Operative Techniken Oper Orthop Traumatol 2014 DOI 10.1007/s00064-014-0321-4 Received: 18 October 2013 Revised: 3 May 2014 Accepted: 30 May 2014 © Springer-Verlag Berlin Heidelberg 2014
Redaktion
M. Mayer, München Zeichner
R. Himmelhan, Mannheim
Introductory remarks Metastatic disease of the thoracic spine may lead to instable pathologic fractures with or without spinal cord compres sion. Surgical treatment with radiothera py is often preferred over radiotherapy alone in patients with a life expectancy of more than 6 months [1, 2]. Several sur gical strategies have been described. Due to its primary stability, a staged posteri or then anterior approach has become a popular method. This involves segmental pedicle screw fixation spanning the meta static level with anterior vertebral body re section and cage placement. However, the morbidity associated with a transthoracic approach with chest tube placement has prompted others to pursue an all-poste rior vertebral column resection (VCR) with placement of an expandable cage [3, 4]. This offers the benefit of a singlestaged procedure, but has a sharp learning curve, may require 360° decompression, and is challenging in terms of complex insitu cage alignment [5, 6]. The purpose of this paper is to describe the technique of a modified all-posterior vertebral body re placement with the XCORE2 cage (Nu vasive®).
Surgical principle and objective All-posterior VCR with cage replacement may allow for safe surgical stabilization of the spine without a transthoracic approach or a staged
P.D. Trobisch1 · K. Verma2 1 Zentrum für Orthopädische Chirurgie, Eifelklinik St. Brigida, Simmerath 2 Department of Orthopaedic Surgery, Thomas-Jefferson University, Philadelphia
Vertebral body replacement by posterior approach for metastatic disease in the thoracic spine—modified technique using an expandable cage
procedure in selected patients. Long endplates and angled seating instruments are attached to the cage to facilitate cage insertion. This offers the advantage of bypassing several complex surgical steps required for in-situ alignment of a round cage.
Advantages F Avoidance of the transthoracic ap proach and subsequent chest tube placement. This may reduce recovery time, which is essential for a patient with metastatic disease. F Reduced anesthesia and operative time as well as intraoperative re-posi tioning are not required. F Reduced surgical tissue trauma due to a single posterior approach. This may lead to lower analgesia requirements postoperatively. F In cases of unexpected difficulties, a staged transthoracic approach is still feasible.
Disadvantages F Steep learning curve for posterior-on ly VCR as there is a limited view of the vertebral body. F Potential for injury to the pleura and/ or aorta due to the limited exposure window, and indirect preparation of anatomical structures using angled instruments.
F Thoracic nerve root sacrifice is often necessary to achieve a good working space. F Cages may have a smaller diame ter compared with cages implanted through an anterior approach. How ever, 30-mm long endplates partial ly compensate this limitation and may prevent cage subsidence.
Indications F Unstable anterior column or meta static lesion compressing the spinal cord in the thoracic spine. F Patients in whom a transthoracic ap proach is contraindicated. F Thoracic instability caused by frac ture or spondylodiscitis is a potential indication.
Contraindications Patients with limited life expectancy (
Redaktion
M. Mayer, München Zeichner
R. Himmelhan, Mannheim
Introductory remarks Metastatic disease of the thoracic spine may lead to instable pathologic fractures with or without spinal cord compres sion. Surgical treatment with radiothera py is often preferred over radiotherapy alone in patients with a life expectancy of more than 6 months [1, 2]. Several sur gical strategies have been described. Due to its primary stability, a staged posteri or then anterior approach has become a popular method. This involves segmental pedicle screw fixation spanning the meta static level with anterior vertebral body re section and cage placement. However, the morbidity associated with a transthoracic approach with chest tube placement has prompted others to pursue an all-poste rior vertebral column resection (VCR) with placement of an expandable cage [3, 4]. This offers the benefit of a singlestaged procedure, but has a sharp learning curve, may require 360° decompression, and is challenging in terms of complex insitu cage alignment [5, 6]. The purpose of this paper is to describe the technique of a modified all-posterior vertebral body re placement with the XCORE2 cage (Nu vasive®).
Surgical principle and objective All-posterior VCR with cage replacement may allow for safe surgical stabilization of the spine without a transthoracic approach or a staged
P.D. Trobisch1 · K. Verma2 1 Zentrum für Orthopädische Chirurgie, Eifelklinik St. Brigida, Simmerath 2 Department of Orthopaedic Surgery, Thomas-Jefferson University, Philadelphia
Vertebral body replacement by posterior approach for metastatic disease in the thoracic spine—modified technique using an expandable cage
procedure in selected patients. Long endplates and angled seating instruments are attached to the cage to facilitate cage insertion. This offers the advantage of bypassing several complex surgical steps required for in-situ alignment of a round cage.
Advantages F Avoidance of the transthoracic ap proach and subsequent chest tube placement. This may reduce recovery time, which is essential for a patient with metastatic disease. F Reduced anesthesia and operative time as well as intraoperative re-posi tioning are not required. F Reduced surgical tissue trauma due to a single posterior approach. This may lead to lower analgesia requirements postoperatively. F In cases of unexpected difficulties, a staged transthoracic approach is still feasible.
Disadvantages F Steep learning curve for posterior-on ly VCR as there is a limited view of the vertebral body. F Potential for injury to the pleura and/ or aorta due to the limited exposure window, and indirect preparation of anatomical structures using angled instruments.
F Thoracic nerve root sacrifice is often necessary to achieve a good working space. F Cages may have a smaller diame ter compared with cages implanted through an anterior approach. How ever, 30-mm long endplates partial ly compensate this limitation and may prevent cage subsidence.
Indications F Unstable anterior column or meta static lesion compressing the spinal cord in the thoracic spine. F Patients in whom a transthoracic ap proach is contraindicated. F Thoracic instability caused by frac ture or spondylodiscitis is a potential indication.
Contraindications Patients with limited life expectancy (
