Surgical Technique
Minimally Invasive Direct Lateral Corpectomy for the Treatment of a Thoracolumbar Fracture Gregory Michael Malham1 1 Neuroscience Institute, Epworth Hospital, Melbourne,
Victoria, Australia
Address for correspondence Gregory Michael Malham, MB ChB, FRACS, Suite 2, Level 1, 517 St Kilda Road, Melbourne, Victoria 3004, Australia (e-mail: [email protected]).
J Neurol Surg A 2015;76:240–243.
Abstract
Keywords
► ► ► ► ►
corpectomy lateral lumbar minimally invasive vertebral fracture
Thoracolumbar corpectomies have historically been performed using open exposure procedures. Thoracotomies carry substantial morbidity due to increased complications and postoperative pain. The extreme lateral interbody fusion (XLIF) approach is a safe, minimally invasive alternative approach to the thoracolumbar spine. A recent modification of XLIF allows thoracolumbar corpectomy to be used for tumors, osteomyelitis, and fractures. We reviewed literature relevant to minimally invasive lateral approaches and thoracolumbar pathology. This case report illustrates the usefulness of this approach in the case of a thoracolumbar flexion distraction fracture treated with a corpectomy. The involved surgical technique is described in detail. This approach can be performed without an access surgeon, and the minimally invasive lateral approach reduces the relative morbidity commonly associated with open approaches.
Introduction Many challenges exist in the surgical management of thoracolumbar vertebral body fractures. Conventional operative treatments use open exposure techniques such as long segment posterior fixation1–3 or a thoracotomy.4,5 These approaches cause increased perioperative morbidity including high intraoperative blood loss, postoperative infections, and persistent incisional pain with extended postoperative recovery.5,6 Specifically, thoracotomies cause the increased risk of diaphragm disfiguration, pulmonary complications, and postthoracotomy pain syndrome.7–9 Decision making in terms of the surgical approach (thoracotomy versus posterior) in thoracolumbar fractures depends on the etiology (tumor or trauma) and morphology of the fracture (anterior and posterior element involvement or retropulsed fragments). Additionally, availability of experienced anesthetists, operating room personnel, and a cardiothoracic access surgeon should be considered.10,11 Minimally invasive lateral approaches provide a safe alternative for thoracolumbar fracture management. The minimally invasive 90-degree lateral approach (extreme lateral interbody fusion [XLIF, NuVasive, Inc., San Diego, CA]) was introduced in the
received April 5, 2013 accepted after revision October 2, 2013 published online May 2, 2014
literature in 2006.12 XLIF is now used to treat thoracic and lumbar spinal disease with minimal blood loss, low procedural morbidity, reduced hospital stay, and early ambulation and return to work, and it has equivalent clinical outcomes compared with conventional approaches.13 A modification of this approach provides a minimally invasive alternative when performing thoracolumbar corpectomies.14 We report a patient with a thoracolumbar junction traumatic flexion distraction fracture treated with XLIF as the utilized corpectomy.
Case Report Presentation A 66-year-old male photographer fell 2 m from a ladder and experienced severe acute lower back pain. He presented to the local emergency department with lumbar X-rays showing an L1 traumatic compression fracture (►Fig. 1). No lower limb pain or sphincter impairment was observed. The patient complained of persistent mechanical back pain exacerbated by standing. He was treated conservatively due to the apparently stable fracture and no neurologic deficit. The patient returned at 3 months postinjury with progressive, debilitating back pain intractable to oral opiates and
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1368094. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
240
Malham
Fig. 2 Preoperative computed tomography lumbar scan 3 months following trauma showing an L1 flexion distraction injury with widened posterior facet joints and progressive anterior column compression failure. Fig. 1 Preoperative lateral lumbar X-ray showing an L1 compression fracture.
preventing him from working. High-definition computed tomography (CT) demonstrated a flexion distraction L1 injury with widened facets joints, anterior vertebral column failure, and localized kyphosis (►Fig. 2). Given the progressive nature of the presenting symptoms and focal deformity, the patient was scheduled to undergo an L1 direct lateral corpectomy via a left-side approach, supplemented with posterior pedicle screw fixation at T11–L3.
Operative Procedure The patient was positioned in the lateral decubitus position, with the break of the table positioned underneath the thoracolumbar junction to expand the intercostal space of the targeted level. Total intravenous anesthesia was used, allowing motor-evoked potential intraoperative neuromonitoring (NeuroVision NV M5, NuVasive, Inc., San Diego, CA) to monitor the spinal cord throughout the procedure.14 Under true lateral and anteroposterior (AP) fluoroscopy, the anterior and posterior vertebral lines of T12–L2 were marked on the skin surface. The T12–L1 and L1–2 disc levels were marked transversely on the skin surface. The orientation of the 10th rib was marked. A 5-cm oblique skin incision along the line of the 10th rib was made between the anterior and posterior vertebral lines. Blunt dissection through the subcu-
taneous tissues exposed the 10th rib. Careful subperiosteal rib dissection using a periosteal elevator and doyens allowed the preservation of the neuromuscular bundle. A 5-cm section of the 10th rib was removed to allow adequate manipulation of the split blade retractor in the cephaladcaudal direction. A small transverse incision was made inferior to the targeted disc space, below the level of the diaphragm, enabling tension in the diaphragm by placing pressure from the retroperitoneal space with the left index finger. The initial dilator was introduced into the retropleural space until the dilator and finger were confirmed to be touching on the diaphragm. The dilator traversed the diaphragm with manual force, protecting the peritoneum with the technique just described and allowing the dilator to dock onto the L1 vertebral body. Using lateral and AP fluoroscopy, the tubular retractor was positioned providing adequate exposure of the T12–L1 and L1–2 disc spaces. The discs were incised to enable large Cobb elevators to be inserted in the subperiosteal plane to open the contralateral superior T12–L1 and inferior L1–2 disc annulus. Using AP fluoroscopy, a large osteotome was used to perform a posterior transvertebral cut and a small osteotome to perform an anterior transvertebral cut to enable en bloc L1 corpectomy. Curettes were used to carefully remove the cartilaginous endplate. This permitted a trial titanium cylindrical expandable cage (VLIFT, Stryker, Allendale, NJ), 18 mm Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
241
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Minimally Invasive Direct Lateral Corpectomy
Minimally Invasive Direct Lateral Corpectomy
Malham
wide 25 mm high with an 18 3-degree superior end cap and an 18 0-degree inferior end cap to be placed in the corpectomy defect. The cage was removed and packed with a harvested bone graft from the resected rib and vertebral body. Under AP and lateral fluoroscopy, the cage was impacted into the L1 corpectomy site for optimal midline positioning. The cage was expanded to reconstruct the anterior column and correct the focal kyphotic deformity. A further harvested bone graft was packed into the corpectomy site around the expandable cage and sealed with DuraSeal Bioglue (Covidien, Waltham, MA). The estimated blood loss was 150 mL. The patient was turned prone for supplemental bilateral pedicle screw and rod fixation from T11 to L3 using intraoperative fluoroscopy. The patient was mobilized the next day and transferred to inpatient rehabilitation on day 5 postoperatively.
Fig. 4 Photograph of the healed skin incision (for the lateral corpectomy) at 12 months postoperative.
Progress At a 6-week postoperative review, the left transverse lateral thoracic incision and posterior midline incision were well healed. The patient had returned to work, performing light duties but continuing on opiate analgesia. At a 6-month postoperative review, the patient was satisfied with his outcome, had returned to full-time work, and had ceased all analgesic medication. An updated CT thoracolumbar spine scan confirmed solid interbody fusion without complication between T12 and L1 (►Fig. 3). At a 12-month follow-up, he reported excellent satisfaction with his pain relief and exhibited left lateral (►Fig. 4) and posterior lumbar skin incisions that were healed with excellent cosmesis. The patient was subsequently discharged from follow-up.
Discussion Progressively destabilizing pathologies of the anterior column such as vertebral fracture, infection, and tumor present a
Fig. 3 Postoperative computed tomography lumbar (A) sagittal and (B) coronal views demonstrating solid interbody fusion at 6 months. Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
challenging clinical paradigm for the operating surgeon. Traditional open approaches to the thoracolumbar spine are a major intervention with significant morbidity including intercostal neuralgia,7 pulmonary complications,9,10 postthoracotomy pain,8 infection,3,4 and prolonged pain and recovery.7 The direct lateral approach has been widely reported in lumbar degenerative pathologies.15,16 However, its usefulness has not been widely reported with respect to the thoracolumbar corpectomy. Exposure to the thoracolumbar spine via the minimally invasive lateral approach when performing a corpectomy is nearly identical to the exposure utilized for lateral interbody fusion, with the fundamentals and benefits of the procedure maintained even in more advanced indications.13,14,17,18 Preoperative planning is paramount with respect to axial magnetic resonance and CT images when determining the side of approach after considering vascular anatomy and the site of pathology. Discussion and intraoperative collaboration with a cardiothoracic surgeon is encouraged for initial cases. An experienced lateral surgeon, once familiar with the relevant anatomy, can perform this approach safely, independently, and reproducibly. Access can be achieved via a direct lateral transpleural approach for pathologies below T5–6 or a retropleural, transdiaphragmatic approach if negotiating the diaphragm at the thoracolumbar junction.16 A prophylactic chest tube is not routinely required. Indications for insertion of a chest tube prior to thoracolumbar wound closure include intraoperative bleeding and/or lung damage with a visceral pleura breach risking a pneumothorax. An intercostal tube connected to an underwater seal at 20 cm H2O suction for 24 hours is recommended. Supplementary fixation is strongly recommended to stabilize the segment and maintain correction. Bilateral pedicle screw fixation provides the most stable construct to complement a thoracolumbar corpectomy.19 Low-profile lateral plating systems have evolved and offer an alternative option when treating single-level intrinsically stable segments.20 The outcome of the patient described in this case report, although limited in making broad conclusions, is corroborated
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
242
Minimally Invasive Direct Lateral Corpectomy
Conclusion Thoracolumbar corpectomy using a direct lateral approach is an extension of the XLIF technique and provides a safe minimally invasive alternative to the standard open thoracotomy. This approach can be performed without an access surgeon and reduces the relative morbidity commonly seen with open approaches. Disclosure No funds were received in support of this work, and no conflicts of interest exist with any commercial party related to this manuscript.
2 Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V.
3
4
5 6
7 8 9
10
11
12
13
14
15
16
17
18
19
Acknowledgments The author thanks Dr. Ngaire J. Ellis for editorial assistance.
20
21
References 1 Sasso RC, Cotler HB. Posterior instrumentation and fusion for
unstable fractures and fracture-dislocations of the thoracic and lumbar spine. A comparative study of three fixation devices in 70 patients. Spine 1993;18(4):450–460
243
22
Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(5):773–781 Lu DC, Lau D, Lee JG, Chou D. The transpedicular approach compared with the anterior approach: an analysis of 80 thoracolumbar corpectomies. J Neurosurg Spine 2010;12(6):583–591 Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech 2005;18 (Suppl):S15–S23 Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of thoracolumbar spine fractures. Instr Course Lect 2004;53:359–373 Verlaan JJ, Diekerhof CH, Buskens E, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine 2004;29(7):803–814 Macrae WA. Chronic pain after surgery. Br J Anaesth 2001;87(1): 88–98 Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin 2004;14(3):345–352 Khoo LT, Beisse R, Potulski M. Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases. Neurosurgery 2002;51(5, Suppl):S104–S117 Dimar JR, Fisher C, Vaccaro AR, et al. Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma 2010;69(6):1497–1500 Vaccaro AR, Lim MR, Hurlbert RJ, et al; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006;19(1):1–10 Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 2006;6(4):435–443 Baaj AA, Dakwar E, Le TV, et al. Complications of the mini-open anterolateral approach to the thoracolumbar spine. J Clin Neurosci 2012;19(9):1265–1267 Smith WD, Dakwar E, Le TV, Christian G, Serrano S, Uribe JS. Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine 2010;35(26, Suppl):S338–S346 Youssef JA, McAfee PC, Patty CA, et al. Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine 2010; 35(26, Suppl):S302–S311 Malham GM, Ellis NJ, Parker RM, Seex KA. Clinical outcome and fusion rates after the first 30 extreme lateral interbody fusions. ScientificWorldJournal 2012;2012:246989 Deviren V, Kuelling FA, Poulter G, Pekmezci M. Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients. J Spinal Disord Tech 2011;24(5):E40–E48 Uribe JS, Smith WD, Pimenta L, et al. Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine 2012;16(3):264–279 Cappuccino A, Cornwall GB, Turner AW, et al. Biomechanical analysis and review of lateral lumbar fusion constructs. Spine 2010;35(26, Suppl):S361–S367 Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine 2012;37(14):1268–1273 Amaral R, Marchi L, Oliveira L, Coutinho T, Pimenta L. Acute lumbar burst fracture treated by minimally invasive lateral corpectomy. Case Rep Orthop 2013;2013:953897 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 2010;35(26, Suppl): S347–S354 Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
by outcomes reported in other larger studies. Smith et al14 in 2010 reported on 52 patients treated with a mini open lateral corpectomy for a traumatic thoracolumbar pathology from T7 to L4. The authors reported a mean operative time, blood loss, and hospital stay of 128 minutes, 300 mL, and 4 days, respectively. Complications occurred in 15.4% of patients with one patient requiring reoperation. Neurologic status was maintained or improved in all patients between the preoperative and postoperative periods. In addition, the authors undertook a literature review summarizing conventional approaches for traumatic corpectomy. They found an average complication rate of 45.5% and a reoperation rate of 19.1%. In a follow-up study by Baaj et al,13 80 mini open lateral corpectomy patients were studied; the overall complication rate was 12.5%. Several other studies have shown similar results to the current case report and to previous literature reports. Amaral et al21 presented a case report of acute management of a burst fracture with neurologic impairment. Through the standard XLIF approach, operative blood loss was 350 mL and fusion was achieved through a wide footprint expandable interbody (X-Core, NuVasive, Inc.) within 24 months. Uribe et al22 reported on 13 patients treated for thoracic tumors with a mini open lateral corpectomy. Despite a varied pathology compared with Smith et al,14 the clinical results were similar. The mean operative time was 124 minutes, blood loss was 374 mL, and hospital stay was 3.5 days. Pain and disability, measured by the visual analogue scale and Oswestry disability index, improved 62% and 53%, respectively. The current work describes an Australasian experience, detailing the initial perioperative and short-term postoperative experience of an L1 traumatic flexion distraction fracture treated with a minimally invasive lateral approach for corpectomy and bilateral pedicle screw fixation.
Malham
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Minimally Invasive Direct Lateral Corpectomy for the Treatment of a Thoracolumbar Fracture Gregory Michael Malham1 1 Neuroscience Institute, Epworth Hospital, Melbourne,
Victoria, Australia
Address for correspondence Gregory Michael Malham, MB ChB, FRACS, Suite 2, Level 1, 517 St Kilda Road, Melbourne, Victoria 3004, Australia (e-mail: [email protected]).
J Neurol Surg A 2015;76:240–243.
Abstract
Keywords
► ► ► ► ►
corpectomy lateral lumbar minimally invasive vertebral fracture
Thoracolumbar corpectomies have historically been performed using open exposure procedures. Thoracotomies carry substantial morbidity due to increased complications and postoperative pain. The extreme lateral interbody fusion (XLIF) approach is a safe, minimally invasive alternative approach to the thoracolumbar spine. A recent modification of XLIF allows thoracolumbar corpectomy to be used for tumors, osteomyelitis, and fractures. We reviewed literature relevant to minimally invasive lateral approaches and thoracolumbar pathology. This case report illustrates the usefulness of this approach in the case of a thoracolumbar flexion distraction fracture treated with a corpectomy. The involved surgical technique is described in detail. This approach can be performed without an access surgeon, and the minimally invasive lateral approach reduces the relative morbidity commonly associated with open approaches.
Introduction Many challenges exist in the surgical management of thoracolumbar vertebral body fractures. Conventional operative treatments use open exposure techniques such as long segment posterior fixation1–3 or a thoracotomy.4,5 These approaches cause increased perioperative morbidity including high intraoperative blood loss, postoperative infections, and persistent incisional pain with extended postoperative recovery.5,6 Specifically, thoracotomies cause the increased risk of diaphragm disfiguration, pulmonary complications, and postthoracotomy pain syndrome.7–9 Decision making in terms of the surgical approach (thoracotomy versus posterior) in thoracolumbar fractures depends on the etiology (tumor or trauma) and morphology of the fracture (anterior and posterior element involvement or retropulsed fragments). Additionally, availability of experienced anesthetists, operating room personnel, and a cardiothoracic access surgeon should be considered.10,11 Minimally invasive lateral approaches provide a safe alternative for thoracolumbar fracture management. The minimally invasive 90-degree lateral approach (extreme lateral interbody fusion [XLIF, NuVasive, Inc., San Diego, CA]) was introduced in the
received April 5, 2013 accepted after revision October 2, 2013 published online May 2, 2014
literature in 2006.12 XLIF is now used to treat thoracic and lumbar spinal disease with minimal blood loss, low procedural morbidity, reduced hospital stay, and early ambulation and return to work, and it has equivalent clinical outcomes compared with conventional approaches.13 A modification of this approach provides a minimally invasive alternative when performing thoracolumbar corpectomies.14 We report a patient with a thoracolumbar junction traumatic flexion distraction fracture treated with XLIF as the utilized corpectomy.
Case Report Presentation A 66-year-old male photographer fell 2 m from a ladder and experienced severe acute lower back pain. He presented to the local emergency department with lumbar X-rays showing an L1 traumatic compression fracture (►Fig. 1). No lower limb pain or sphincter impairment was observed. The patient complained of persistent mechanical back pain exacerbated by standing. He was treated conservatively due to the apparently stable fracture and no neurologic deficit. The patient returned at 3 months postinjury with progressive, debilitating back pain intractable to oral opiates and
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0034-1368094. ISSN 2193-6315.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
240
Malham
Fig. 2 Preoperative computed tomography lumbar scan 3 months following trauma showing an L1 flexion distraction injury with widened posterior facet joints and progressive anterior column compression failure. Fig. 1 Preoperative lateral lumbar X-ray showing an L1 compression fracture.
preventing him from working. High-definition computed tomography (CT) demonstrated a flexion distraction L1 injury with widened facets joints, anterior vertebral column failure, and localized kyphosis (►Fig. 2). Given the progressive nature of the presenting symptoms and focal deformity, the patient was scheduled to undergo an L1 direct lateral corpectomy via a left-side approach, supplemented with posterior pedicle screw fixation at T11–L3.
Operative Procedure The patient was positioned in the lateral decubitus position, with the break of the table positioned underneath the thoracolumbar junction to expand the intercostal space of the targeted level. Total intravenous anesthesia was used, allowing motor-evoked potential intraoperative neuromonitoring (NeuroVision NV M5, NuVasive, Inc., San Diego, CA) to monitor the spinal cord throughout the procedure.14 Under true lateral and anteroposterior (AP) fluoroscopy, the anterior and posterior vertebral lines of T12–L2 were marked on the skin surface. The T12–L1 and L1–2 disc levels were marked transversely on the skin surface. The orientation of the 10th rib was marked. A 5-cm oblique skin incision along the line of the 10th rib was made between the anterior and posterior vertebral lines. Blunt dissection through the subcu-
taneous tissues exposed the 10th rib. Careful subperiosteal rib dissection using a periosteal elevator and doyens allowed the preservation of the neuromuscular bundle. A 5-cm section of the 10th rib was removed to allow adequate manipulation of the split blade retractor in the cephaladcaudal direction. A small transverse incision was made inferior to the targeted disc space, below the level of the diaphragm, enabling tension in the diaphragm by placing pressure from the retroperitoneal space with the left index finger. The initial dilator was introduced into the retropleural space until the dilator and finger were confirmed to be touching on the diaphragm. The dilator traversed the diaphragm with manual force, protecting the peritoneum with the technique just described and allowing the dilator to dock onto the L1 vertebral body. Using lateral and AP fluoroscopy, the tubular retractor was positioned providing adequate exposure of the T12–L1 and L1–2 disc spaces. The discs were incised to enable large Cobb elevators to be inserted in the subperiosteal plane to open the contralateral superior T12–L1 and inferior L1–2 disc annulus. Using AP fluoroscopy, a large osteotome was used to perform a posterior transvertebral cut and a small osteotome to perform an anterior transvertebral cut to enable en bloc L1 corpectomy. Curettes were used to carefully remove the cartilaginous endplate. This permitted a trial titanium cylindrical expandable cage (VLIFT, Stryker, Allendale, NJ), 18 mm Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
241
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Minimally Invasive Direct Lateral Corpectomy
Minimally Invasive Direct Lateral Corpectomy
Malham
wide 25 mm high with an 18 3-degree superior end cap and an 18 0-degree inferior end cap to be placed in the corpectomy defect. The cage was removed and packed with a harvested bone graft from the resected rib and vertebral body. Under AP and lateral fluoroscopy, the cage was impacted into the L1 corpectomy site for optimal midline positioning. The cage was expanded to reconstruct the anterior column and correct the focal kyphotic deformity. A further harvested bone graft was packed into the corpectomy site around the expandable cage and sealed with DuraSeal Bioglue (Covidien, Waltham, MA). The estimated blood loss was 150 mL. The patient was turned prone for supplemental bilateral pedicle screw and rod fixation from T11 to L3 using intraoperative fluoroscopy. The patient was mobilized the next day and transferred to inpatient rehabilitation on day 5 postoperatively.
Fig. 4 Photograph of the healed skin incision (for the lateral corpectomy) at 12 months postoperative.
Progress At a 6-week postoperative review, the left transverse lateral thoracic incision and posterior midline incision were well healed. The patient had returned to work, performing light duties but continuing on opiate analgesia. At a 6-month postoperative review, the patient was satisfied with his outcome, had returned to full-time work, and had ceased all analgesic medication. An updated CT thoracolumbar spine scan confirmed solid interbody fusion without complication between T12 and L1 (►Fig. 3). At a 12-month follow-up, he reported excellent satisfaction with his pain relief and exhibited left lateral (►Fig. 4) and posterior lumbar skin incisions that were healed with excellent cosmesis. The patient was subsequently discharged from follow-up.
Discussion Progressively destabilizing pathologies of the anterior column such as vertebral fracture, infection, and tumor present a
Fig. 3 Postoperative computed tomography lumbar (A) sagittal and (B) coronal views demonstrating solid interbody fusion at 6 months. Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
challenging clinical paradigm for the operating surgeon. Traditional open approaches to the thoracolumbar spine are a major intervention with significant morbidity including intercostal neuralgia,7 pulmonary complications,9,10 postthoracotomy pain,8 infection,3,4 and prolonged pain and recovery.7 The direct lateral approach has been widely reported in lumbar degenerative pathologies.15,16 However, its usefulness has not been widely reported with respect to the thoracolumbar corpectomy. Exposure to the thoracolumbar spine via the minimally invasive lateral approach when performing a corpectomy is nearly identical to the exposure utilized for lateral interbody fusion, with the fundamentals and benefits of the procedure maintained even in more advanced indications.13,14,17,18 Preoperative planning is paramount with respect to axial magnetic resonance and CT images when determining the side of approach after considering vascular anatomy and the site of pathology. Discussion and intraoperative collaboration with a cardiothoracic surgeon is encouraged for initial cases. An experienced lateral surgeon, once familiar with the relevant anatomy, can perform this approach safely, independently, and reproducibly. Access can be achieved via a direct lateral transpleural approach for pathologies below T5–6 or a retropleural, transdiaphragmatic approach if negotiating the diaphragm at the thoracolumbar junction.16 A prophylactic chest tube is not routinely required. Indications for insertion of a chest tube prior to thoracolumbar wound closure include intraoperative bleeding and/or lung damage with a visceral pleura breach risking a pneumothorax. An intercostal tube connected to an underwater seal at 20 cm H2O suction for 24 hours is recommended. Supplementary fixation is strongly recommended to stabilize the segment and maintain correction. Bilateral pedicle screw fixation provides the most stable construct to complement a thoracolumbar corpectomy.19 Low-profile lateral plating systems have evolved and offer an alternative option when treating single-level intrinsically stable segments.20 The outcome of the patient described in this case report, although limited in making broad conclusions, is corroborated
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
242
Minimally Invasive Direct Lateral Corpectomy
Conclusion Thoracolumbar corpectomy using a direct lateral approach is an extension of the XLIF technique and provides a safe minimally invasive alternative to the standard open thoracotomy. This approach can be performed without an access surgeon and reduces the relative morbidity commonly seen with open approaches. Disclosure No funds were received in support of this work, and no conflicts of interest exist with any commercial party related to this manuscript.
2 Wood K, Buttermann G, Mehbod A, Garvey T, Jhanjee R, Sechriest V.
3
4
5 6
7 8 9
10
11
12
13
14
15
16
17
18
19
Acknowledgments The author thanks Dr. Ngaire J. Ellis for editorial assistance.
20
21
References 1 Sasso RC, Cotler HB. Posterior instrumentation and fusion for
unstable fractures and fracture-dislocations of the thoracic and lumbar spine. A comparative study of three fixation devices in 70 patients. Spine 1993;18(4):450–460
243
22
Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(5):773–781 Lu DC, Lau D, Lee JG, Chou D. The transpedicular approach compared with the anterior approach: an analysis of 80 thoracolumbar corpectomies. J Neurosurg Spine 2010;12(6):583–591 Wood KB, Bohn D, Mehbod A. Anterior versus posterior treatment of stable thoracolumbar burst fractures without neurologic deficit: a prospective, randomized study. J Spinal Disord Tech 2005;18 (Suppl):S15–S23 Vaccaro AR, Kim DH, Brodke DS, et al. Diagnosis and management of thoracolumbar spine fractures. Instr Course Lect 2004;53:359–373 Verlaan JJ, Diekerhof CH, Buskens E, et al. Surgical treatment of traumatic fractures of the thoracic and lumbar spine: a systematic review of the literature on techniques, complications, and outcome. Spine 2004;29(7):803–814 Macrae WA. Chronic pain after surgery. Br J Anaesth 2001;87(1): 88–98 Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac Surg Clin 2004;14(3):345–352 Khoo LT, Beisse R, Potulski M. Thoracoscopic-assisted treatment of thoracic and lumbar fractures: a series of 371 consecutive cases. Neurosurgery 2002;51(5, Suppl):S104–S117 Dimar JR, Fisher C, Vaccaro AR, et al. Predictors of complications after spinal stabilization of thoracolumbar spine injuries. J Trauma 2010;69(6):1497–1500 Vaccaro AR, Lim MR, Hurlbert RJ, et al; Spine Trauma Study Group. Surgical decision making for unstable thoracolumbar spine injuries: results of a consensus panel review by the Spine Trauma Study Group. J Spinal Disord Tech 2006;19(1):1–10 Ozgur BM, Aryan HE, Pimenta L, Taylor WR. Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 2006;6(4):435–443 Baaj AA, Dakwar E, Le TV, et al. Complications of the mini-open anterolateral approach to the thoracolumbar spine. J Clin Neurosci 2012;19(9):1265–1267 Smith WD, Dakwar E, Le TV, Christian G, Serrano S, Uribe JS. Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine 2010;35(26, Suppl):S338–S346 Youssef JA, McAfee PC, Patty CA, et al. Minimally invasive surgery: lateral approach interbody fusion: results and review. Spine 2010; 35(26, Suppl):S302–S311 Malham GM, Ellis NJ, Parker RM, Seex KA. Clinical outcome and fusion rates after the first 30 extreme lateral interbody fusions. ScientificWorldJournal 2012;2012:246989 Deviren V, Kuelling FA, Poulter G, Pekmezci M. Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients. J Spinal Disord Tech 2011;24(5):E40–E48 Uribe JS, Smith WD, Pimenta L, et al. Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine 2012;16(3):264–279 Cappuccino A, Cornwall GB, Turner AW, et al. Biomechanical analysis and review of lateral lumbar fusion constructs. Spine 2010;35(26, Suppl):S361–S367 Le TV, Baaj AA, Dakwar E, et al. Subsidence of polyetheretherketone intervertebral cages in minimally invasive lateral retroperitoneal transpsoas lumbar interbody fusion. Spine 2012;37(14):1268–1273 Amaral R, Marchi L, Oliveira L, Coutinho T, Pimenta L. Acute lumbar burst fracture treated by minimally invasive lateral corpectomy. Case Rep Orthop 2013;2013:953897 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 2010;35(26, Suppl): S347–S354 Journal of Neurological Surgery—Part A
Vol. 76
No. A3/2015
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by outcomes reported in other larger studies. Smith et al14 in 2010 reported on 52 patients treated with a mini open lateral corpectomy for a traumatic thoracolumbar pathology from T7 to L4. The authors reported a mean operative time, blood loss, and hospital stay of 128 minutes, 300 mL, and 4 days, respectively. Complications occurred in 15.4% of patients with one patient requiring reoperation. Neurologic status was maintained or improved in all patients between the preoperative and postoperative periods. In addition, the authors undertook a literature review summarizing conventional approaches for traumatic corpectomy. They found an average complication rate of 45.5% and a reoperation rate of 19.1%. In a follow-up study by Baaj et al,13 80 mini open lateral corpectomy patients were studied; the overall complication rate was 12.5%. Several other studies have shown similar results to the current case report and to previous literature reports. Amaral et al21 presented a case report of acute management of a burst fracture with neurologic impairment. Through the standard XLIF approach, operative blood loss was 350 mL and fusion was achieved through a wide footprint expandable interbody (X-Core, NuVasive, Inc.) within 24 months. Uribe et al22 reported on 13 patients treated for thoracic tumors with a mini open lateral corpectomy. Despite a varied pathology compared with Smith et al,14 the clinical results were similar. The mean operative time was 124 minutes, blood loss was 374 mL, and hospital stay was 3.5 days. Pain and disability, measured by the visual analogue scale and Oswestry disability index, improved 62% and 53%, respectively. The current work describes an Australasian experience, detailing the initial perioperative and short-term postoperative experience of an L1 traumatic flexion distraction fracture treated with a minimally invasive lateral approach for corpectomy and bilateral pedicle screw fixation.
Malham
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