neurological examination, computed tomography and magnetic resonance imaging. All tumors were ventrally located and removed via a posterior approach. Transcranial motor-evoked potentials (TcMEPs), somatosensory-evoked potential (SSEP) and free running electromyography (EMG) were monitored intraoperative. Postoperative all patients had regular follow-up examinations. There were four males and six females. The mean age was 68.2 years (range 39-82 years). In nine out of ten cases, the tumor was located in the thoracic spine. A case of a lumbar meningioma was recorded. The most common presenting symptom was motor and sensory deficits and unsteady gait, whereas no patient presented with paraplegia. All meningiomas were operated using a microsurgical technique via a posterior approach. During the operation, free running EMG monitoring prompted a surgical alert in case of irritation, whereas TcMEP and SSEP amplitudes remained unchanged. Histopathology revealed the presence of typical (World Health Organisation grade I) meningiomas. The mean Ki-67/MIB-1 index was 2.75% (range 0.5-7). None of our patients sustained a transient or permanent motor deficit. After a mean follow-up period of 26 months (range 56-16 months), no tumor recurrence and no instability were found. Posterior approach for anteriorly located meningiomas is a safe procedure with the use of intraoperative monitoring, less invasive and well-tolerated especially in older patients. Complete tumor excision can be performed with satisfactory results.

Simultaneously anterior decompression and posterior instrumentation by extrapleural retroperitoneal approach in thoracolumbar lesions

BACKGROUND

Anterior decompression with posterior instrumentation when indicated in thoracolumbar spinal lesions if performed simultaneously in single-stage expedites rehabilitation and recovery. Transthoracic, transdiaphragmatic approach to access the thoracolumbar junction is associated with significant morbidity, as it violates thoracic cavity; requires cutting of diaphragm and a separate approach, for posterior instrumentation. We evaluated the clinical outcome morbidity and feasibility of extrapleural retroperitoneal approach to perform anterior decompression and posterior instrumentation simultaneously by single "T" incision outcome in thoracolumbar spinal trauma and tuberculosis.

PATIENTS AND METHODS

Forty-eight cases of tubercular spine (n = 25) and fracture of the spine (n = 23) were included in the study of which 29 were male and 19 female. The mean age of patients was 29.1 years. All patients underwent single-stage anterior decompression, fusion, and posterior instrumentation (except two old traumatic cases) via extrapleural retroperitoneal approach by single "T" incision. Tuberculosis cases were operated in lateral position as they were stabilized with Hartshill instrumentation. For traumatic spine initially posterior pedicle screw fixation was performed in prone position and then turned to right lateral position for anterior decompression by same incision and approach. They were evaluated for blood loss, duration of surgery, superficial and deep infection of incision site, flap necrosis, correction of the kyphotic deformity, and restoration of anterior and posterior vertebral body height.

RESULTS

In traumatic spine group the mean duration of surgery was 269 minutes (range 215-315 minutes) including the change over time from prone to lateral position. The mean intraoperative blood loss was 918 ml (range 550-1100 ml). The preoperative mean ASIA motor, pin prick and light touch score improved from 63.3 to 74.4, 86 to 94.4 and 86 to 96 at 6 month of follow-up respectively. The mean preoperative loss of the anterior vertebral height improved from 44.7% to 18.4% immediate postoperatively and was 17.5% at final follow-up at 1 year. The means preoperative kyphus angle also improved from 23.3° to 9.3° immediately after surgery, which deteriorated to 11.5° at final follow-up. One patient developed deep wound infection at the operative site as well as flap necrosis, which needed debridement and removal of hardware. Five patients had bed sore in the sacral region, which healed uneventfully. In tubercular spine (n=25) group, mean operating time was approximately 45 minutes less than traumatic group. The mean intraoperative blood loss was 1100 ml (750-2200 ml). The mean preoperative kyphosis was corrected from 55° to 23°. Wound healing occurred uneventful in 23 cases and wound dehiscence occurred in only 2 cases. Nine out of 11 cases with paraplegia showed excellent neural recovery while 2 with panvertebral disease showed partial neural recovery. None of the patients in both groups required intensive unit care.

CONCLUSIONS

Simultaneous exposure of both posterior and anterior column of the spine for posterior instrumentation and anterior decompression and fusion in single stage by extra pleural retroperitoneal approach by "T" incision in thoracolumbar spinal lesions is safe, an easy alternative with reduced morbidity as chest and abdominal cavities are not violated, ICU care is not required and diaphragm is not cut.