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C. Schultz
Fig. 41.5 MACS TL Implant (with permission of Aesculap, Tuttlingen,
Germany) with iliac crest bone graft T12
41.3.2 Vertebral Body Replacement (VBR)
For special indications, like multilevel corporectomy in
tumour cases, there are still non-expandable cages available
like the titanium mesh cage SynMesh (DePuySynthes). They
are designed to ll with bone to achieve healing and resulting
in stability. Alternatives are the Trabecular Metal VBR’s
(Zimmer Biomet). Amongst other things, the endoscopic
approaches and the request for primary stability have the use
of expandable titanium cages for vertebral body replacement
well established. Commonly, today’s devices are mechanically expandable like the Obelisc (Ulrich) and the XRL
Vertebral Body Replacement (DePuySynthes).
There are further designs like the Fortify I (Globus
Medical) with integrated titanium plates and screws for additional stabilization between vertebral body and spacer.
Advantages of these devices:
• Small size of the compressed VBR.
• Adjustment of the height of the VBR to the length of the
cavity.
• High primary stability.
Because of the manually application until the VBR ts
tightly into the resection area, there is usually no reliable
Fig. 41.6 Hydrolift VBR (with permission of Aesculap AG, Tuttlingen,
Germany) T10
feedback of the applied forces. Especially in case of reduced
bone quality an overextension could lead to an impression of
the end plates. The Hydrolift (Aesculap) is an example for a
VBR (Fig. 41.6) with special features to avoid these
complications:
• Hydraulic manometer-controlled distraction.
• Continuously adjustable endcaps to improve force transmission at the bone–cage interface.
References
1. Xiao ZM, Li ZX, De Feng G, etal. Surgical management for upper
thoracic spine tumors by a transmanubrium approach and a new
space. Eur Spine J. 2007;16:439–44.
2. Anderson TMMK, Jl M.Approaches to anterior spinal operations:
anterior thoracic approaches. Ann Thorac Surg. 1993;55:1447–52.
3. Cauchoix J, Binet JP.Anterior surgical approaches to the spine. Ann
R Coll Surg Engl. 1957;21(4):234–43.
4. Ikard Robert W.Methods and complications of anterior exposure of
the thoracic and lumbar spine. Arch Surg. 2006;141:1025–34.
5. Cheung KMC, Al Ghazi S.Approach-related complications of open
versus thoracoscopic anterior exposures of the thoracic spine. J
Orthop Surg. 2008;16:343–7.
Anterolateral Endoscopic Stabilization
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OliverGonschorek
42.1 Introduction and Core Messages
The use of minimally invasive techniques in thoracoscopically assisted procedures allows the reconstruction of the anterior column after vertebral fractures of
the thoracolumbar region with reduced approach morbidity. Further indications are secondary reconstruction after malalignment and non-union and resection
of tumour and metastasis. After resection of the
destroyed discs and vertebra, vertebral body replacement together with an angle-stable double-rod instrumentation results in a biomechanical stable anterior
column. The aims of this procedure are: reconstruction
and stabilization of the anterior column, decompression of the spinal canal, resection of destroyed discs,
restoration of the sagittal alignment, early functional
treatment, and reduced comorbidity by using the minimally invasive approach.
42
42.2.2 Monosegmental Anterior
Spondylodesis
• Incomplete burst fracture A3.1 and A1.2 fractures.
• Good bone quality (young patient, no osteoporosis).
• One destroyed disc.
42.2.3 Bisegmental Anterior Spondylodesis
• Burst (split) fractures A3.2/A3.3, Pincer fracture A2.3 [3].
• Two destroyed discs.
42.3 Contraindications
• Limited general condition.
• Restricted cardiopulmonary function.
• Severe thoracic trauma.
• Acute post-traumatic lung failure.
42.2 Indications [1, 2]
42.2.1 General
• Unstable fractures between T3 and L3.
• Fractures A1.2, A1.3 and A2 with kyphosis >15° [3].
• Burst fractures A3 (main indication) [3].
• Tumour and metastasis.
• Secondary operations, that is, after malalignment and
non-union.
O. Gonschorek (*)
Department of Spine Surgery, BGU Trauma Center Murnau,
Murnau, Germany
e-mail: oliver.gonschorek@bgu-murnau.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_42
42.4 Technical Prerequisites
Fluoroscopy, carbon table, vacuum mattress, thoracoscopy
unit (see Fig. 42.1), special thoracoscopical instruments
(Fig.42.2), monosegmental cages (i.e. Tantalum, Zimmer
Spine, monosegmental procedure), expandable cages (i.e.
Hydrolift, Aesculap, bisegmental procedure), angle-stable
double-rod system (MACS, Aesculap). For monosegmental
spondylodesis, bone grafts may be used. Due to the harvest
morbidity, we prefer to use a non-expandable cage, that is,
Tantalum (Fig.42.3). Small expandable cages may be used
as well. However, in most cases, they are too big. For bisegmental spondylodesis, expandable cages are advantageous
(Fig. 42.4). Beside the mentioned Hydrolift (Aesculap),
there are many other products (VLift, Stryker; Obelisk,
Ulrich; Xtenz, Königsee). For lateral stabilization, an
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O. Gonschorek
Fig. 42.3 Monosegmental spondylodesis with Tantalum cage and
MACS shown as 3D-CT scan
Fig. 42.1 The thoracoscopy unit with three HD screens allows all par-
ticipants an excellent view
Fig. 42.2 Special instruments are necessary to operate under endo-
scopical control
Fig. 42.4 Bisegmental spondylodesis with Hydrolift and MACS
shown as 3D-CT scan
angle- stable system should be used. Alternatives to the
MACS system are Xia anterior (Stryker) and Telex or
Arcox (Synthes), respectively [4, 5].
42.5 Planning, Preparation
andPositioning
The CT scan is used to measure the sizes of all implants to be
used during the anterior spondylodesis. During the operation, measurements are re-evaluated using intraoperative
special measuring devices and uoroscope. Navigation may
be useful. Stable lateral positioning on the right side of the
patient on a carbon table is performed using a vacuum mattress. Free tilt of the C-arm must be checked. Entrance points
for the working and optical channels and the target area are
marked on the skin using the uoroscope (see Fig.42.5).
42 Anterolateral Endoscopic Stabilization
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Fig. 42.5 Patient in lateral
position on a vacuum
mattress; approaches are
marked under uoroscopic
control
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42.6 Surgical Technique
42.6.1 Approach
• Four trocars are placed after the one-lung ventilation has
started, the rst one using a mini-open procedure to avoid
lung lesions (see Fig.42.6).
• From this point, all operative steps are under thoracoscopic control.
• Lung retractor and suction instrument are inserted using
the anterior portals; the working channel is caudal
posterior.
• To reach L1–3, a diaphragm split is necessary [6].
42.6.2 Instrumentation
• A K-wire is placed in the vertebra superior to the fractured one using the K-wire impactor under uoroscopic
control. The correct position is close to the ground plate
∼1cm from the posterior border (see Fig.42.7).
• The entry hole is prepared using a cannulated punch (see
Fig.42.8).
• The posterior polyaxial screw, the polyaxial plate and the
centralizer have to be preassembled and then placed over
the K-wire (see Fig.42.9).
• To avoid the risks by pushing forward the K-wire, it has to
be removed after the initial turns.
• The polyaxial plate is then screwed down but not tightened. The precise alignment may be controlled by
uoroscope.
a
b
Suction device
Lung retractor
Optic trocar
Th
^2
L
2
L
^
Working trocar
Fig. 42.6 (a) Situs with the portals for endoscopic operation tech-
nique. (b) Illustration of the portal placements. (With permission of
Aesculap AG, Tuttlingen, Germany)
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Fig. 42.7 K-wire placed close to the end plate of the vertebra
O. Gonschorek
Fig. 42.9 The polyaxial screw together with the polyaxial plate is
placed over the K-wire
Fig. 42.8 Entry hole prepared by punch
• Same procedure has to be performed with the second
screw (see Fig.42.10).
42.6.3 Monosegmental Procedures
• The second screw has to be placed close to the ground
plate of the fractured vertebra.
• The ruptured intervertebral disc and the fractured parts of
the vertebra are resected.
• The cancellous bone of the remaining vertebra is compressed by using the probes of the cage.
• The Tantalum cage is then inserted in a ‘press-t
technique’.
Fig. 42.10 Both polyaxial plates and screws together with the central-
izer in place
42.6.4 Bisegmental Procedures
• The second screw has to be placed close to the end plate
of the adjacent vertebra.
• Both discs are resected and partial corpectomy is
performed.
• The expandable cage is inserted and expanded.
• Cancellous bone graft (from the resected vertebra) is
attached laterally.
• The double-rod system congured as a frame plate is laid
onto the clamping elements (see Fig.42.11) and xed by
nuts, using a torque of 15Nm (see Fig.42.12).
• A guide sleeve is inserted to place the anterior screw after
opening the cortex using a punch (see Fig.42.13).
42 Anterolateral Endoscopic Stabilization
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Fig. 42.11 Insertion of the frame plate
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Fig. 42.12 The frame plate is xed to the clamping elements rmly
using a torque wrench
• The anterior screws are inserted through the guide sleeve
(see Fig.42.14).
• The guiding sleeve is then removed and the polyaxial
mechanism is locked by inserting a locking screw (see
Figs.42.15 and 42.16).
• If a diaphragma split has been performed, the gap in the
diaphragma is closed using adaptive sutures.
• A chest tube is placed with its end in the costodiaphragmatic recess, and all instruments and trocars are removed,
the portals closed.
• The posterior screws are tightened down to press the plate
rmly to the vertebra (see Fig.42.17).
Fig. 42.13 Entry hole for the anterior screw is prepared by punch
Fig. 42.14 Anterior screw in place
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Fig. 42.15 Locking of the polyaxial mechanism
Fig. 42.16 Final construction of the MACS in a bisegmental anterior
spondylodesis (with hydrolift as expandable cage)
O. Gonschorek
42.7 Tips andTricks
• Screwdrivers should be inserted perpendicular to the
screws. This is facilitated by ‘switching over the rib’
using one working portal.
• Posterior screws together with the polyaxial plate– once
correctly placed– may serve as a ‘navigation frame’ during the resection of the fractured vertebra. Thereby, orientation on the thoracoscopic view is facilitated.
• The K-wires and screws should be placed close to the end
plates. So it is very unlikely to set lesions to the segmental
vessels.
References
1. Beisse R, Potulski M, Beger J, etal. Entwicklung und klinischer
Einsatz einer thorakoskopisch implantierbaren Rahmenplatte
zur Behandlung thorakolumbaler Frakturen und Instabilitäten.
Orthopade. 2002;31:413–22.
2. Gonschorek O, Bühren V. Verletzungen der thorakolumbalen
Wirbelsäule. Orthop Unfall Up2date. 2006;1:195–222.
3. Magerl F, Harms J, Gertzbein SD, etal. A comprehensive classication of thoracic and lumbar injuries. Eur Spine J. 1990;3:184–201.
4. Josten C, Katscher S, Gonschorek O.Therapiekonzepte bei Frakturen
des thorakolumbalen Überganges und der Lendenwirbelsäule.
Orthopade. 2005;34:1021–32.
5. Raju S, Balabhadra V, Kim DH.Thoracoscopic decompression and
xation (MACS-TL). In: Kim DH, Fessler RG, Regan JJ, editors.
Endoscopic spine surgery and instrumentation. NewYork: Thieme;
2005.
6. Kim DH, Jahng TA, Balabhadra RS, etal. Thoracoscopic transdiaphragmatic approach to thoracolumbar junction fractures. Spine.
2004;4:317–28.
Fig. 42.17 The frame plate is tightened to the vertebra
Vertebral Body Replacement
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JürgenNothwang
43.1 Introduction and Core Messages
The anterior support in thoracolumbar spine fractures
and in some special cases of tumour diseases is one of
the most important steps for reconstructing the shape
of the vertebral column to preserve satisfying longterm results. A lot of biomechanical and clinical investigations conrm the necessity of anterior
reconstruction in bisegmental posterior stabilizations
to avoid posterior implant failure. Potential of healing
of a bisegmental corticocancellous graft is limited.
With vertebral body replacements (VBR), the loss of
correction after removal of the posterior stabilization
device is small. VBRs with expandable components
(Fig.43.1) allow an adapted anterior defect bridging
and open the possibility of anterior reduction.
43
J. Nothwang (*)
Rems-Murr-Klinik Schorndorf, Department for Trauma Surgery
and Orthopedics, Schorndorf, Germany
e-mail: juergen.nothwang@freenet.de; jnothwang@khrmk.de
© Springer-Verlag GmbH Germany 2023
U. Vieweg, F. Grochulla (eds.), Manual of Spine Surgery, https://doi.org/10.1007/978-3-662-64062-3_43
Fig. 43.1 Expandable vertebral body replacement system Hydrolift
(Aesculap) (With permission Aesculap AG Tuttlingen, Germany)
43.2 Indications
Indication of vertebral body replacement is depending on the
entity of the lesion, bone quality, and general condition of the
patient. A careful analysis of the pathology protects further
complications. We have to remind that even in endoscopic
techniques, the perioperative risk [1–3] is respectable.
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J. Nothwang
• Fractures of thoracolumbar spine (Type A2.3, A3.2.,
A3.3., Type B and C1 fracture in combination of bisegmental fractures of the vertebral body, Type C2.2 and C3
fractures with severe destruction of the vertebral body).
• Total corporectomy/spondylectomy in primary tumour
treatment,
• Metastases of vertebral body in epithelial tumours with
mild prognosis: corporal destruction >40% (lumbar spine)
and 60% (thoracic spine) [4].
• Persistent instability after total vertebral collapse due to
osteoporosis,
• Post infectious, post-traumatic or kyphotic deformities in
degenerated diseases (Fig.43.2).
43.3 Contraindications
• Reduced general conditions of the patient: pulmonary and
cardiac risk factors (ASA risk score≥IV, NYHA score IV).
• Pre-existing lung diseases with mayor reduction of vital
capacity, pleural diseases as pleural rind, adhesions of the
lung, and residuals after lung contusion may disable a
thoracic transpleural approach and one-lung ventilation in
endoscopic approach.
• Disturbance of haemostasis.
• Extensive osteoporosis with severe pre-existing
deformities.
• Bad prognosis in tumour diseases and reduced general
conditions of the patient.
• Malformation of the thorax and its cavity, and.
• Previous surgery with the same approach (relative).
43.4 Technical Prerequisites
Fluoroscopy, radiolucent operating table, retraction device, rip
raspatory, rip resector, light source, long instruments, thoracotomy set, lung retractor, electric scissor and hook for preparation of the pleura parietalis, osteotomes, hook probes, sharp
and blunt rongeurs, Kerrisson rongeur, curettes, clip applicator
and if disposable, shaver for disc preparation. Not only for
endoscopic preparation ultrasound dissector is helpful and
enables an operation technique with reduced blood loss.
For endoscopic techniques, there is further need for three
chip camera, 30° angled rigid scope, light source, monitors,
video-recorder and printer, irrigation/suction unit, fan
retractor.
In endoscopic technique, double tube for one-lung ventilation intraoperatively is mandatory. Further advantages
might be offered by three-dimensional thoracoscopy [5].
43.5 Basic Clinical andBiomechanical
Messages
• Reduced load-bearing capacity of the anterior column
(i.e. burst fractures, extended vertebral body defects) is
the mayor risk for loss of correction and implant failure
[6–8].
• Several biomechanical investigations have demonstrated the
breakage of the posterior implant under cyclic load [9, 10].
• In vitro biomechanical investigations showed that the
maximum load was lower in the strut grafted spines,
when compared with those with pedicle xation only
[11]. It is also of concern that the potential of healing of
a bisegmental corticocancellous graft is limited.
Pseudarthrosis and even fractures of the grafts are
described [12].
• To minimize principle loss of correction, a metallic tita-
nium or peek expandable (Fig. 43.1) vertebral body
replacement can offer higher guarantee [13–15].
• Collapse of the VBR implant into the vertebral body
remains a point of concern [7, 16]. Several clinical and
invivo measurements conrm force reduction in the rst
two months after operation due to subsidence of the
implant [17].
• Currently, little is known about the amount of loads which
is created by VBRs and which stresses the end plates
under daily life movements [16, 17]. Additional axial
loads in upright position in interaction with individual
factors due to bone mineral density further modify the
resistance capabilities. In rotatory instabilities,
VBR + anterolateral plate+ posterior screw-rod-system
offers the highest stability in biomechanical testings com-
pared to the normal spine [18]. The contribution of the
muscle corset to spinal stability is still well known, its
effects in spinal instability not yet [19].
• In poor bone quality, the subsidence of VBR into the end-
plate may cause an increased loss of correction [15]. Our
clinical experience that a near endplate anterior vertebro-
plasty in adjacent level can provide good results is found
in literature [20].
• The question of near endplate vascularisiation, which is
interrupted by cementing, is not answered in the end.
ab
cd
43 Vertebral Body Replacement
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Fig. 43.2 (a and b)
Posttraumatic and
degenerative deformity:
preoperative X-rays. (c and d)
Postoperative X-rays after
ventrodorsal reconstruction
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