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Fig. 51.6 Removal of the vertebral body including pedicle/transverse
process en bloc
M. Ruf et al.
Fig. 51.8 Photograph of an en bloc specimen, including three verte-
bral bodies and the inltrated upper lobe of the lung
rst to mobilize a pulmonary lobe, which allows leaving
the lobe in one piece with the vertebral bodies (Fig.51.8).
Important arteries may be replaced by a vascular prosthesis (Fig.51.9).
Fig. 51.7 Anterior support, posterior compression
• Debridement of the adjacent endplates. Reconstruction of
the anterior column with an anterior support (Harms cage,
lled with bone cement / expandable cage) (Fig.51.7).
• Insertion of both rods, compression via the instrumentation (Case 1).
51.6.2 Anterior Approach
When the tumor exceeds the anterior border of the vertebral body with inltration of the adjacent soft tissues (vessels, lung), an additional anterior approach is necessary.
This approach allows for a widespread visualization of the
anterior vessels (aorta, azygos vein, segmental vessels),
pleura and lung, mediastinum. In case of inltration of the
lung or major vessels, a thoracic surgeon or cardiovascular
surgeon should be consulted. It may be necessary to dissect the bronchus and the pulmonary vessels at the hilus
51.6.2.1 Thoracic Approach (T4–T9)
For thoracotomy in the midthoracic spine, the right-sided
approach is preferred to avoid the aorta. However, a leftsided approach may be necessary when the tumor expands at
the left side to dissect the segmental vessels and mobilize the
aorta.
• Anesthesia with a double-lumen endotracheal tube for
single lung ventilation is recommended. To decrease the
risk of atelectasis, reinate the lung every 30min.
• The patient is placed in lateral decubitus position with the
desired side up on the table with elevated arm.
• After dissection of the trapezius muscle and mobilization/
dissection of the serratus anterior muscle, thoracotomy is
performed usually 1–2 ribs above the involved segment.
Osteotomy of the lower rib distally facilitates a sufciently dimensioned approach.
• The margins of the tumor are localized under uoroscopic
control; the disks adjacent to the planned resectate are
marked.
• The parietal pleura is usually left at the tumor. The segmental vessels at the tumor level are ligated close to the
aorta, the aorta is carefully mobilized. The intervertebral
disks are incised and removed (most parts of the disks,
especially posterior annulus, posterior longitudinal
51 Thoracic Vertebrectomy andSpinal Reconstruction Via Posterior orCombined Approaches
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• Ligation of the segmental vessels, mobilization and
removal of the tumor, as well as the stabilization is similar
as described for the midthoracic area.
• If needed, the psoas muscle can be removed in one piece
with the tumor.
51.6.2.3 Cervicothoracic Junction
• The patient is placed in a supine position.
• A common left-sided approach to the lower cervical spine
is performed.
• Complete or partial osteotomy of the sternum after release
of the soft tissue dorsal to the sternum.
• Dissection of the omohyoides, sternohyoideus, and sternothyroideus muscles.
• The inferior thyroid artery is ligated and transsected.
• If necessary, the brachiocephalic vein may be ligated
andcut.
• A blunt dissection in front of the vertebral column is possible down to T4. Esophagus and trachea are retracted
medially, thoracic duct and vessels laterally (Case 3).
365
Fig. 51.9 Intraoperative situs after resection of a cervicothoracic
tumor with inltration of the subclavian artery; goretex substitute of the
vessel
ligament, and annulus of the contralateral side should
already be removed by the posterior approach).
• The tumor resectate is now mobile and can be carefully
lifted from the spinal cord. It is removed in one piece.
• The adjacent endplates are debrided and an anterior column support is inserted. A meshgraft can be used to close
the defect of the parietal pleura.
• A second posterior approach can be performed to apply
compression forces at the posterior instrumentation,
thus increasing the overall stability of the construct
(Case 2).
51.6.2.2 Thoracolumbar Approach (T9–T12)
• In the thoracolumbar region, a left-sided approach is
preferred.
• The planning and positioning in lateral decubitus position
is similar to a midthoracic approach.
• If a phrenotomy is necessary, the peritoneal sac is mobilized starting at the costodiaphragmatic angle. The diaphragm is cut close to the costal insertion.
51.7 Tips andTricks
• A meticulous dissection and mobilization of the tumor by
the posterior approach extremely facilitates the anterior
part of the surgery. All connections to the surrounding
structures that can be reached from posterior should be
cut from posterior.
• When to use an additional anterior approach – it is not
always easy to answer. Based on our experience, we suggest the following strategy: if mobilization of the big vessels is too difcult and the tumor mass is too big, use an
additional anterior approach.
• The use of autologous bone or bone substitute in the primary tumor resection surgery is hindering the postoperative CT and MRI imaging in detecting early tumor
recurrences. Bone may be added after a longer tumor-free
interval to achieve a lifetime bony fusion.
• In case of resection of two or more vertebrae with pedicles, the nerve roots at the tumor side must be cut in the
spinal canal to allow the removal of the vertebrae without
traction at the spinal cord. The dura can be sutured after
removal of the tumor.
• Compression of the facet joints of the adjacent vertebrae
via the instrumentation increases the rotational stability.
In short monovertebral xations, a cross-link is able to
resist rotational forces (Case 4).
• Take care to check SSEP and MEP in the patient before
anesthesia is injected; so, you will not be surprised in case
neuromonitoring is not possible due to any reason!
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51.8 Clinical Cases
Case 1 Aneurysmatic Bone Cyst
A 27-year-old male with nonspecic, nontraumatic back
pain at mid-thoracic level. After complete preoperative diagnostics (CT, MRI) (see Figs. 51.10a–c and 51.11) and additional angiographic embolization, an en bloc vertebrectomy
T8 and 9 (see Figs. 51.12a, b and 51.13) via costotransverectomy, instrumentation with internal xator system T6 to 11,
and vertebral body replacement with a titanium mesh cage
lled with bone cement were performed.
abc
M. Ruf et al.
Fig. 51.11 Preoperative MRI scan, axial view, Case 1
Fig. 51.10 Preoperative CT scans with sagittal (a, b) and axial views (c), Case 1
51 Thoracic Vertebrectomy andSpinal Reconstruction Via Posterior orCombined Approaches
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a
b
Fig. 51.13 Photograph of the en bloc specimen (aneurysmatic bone
cyst), Case 1
Case 2 Ewing’s Sarcoma
A 15-year-old teenager with severe paraparesis which was
caused by a tumor in the level T8. Under emergency conditions, a laminectomy was performed to decompress the spinal cord (histology: Ewing’s sarcoma). A chemotherapy
according to Ewing protocol was performed (see Figs.
51.14a, b and 51.15a, b). The surgical therapy consisted of a
posterior-anterior en bloc resection of T8 with the adjacent
rib and posterior muscle, instrumentation T6 to 10, and vertebral body replacement with titanium mesh cage lled with
bone cement (see Figs. 51.16, 51.17, and 51.18).
Fig. 51.12 Postoperative whole spine x-ray (a-AP, b-lateral view)
after en bloc vertebrectomy T8 and 9 via costotransversectomy, instrumentation with internal xator system, and vertebral body replacement
with a titanium mesh cage lled with bone cement, Case 1
Fig. 51.14 MRI scan
(a-sagittal, b-axial view) of a
15-year-old teenager with
severe paraparesis before the
rst chemotherapy, Case 2
ab
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M. Ruf et al.
ba
Fig. 51.15 MRI scan (a-sagittal, b-axial view) after the chemotherapy according to Ewing protocol, Case 2
a
Fig. 51.16 Intraoperative view (right-sided thoracotomy), (a) defect following vertebrectomy (above) with a spatula in place, myelon with
ligation of the nerve root (middle), posterior instrumentation, and (b) vertebral body replacement with titanium mesh cage lled with bone
cement
b
51 Thoracic Vertebrectomy andSpinal Reconstruction Via Posterior orCombined Approaches
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Case 3 Giant Cell Bone Tumor
A 29-year-old male with a destructive giant cell bone tumor
T1, T2, and T3; status post vertebroplasty, laminectomy, and
instrumentation C7 to T3 elsewhere (see Fig. 51.19a–d). A
two-stage surgery was performed with (1) posterior pedicle
screw instrumentation C5 to T6 with laminectomy T1–3 and
tumor mobilization via costotransversectomy and (2) anterior vertebrectomy T1, T2, and T3 and vertebral body
replacement with titanium mesh cage lled with bone cement
via sternotomy (see Figs. 51.20a, b and 51.21).
Fig. 51.17 Axial CT scan following the total en bloc vertebrectomy,
Case 2
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a
b
Fig. 51.18 Postoperative AP (a) and lateral X-ray scan (b) after poste-
rior-anterior en bloc resection of T8, instrumentation T6 to 10, and vertebral body replacement with titanium mesh cage lled with bone
cement, Case 2
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M. Ruf et al.
a
b
Fig. 51.19 Preoperative CAT (a–c) and MRI (d) scans after vertebroplasty, laminectomy, and instrumentation C7 to T3 elsewhere, Case 3
(histology: destructive giant cell bone tumor)
51 Thoracic Vertebrectomy andSpinal Reconstruction Via Posterior orCombined Approaches
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a
Fig. 51.20 Postoperative X-rays in the AP (a) and lateral (b) view and CAT scan (c), Case 3
b
c
Fig. 51.21 MRI scan at 5-year follow-up with no evidence of tumor
recurrence, Case 3
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M. Ruf et al.
Case 4 Osteoblastoma
An 8-year-old boy with an osteoblastoma L3, status post
curettage and lling with calcium sulfate (see Fig. 51.22a, b)
elsewhere in a hospital. A posterior-anterior-posterior en
Fig. 51.22 Preoperative MRI
in sagittal (a) and axial (b)
view of an 8-year-old boy
(histology: osteoblastoma)
after curettage and lling with
calcium sulfate, Case 4
a
bloc resection of L3 with instrumentation and fusion L2 to
L4 was performed (see Figs. 51.23 and 51.24a, b).
b
51 Thoracic Vertebrectomy andSpinal Reconstruction Via Posterior orCombined Approaches
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ba
Fig. 51.23 Intraoperative view, short instrumentation L2 to L4, cross-
link connector to compensate shear and rotational forces
Fig. 51.24 Radiographs 12 years postoperatively in anterior-posterior
(a) and lateral (b) view, Case 4
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