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J. Nothwang
43.6 Planning, Preparation
andPositioning
• Analysis of the preoperative x-rays and CT scans to eval-
uate the region of lesion and special conditions of the vessels (King-King phenomenon, atypical veins). In some
special cases, Angio CT or MRI may provide further
information of blood supply and FSU.
Attention is demanded to the number of lumbar vertebrae
and stump rips to identify the correct segment level.
• Measurement of FSU height is recommendable, espe-
cially cranial T9. In small patients, the predetermined
space is smaller than the smallest expandable VBR, and
the strategy of treatment has to be modied. (In endo-
scopic approaches, the patient should be informed of
switching to open procedure techniques if endoscopic
approach has to be quit by technical reasons or
complications.)
• Preoperative preparation of the patient should include
shaving of the operative eld and catheter of urinary
bladder. (In our experience, in transthoracic operations
further preparations as intestinal preparation by laxatives are dispensable, even if a split of diaphragm is
necessary).
• Right-side positioning is chosen in all lesions of T9 and
lower, left-side positioning above T9. (This decision is
due to the course of the vessels, which by trend prefer a
Dexter course lower than T9 and a sinistral one in the
upper regions).
• A straight lateral position should be favoured. With uo-
roscopy, the posterior wall has to form a singular line and
the end plates should be hit perpendicular to the radiologic beam.
• In the lower lumbar, spine positioning of the patient depends
on the pelvic rim. In some cases, a backward tilting of the
table is necessary to provide access to the target area.
• The patient has to be xed in pillars with anterior and
posterior support. To avoid decubital problems to the legs,
we use a special bedding pillow, so-called ‘tunnel’ and
gel blankets to protect bony prominences.
• Before starting the operation under uoroscopic control,
the incisions are marked. Especially in endoscopic
approach, the denition of the portals is one of the most
important steps.
• In minimal open and endoscopic approaches, the inci-
sion of the working channel should be exactly in projection to the target area. The length of the skin incision
depends on the presumed size of the vertebral body
replacement (Fig.43.3).
• In endoscopic technique, which we prefer in thoracic
spine surgery and at thoracolumbar junction, the portal
for the endoscope should be marked two segments above
the working channel, the incisions of the fan retractor and
the suction form of a trapezoid.
43.7 Surgical Technique
43.7.1 Approach
• We always start the operation with the working channel
(Fig.43.3)
(It has the largest size, and the success of one-lung
ventilation can be controlled visually without danger of
lung damage even in case of adhesions.)
In thoracolumbar junction, attention should be given to
the course of the diaphragmal line, especially in cases of
raised dome position.
• In case of pleural adhesions, due to former inammations,
mobilize pleura visceralis through the working channel.
Develop an anterior portal, then change position to the
abdominal side of the patient and continue pleural mobilization to reach the lateral vertebral surface from anterior
portal under guidance of endoscope, which then is positioned through the working channel.
• If elasticity of the chest is obviously limited, we recommend a limited resection of the rip in projection to the
target segment to reduce stress and risk of intraoperative
rip fracture. If required, the bone of the rip can be saved
for grafting.
Usually in the upper thoracic spine, the resection of
the rip is necessary due to the horizontal and narrow
course of the rips.
• In terms of the further steps in endoscopic approach, see
the specic chapter.
• If diaphragma’s split is necessary, we expose the line of
insertion with the fan retractor and then incise it with the
help of an electric hook or scissor. After having opened
the diaphragma in the line of insertion, a split of the diaphragma follows and the fan retractor can be placed into
the diaphragma’s gap. With the same instruments, the
parietal pleura is incised in a T-shape and mobilized anteriorly and posteriorly.
• The segmental vessels of the target vertebral body are
mobilized, closed with clips and dissected.
• The adjacent discs are identied and cut with a longarmed scalpel.
• With a raspatory, the disc is separated from the endplates
and nally removed with Kerrison rongeurs.
• If decompression of the spinal canal is necessary, the
lower border of the pedicle is identied and the base of
the pedicle is then resected in a cranial direction with the
help of a Kerrison rongeur and punches.
ab
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Fig. 43.3 (a) Positioning of the patient for minimal invasive lumbotomy an incision line exactly in projection to the target area. (b) Slight skin
extension for a smaller approach. (c) Size of incision for minimal invasive lumbotomy for a VBR
• Having nished the resection, the clearance of the spinal
canal can be performed.
• The bed for the vertebral body replacement has
to be prepared and modelized by chisels. Angulated
chisels are available to shape the corners precisely
(Fig.43.4a).
• The end plate and the suitable length of the vertebral
replacement can be appreciated by test implants
(Fig.43.5a, b).
• Choose a size close to the measured length to create high
stiffness of the spacer and avoid weakening of the implant
by long expansion’s distance.
• The ex situ angle of the end plate can be gently xed
along with the safety screw for distraction.
• With a holding device, the VBR is inserted (Fig.43.6).
• Under uoroscopic control the VBR is placed in a midline
position in both planes.
• The safety screw is opened and the spacer can be expanded
• and hydraulically controlled (Fig.43.7).
• The compression forces should not pass 30atm.
• The screws for end-plate xation are opened to allow
optimal adaption to the end plates of the next segments.
• If ideal positioning is achieved, all screws have to be
tightened by torque wrench.
• With the preparation of the spacer’s bed, usually plenty
enough cancellous bone graft can be harvested, used for
lateral spondylodesis and covering of the VBR.
• In osteoporosis, vertebroplasty of the adjacent vertebral
bodies is recommendable to avoid subsidence of the
implant. The cement augmentation should be applied
close to the endplates (Fig.43.8).
• In tumorous diseases, cement augmentation should be
considered to enlarge local stability (so-called compound
spondylodesis).
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Fig. 43.4 (a and b) Endoscopic preparation of the bed of VBR by angulated chisels and insertion of the VBR
J. Nothwang
43.8 Tips andTricks
• A strict lateral positioning of the patient is extremely
important to avoid malposition of the VBR. Respecting
the correct position means eliminating any risk of spinal
canal compromising.
• If the collapse of the lung hasn’t been succeeded totally,
it is possible to push the lung back by an abdominal
cloth.
• To reduce the frequency of uoroscopic control, we
mark the midline of the adjacent vertebral bodies in the
lateral view by k-wires before starting the vertebral body
resection. In our experience, further uoroscopy is not
required until the denite implantation of the VBR.
• Having clipped the segmental vessels, due to the anatomically more stable situation, we always start the osteotomy
anteriorly with a 2cm chisel, parallel to the anterior vertebral border. In a second step, the posterior osteotomy
follows. This avoids a ‘swinging’ of the vertebral body
with a higher safeness during osteotomy.
• Always respect the curvated shape of the anterior border
of vertebral body to minimize risk of vascular damage.
• In case of anterior kyphectomy, good results can be
achieved, if the anterior longitudinal ligament is completely cut in the level of the discs (Zielke- adapted procedure [21]).
• Use the largest implant which can be inserted in the prepared cavity without additional forces.
• If reduction is desired, the angle of the VBR endplates
must be denitely xed in the favoured position before
introduction of the spacer. For this procedure, special
templates are provided by the companies.
• In the lower lumbar spine, it is sometimes difcult to
reach the posterior locking screw riskless, especially
after anterior spinal decompression. In these cases, it is
helpful to measure the necessary angle in the CT-scan
and prex the locking screw denitely before insertion of
the VBR.
• The aim of the vertebral replacement is to achieve high
contact zones between the VBR endplates and the endplates of the adjacent vertebral bodies. The larger the contact zone, the lesser the risk of implant penetration.
• Inltration of intercostal space where the thoracic drainage is inserted reduces postoperative pain. If harvesting
bone graft from the anterior or posterior iliac crest is
required, we recommend periostal denerving by electric
knife and nally inltration with Ropivacain®.
At the end of a transpleural reconstruction, we applicate
250ml Ropivacain per infusion into the pleura. In our experience, this signicantly reduces the patients demand for
central effective analgesics.
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c
Fig. 43.5 (a, b) Measurement device for the ident length of the implant. (c) Endoscopic intraoperative view of the measurement device in the
prepared implant bed (With permission Aesculap AG, Tuttlingen, Germany)
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Fig. 43.6 Holding instrument for the vertebral body replacement
(VBR) device. (With permission Aesculap AG, Tuttlingen, Germany)
J. Nothwang
Fig. 43.7 (a) Positioning of
the VBR and expansion under
pressure control (With
permission Aesculap AG,
Tuttlingen, Germany) (b)
intraoperative situation with
the holding instrument
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Fig. 43.8 (a) Pre- and (b) postoperative X-ray of pathologic fracture of L4 with augmentation of the adjacent levels with PMMA- cement and
posterior augmented pedicle screw
6. McLain RF, Sparling D, Benson DR.Early failure of short segment
References
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T-J. Video-assisted thoracoscopic surgery and minimal access
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3. Matschke S, Wagner C, Davids D, etal. Complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. Eur J
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4. Taneichi H, Kaneda K, Takeda N, Abumi K, Satoh S.Risk factors
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5. Smits AJ, Deunk J, and. Bloemers F.W. Three-dimensional
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pedicle instrumentation for thoraco-lumbar fractures. A preliminary report. J Bone Joint Surg Am. 1993;75:162–9.
7. Sasso RC, Cottler HB. Posterior instrumentation and fusion for
unstable fractures and fracture dislocations of the thoracic and lumbar spine. Spine. 1993;18:450–560.
8. Reinhold M, Schmölz W, Canto F, Krappinger D, Blauth M, Knop
C. An improved vertebral body replacement for the thoracolumbar spine. A biomechanical invitro test on human lumbar vertebral
bodies. Unfallchirurg. 2007;110(4):327–33.
9. Cripton PA, Jain GM, Wittenberg RH, et al. Load sharing
characteristics of stabilized lumbar spine segment. Spine.
2000;25(1):170–9.
10. Cunningham BW, Sefter JC, Shono Y. Static and cyclic biomechanical analysis of pedicle screw spinal constructs. Spine.
1993;18(12):1677–88.
11. Maiman DJ, Pintar F, Yoganandan N, Reinhartz J.Effects of anterior vertebral grafting on the traumatized lumbar spine after pedicle
screw-plate xation. Spine. 1993;18:2423–30.
12. Knop C, Blauth M, Bühren V, etal. Operative treatment of thoracolumbar fractures– results of a prospective multicenter study by the
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working group “spine” of the German Society of Trauma Surgery
Part 3 follow-up. Unfallchirurg. 2001;104:583–600.
13. Kreinest M, Schmahl D, Grützner PA, Matschke S.Radiological
results and clinical patient outcome after implantation of a hydraulic expandable vertebral body replacement following traumatic
vertebral fractures in the thoracic and lumbar spine: a 3-year follow- up. Spine. 2017;42(8):482–9.
14. Nothwang J, Ulrich C.The reconstruction of the anterior column of
thoracolumbar spine fractures. Osteosynthese Int. 2000;8:1–6.
15. Vieweg U, Solch O, Kalff R. Titandistraktionselement als
Wirbelkörperersatz bei instabilen Berstungsfrakturen der Brustund Lendenwirbelsäule- Eine retrospektive Studie bei 30 Patienten.
Zentralbl Neurochir. 2003;64:58–64.
16. Rohlmann A, Dreischarf M, Zander T, Graichen F, Strube P, Schmidt
H, Bergmann G.Monitoring the load on a telemeterised replacement
for a period of up to 65 months. Eur Spine J. 2013;22:2575–81.
17. Rohlmann A, Graichen F, Bender A, etal. Loads on a telemeterized
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18. Ulmar B, Erhard S, Unger S, Weise K, Schmoelz W.Biomechanical
analysis of a new expandable vertebral body replacement combined
with a new polyaxial antero-lateral plate and/or pedicle Screw and
rods. Eur Spine J. 2012;21:546–53.
19. Maciaszek J.Muscle training for the stability of the spine. Trend
Sport Sci. 2017;2(24):59–65.
20. Geiger F, Kafchitsas K, Rauschmann M. Anterior vertebroplasy
of adjacent levels after vertebral body replacement. Eur Spine J.
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21. Richter A, Quante M, Macherei A, Halm H. Modied primary
stable ventral derotation spondylodesis with Halm-Zielke instrumentation for the treatment of idiopathic scoliosis. Operative
Orthopädie Traumatolol. 2010;22:164–76.
Anterior Correction ofScoliosis
https://t.me/medicina_free
CorneliusWimmer
44.1 Introduction and Core Messages
In 1969, Dwyer developed instrumentation for spinal
correction and xation through an anterior approach
[1]. The Dwyer device is a cable attached to vertebral
bodies with large screws. The discs are removed and
compression is applied on the convex side of the curve.
This is powerful system with a lot of complications
such as pseudarthrosis, cable fractures and loss of correction. Postoperative bracing was necessary
(Fig.44.1). In 1976, Zielke [2] developed a modication of Dwyer system using a rod of 3,2mm instead of
the cable. The application of the Zielke derotation
technique using the solid exible rod allows controlled
production of lordosis and lessens kyphosis (Fig.44.2).
There was a high rod breakage rate. Over the years,
double-rod systems with powerful correction and postoperative mobilization without braces have been developed and are currently the state of the art [3–9].
44
44.2 Indication
Indication is idiopathic scoliosis in the thoracic or thoracolumbar or lumbar spine (Lenke 1 and 5 [10, 11]). The cranial
end fusion level should not be higher than T4, and the caudal
end level should be utmost L4. The curve should be exible
with a coronal Cobb measurement of at least 45° and should
not exceed 90°. Bending lms are necessary to ensure the
exibility of the fractional curve. Treatment is only possible
for a single major curve.
C. Wimmer (*)
Department of Spine Surgery, Trauma Center, Trostberg, Germany
e-mail: ProfWimmer@t-online.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_44
Fig. 44.1 Postoperative x-ray after Dwyer instrumentation
44.3 Contraindication
Absolut contraindication is an osteoporosis, infection, allergic reaction to the metal of the implant, structured kyphosis in
the major curve, minor curve that does not correct to 25° on
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C. Wimmer
a
b
Fig. 44.3 (a, b) Positioning of the patient in lateral decubitus position
with the convex side of the curve elevated
Fig. 44.2 Postoperative x-ray after VDS instrumentation
bending lm, sagittal malalignment with pathological kyphosis cranial or caudal of the instrumented segments [12].
44.4 Positioning ofthePatient
Place the patient in the lateral decubitus position with the
convex side of the curve elevated (Fig.44.3a, b).
44.5 Technical Prerequisites
– X-ray of the whole spine in standing ap and lateral view,
– Bending lms to detect exibility of single major, double
major or triple major curve,
– Measurement of the Cobb angles,
– CT scan of the part of the instrumentation,
– MRI to detect intraspinal pathology (tethered cord, dia-
stematomyelie, Arnold Chiari Malformation),
– Double lumen tube,
– Controlled hypotension,
– Neuromonitoring with MEPs,
– Fluoroscopy,
– Chest tube,
– Cell saver.
44.5.1 Approach [13–16]
If the curve to be instrumented is a thoracolumbar curve,
lumbar or thoracic curve, a thoracolumbar, lumbar retroperitoneal or thoracic approach can be used.
44.5.1.1 Thoracic Approach
Once the patient is positioned (Fig.44.4a), perform a curvilinear incision along the rib that is one level higher than the
most proximal level to be instrumented (Fig.44.4b). Perform
the incision along the rib. Expose and excise the rib. Enter
the chest and retract the lung (Fig. 44.4c, d). Identify the
vertebral bodies and carefully dissect the muscle laterally of
the vertebral disc spaces. Divide the prevertebral fascia in
direction of the spine. Identify the segmental arteries over
the waist of each vertebral body, isolate and ligate them
(Fig.44.4e). Expose the bone extraperiostally. The exposure
from T7 to T11 is simple. A double thoracotomy is necessary
for six or more levels. The second thoracotomy is best performed at T11.
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c
de
Fig. 44.4 (a) Skin incision for thoracolumbar approach. (b) Exposure after opening thorax. (c) Exposure of thorax with diaphragm. (d) Exposure
of spine before ligation of segmental vessels. (e) Intraoperative view after ligation of segmental vessels
44.5.1.2 Thoracoabdominal Approach
Once the patient is positioned, perform a curvilinear incision
along the rib that is one level higher than the most proximal
level to be instrumented. Perform the incision along the rib
and extend it distally along the anterolateral abdominal wall
just lateral to the rectus abdominus muscle. Expose and
excise the rib. Enter the chest and retract the lung. Identify
the diaphragm as a separate structure:
Remove the diaphragm from the chest cavity and con-
tinue with retroperitoneal dissection distally. Enter the chest
cavity transpleurally through the bed of the rib. Use the elec-
44.5.1.3 Lumbar Extraperitoneal Approach
Place the patient in a lateral decubitus position with the convex side up (Fig.44.5a). Perform a midank incision from
the midline anteriorly to midline posteriorly. Divide the
abdominal oblique muscles in line with the incision, split the
transversal muscle (Fig.44.5b). Dissect the peritoneum anteriorly. Posterior dissection allows access to the spine. Repair
any inadvertent entry into the peritoneum immediately
because it may not be identiable later. Locate the major vessels in the midline, divide the segmental arteries and veins
and ligate them.
trocautery to divide the diaphragm close to the chest wall.
Leave a small tag of diaphragm for reattachment. Now
expose the retroperitoneal space. Dissect the peritoneal cavity and split the oblique muscles and transvers muscles in
line with the skin incision and exposure distally as far as necessary. Identify the vertebral bodies and carefully dissect the
muscle psoas laterally to the vertebral disc spaces. Divide the
prevertebral fascia in the direction of the spine. Identify the
segmental arteries over the waist of each vertebral body, isolate and ligate them. Expose the bone extraperiostally.
44.5.1.4 Disc Excision
The disc can be felt as soft, rounded protuberant area of the
spine compared with the concave surface of the vertebral
body. Divide the annulus sharply with a long handled scalpel
and remove it (Fig.44.6). Remove the nucleus pulposus with
rongeurs and curets. If necessary, remove the anterior or pos-
terior longitudinal ligaments. Remove the cartilaginous end-
plates using a ring curet or osteotome. Obtain hemostasis
with Gelfoam. Signicant correction of the curve occurs dur-
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