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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6013_Библиотеки_им_академика_М_И_Перельмана.pdf
S T E P 1
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Bovie electrocautery
• Alexander elevator
• Cobb and Doyen elevators
S T E P 1 C ON T R O V ER S I E S
• Some surgeons differ on the timing
of the rib resection: before the
instrumentation and correction, or after
the spinal procedure. The authors
favor the rib resection before curve
correction, to obtain additional
flexibility of the spinal deformity and
achieve superior correction of the spine.
Procedure 23 | Thoracoplasty for Rib Deformity 227
n
A Freer elevator, a small Cobb elevator, or an Alexander elevator is used to
subperiosteally expose each rib on its dorsal surface over the entire length of
the resection (usually 2 cm is needed).
n
A small elevator or curved hemostat is gently passed underneath (ventrally) the
rib subperiosteally; care is taken to avoid injury to the pleura underneath
(Figures 23-3 and 23-4).
n
A Doyen elevator is passed circumferentially and swept both medially and later-
ally to extend the exposure for a short distance, facilitating confirmation of
adequate subperiosteal release of the rib (Figures 23-5 and 23-6).
FIGURE 23-3 FIGURE 23-4
FIGURE 23-5 FIGURE 23-6
228 Procedure 23 | Thoracoplasty for Rib Deformity
FIGURE 23-7 FIGURE 23-8
FIGURE 23-9 FIGURE 23-10
S T E P 2 P EA R L S
• The rib is held with a towel clip to
prevent its sharp edge from plunging
through the pleura when it is cut.
• One can always return after the spinal
correction and instrumentation portion
of the procedure is completed to take
more rib out, but it cannot be put
back. Taking too much rib and creating
a concavity is worse than leaving a
residual rib deformity.
• The apex of the curve will translate to
the midline of the spine, ultimately
leaving a much larger gap than
apparent at the time of rib resection.
S T E P 2 P IT FA L L S
• Pleural violation should be recognized
and immediately repaired with 2-0
absorbable suture.
• It is important to resect the medial
portion of the ribs as well, because
failure to do so will create a ridge.
Step 2
n
Two right-angle retractors are placed on the medial side of the rib, pulling back
the paraspinal muscle.
n
A Cobb elevator is used to strip the periosteum further to expose the medialmost
attachment of the rib to the transverse process (Figure 23-7).
n
A rib cutter is then passed around the rib and pushed as far medially as possible,
up against the transverse process (Figure 23-8). The rib is then cut medially,
with the ideal cutting plane being exactly parallel to the floor.
n
The rib cutter is moved laterally, and about 2 cm should be initially resected
(Figure 23-9). Starting at the apical levels, a symmetric resection of the ribs is
made both proximal and distal to the apex. In general, as one goes more proximal and distal, less rib is cut. The most important and challenging aspect of this
procedure is achieving ideal visual assessment of the rib deformity, which guides
the extent of the resection (Figure 23-10).
n
Bone wax is applied to the ends of the ribs (lightly), and Gelfoam is packed into
the periosteal bed to assist with hemostasis (Figure 23-11).
Procedure 23 | Thoracoplasty for Rib Deformity 229
FIGURE 23-11
S T E P 2
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• Cobb elevator
• Right-angle retractors
• Rib cutter
• Towel clip
S T E P 3 P EA R L S
• A postoperative chest radiograph may
rule out pneumothorax or pleural
effusion.
• Perform chest physiotherapy
postoperatively.
S T E P 3 P IT FA L L S
• Unrecognized pleural effusion or
hemothorax/pneumothorax
Step 3
n
The portions of the ribs that are resected can be morselized and used for
autologous bone graft for fusion.
n
After the spinal instrumentation, correction, and bone grafting, the ribs may
be brought together with heavy absorbable suture through small drill holes in
the rib ends. This provides additional correction of the rib hump and stability of
the rib ends to facilitate healing and patient comfort. The rib periosteum is
approximated.
n
A water test is performed to make absolutely certain the pleura is intact. Using
a small pitcher, saline is poured into the wound carefully so as not to create
any additional air bubbles. The anesthesiologist performs a Valsalva maneuver
three times to look for a leak in the pleura. Any pleural leaks are repaired with
2-0 absorbable suture.
n
The intercostal muscle layer is approximated with a suture, and a medium
Hemovac drain (Zimmer Inc., Warsaw, Ind.) is placed over the resected rib bed
and brought out lateral to the spine. The thoracolumbar fascia is closed with a
running long-acting absorbable suture, starting at the distal end of the wound.
Postoperative Care and Expected Outcomes
n
A small protective shell is applied over the rib resection area if desired. This shell
helps avoid a postoperative flail chest and minimizes the motion of the cut ribs
over the pleura, and it may decrease the accumulation of a pleural effusion.
(This is optional.)
n
Thoracoplasty may increase pain or mildly prolong the postoperative course
following spinal fusion with instrumentation.
n
To allow mobilization, aggressive pulmonary toileting and chest physiotherapy
is necessary, with adequate pain control.
n
Patients with moderate or severe pulmonary symptoms are monitored with
semierect radiographs for 2 to 3 days. If a significant amount of pleural fluid
accumulates and the patient is symptomatic, a thoracocentesis is performed; if
fluid accumulation occurs a second time, a chest tube is considered.
n
For small pleural effusions, oral or intravenous furosemide may be used to
diurese the patient.
230 Procedure 23 | Thoracoplasty for Rib Deformity
n
A consistent decrease in pulmonary function is observed in the early postopera-
tive period, which mandates proper patient selection. A decline of forced vital
capacity (FVC) of 22%, forced expiratory volume in 1 second (FEV-1) of 24%,
and total lung capacity of 25% were found in the first 6 months. Gradual
improvement occurs over the next 3 years. Patients with less than 60% of predicted values should be cautiously approached as candidates for thoracoplasty.
n
In 2007, Newton and colleagues set out to determine what factors could predict
2-year postoperative pulmonary function tests (PFTs) in patients with adolescent
idiopathic scoliosis. In their prospective study, they found thoracoplasty to result
in a significant PFT reduction. Their cohort included 107 patients who underwent
thoracoplasty, out of 254 total patients. Of these 107, 51 were posterior spinal
fusion (PSF) with thoracoplasty, and 56 were anterior approach with thoracoplasty. Fifty-four percent of thoracoplasty patients saw a 15% or greater
decrease in their predicted PFTs. The decrease in PFTs was greater in the group
who underwent anterior surgery.
n
In 2008, Suk and associates retrospectively reviewed outcomes of thoracoplasty
in the setting of thoracic adolescent idiopathic scoliosis corrected with pedicle
screw instrumentation. Three surgical groups were compared, looking specifically at deformity correction, the effects on pulmonary function tests, and
complications. The groups were representative of no thoracoplasty, thoracoplasty without direct vertebral rotation, and thoracoplasty with direct vertebral
rotation.
n
Suk demonstrated a statistically significant difference in the correction of rib
hump deformities across the three surgical groups. Thoracoplasty with direct
vertebral correction offered the greatest amount of correction. Additionally,
there were no statistically significant decreases, nor differences between surgical
groups regarding pulmonary function testing at the time of most recent follow-up
(specifically measuring FVC and FEV-1). Suk recognized the failure to include a
group with direct vertebral rotation alone and states this was because the
population numbers were too small to include in statistical analyses.
n
Greggi and colleagues retrospectively reviewed outcomes of patients treated by
posterior spinal fusion compared with those who underwent posterior spinal
fusion with thoracoplasty. Their cohorts consisted of 40 patients each, with the
majority of curves classified as Lenke 1 in both groups.
n
They found that PSF with thoracoplasty resulted in a significantly better main
thoracic curve reduction, in addition to the absolute rib hump correction and
the percent reduction of rib hump. Scoliosis Research Society scores were used
to assess patient satisfaction, and no statistically significant differences were
found between the groups, indicating thoracoplasty did not necessarily result in
a more satisfactory cosmetic improvement than PSF alone. Regarding PFTs, there
were no significant differences between the groups preoperatively and postoperatively. However, within each group, FVC and FEV-1 showed a statistically
significant improvement postoperatively at the latest follow-up.
n
Newton demonstrated that curves greater than 50 degrees in magnitude had
a high risk of restrictive lung disease. None of the patients in the Suk or Greggi
study suffered restrictive lung disease preoperatively. Thus the data they have
presented demonstrating improvements in pulmonary function postoperatively,
although statistically significant, may not be clinically significant.
n
In summary, thoracoplasty does improve appearance and patient satisfaction in
those patients undergoing surgery for scoliosis but increases operative time,
blood loss, and may have a cost to pulmonary function and patient comfort.
Procedure 23 | Thoracoplasty for Rib Deformity 231
Evidence
Barnes J. Rib resection in infantile idiopathic scoliosis. J Bone Joint Surg Br
1979;61:31-5.
Barret DS, Maclean JG, Betany J, et al. Costoplasty in adolescent idiopathic
scoliosis: objective results in 55 patients. J Bone Joint Surg Br 1993;75:881-4.
Flinchum D. Rib resection in the treatment of scoliosis. South Med J
1979;36:1378-80.
Geissele AE, Ogilvie JW, Cohen M, et al. Thoracoplasty for treatment of rib
prominence in thoracic scoliosis. Spine 1994;19:1636-39.
Greggi T, Bakaloudis G, Fusaro I, et al. Pulmonary function after thoracoplasty in
the surgical treatment of adolescent idiopathic scoliosis. J Spinal Disord Tech
2010;23:e63-9.
Harvey CJ Jr, Betz RR, Clements DH, Huss GK, Clancy M. Are there indications for
partial rib resection in patients with adolescent scoliosis treated with CotrelDubboset instrumentation? Spine 1993;18:1593-8.
Manning CW, Prime FJ, Zorab PA. Partial costectomy as a cosmetic operation in
scoliosis. J Bone Joint Surg Br 1973;55:521-7.
Newton PO, Perry A, Bastrom T, et al. Predictors of change in postoperative
pulmonary function in adolescent idiopathic scoliosis: a prospective study of 254
patients. Spine 2007;32:1875-82.
Owen R, Turner A, Banforth JSG, Taylor JF, Jones RS. Costectomy as the first stage
of surgery for scoliosis. J Bone Joint Surg Br 1986;68:91-5.
Shufflebarger HL, Smiley K, Roth HJ. Internal thoracoplasty: a new procedure.
Spine 1994;19:840-4.
Steel HH. Rib resection and spine fusion in correction of convex deformity in
scoliosis. J Bone Joint Surg Am 1983;65:920-5.
Suk SI, Kim JH, Kim SS, Lee JJ, Han YT. Thoracoplasty in thoracic adolescent
idiopathic scoliosis. Spine 2008;33:1061-7.
Thulburne T, Gillespie R. The rib hump in idiopathic scoliosis: measurement,
analysis and response to treatment. J Bone Joint Surg Br 1976;56:64-71.
Westgate HD, Moe JH. Pulmonary function in kyphoscoliosis before and after
correction by Harrington instrumentation method. J Bone Joint Surg Am
1969;51:935-46.
P R O C ED U R E 2 4
Complete Vertebral
Resection for Primary
Spinal Tumors
Rick C. Sasso and Paul Kraemer
I N D I CAT I O NS P I T F A L L S
• Complete vertebral resection is
indicated only for confirmed primary
tumors without distant spread, and
some isolated metastasis (i.e., renal
cell).
• Complete vertebral resection is
contraindicated in tumors with multiple
skip lesions.
• Contiguous involvement of more
than three vertebrae is a relative
contraindication for complete vertebral
resection.
T R E A T M E N T OP T I O N S
• Careful preoperative planning includes
reviewing the relative positions of the
arterial, venous, or other soft tissue
structures at the involved level.
• Consider preoperative embolization
of bilateral segmental arteries at
the affected level. Also consider
preoperative embolization of the
segmental arteries cephalad and caudal
to the affected level. Embolization may
reduce blood flow to the involved
vertebra by 75% without influencing
spinal cord evoked potentials, thus
decreasing intraoperative hemorrhage.
P O S I TI O N I N G PE A R L S
• Ensure the eyes are free of any external
compression.
• Suspending the abdominal wall reduces
venous plexus filling around the spinal
cord and reduces intraoperative blood
loss.
P O S I TI O N I N G EQ U I P M EN T
• A specialized table such as a Jackson
table can be used to allow freedom of
the chest and abdominal walls.
Indications
n
Malignant or locally aggressive benign primary spinal tumors
n
Intracompartmental lesions involving the vertebral body and extending into the
pedicles and posterior elements (Weinstein-Boriani-Biagini [WBB]: zones 1-12,
layers B and C)
n
Extracompartmental lesions with only epidural or paravertebral extension (WBB:
zones 1-12, layers A and D)
n
Lesions without spread to or invasion of adjacent viscera, with only minimal
adhesion to the vena cava or aorta
n
Solitary metastatic lesions without extension to the paraspinal area
Examination/Imaging
n
Preoperative magnetic resonance imaging (MRI) is needed for proper tumor
staging.
n
Preoperative computed tomography (CT) is needed to confirm absence of distant
metastasis.
n
MRI is also crucial for identification of vulnerable vascular anatomy and appro-
priate preoperative planning.
Surgical Anatomy
n
The thoracic aorta is in intimate contact with the anterior vertebral column
distal to T5 and must be carefully dissected and retracted anteriorly before
resection of the involved vertebra. The aorta is less likely to be damaged from
T1 to T4.
n
The thoracic segmental arteries surrounding the involved vertebra must be
identified and ligated. Variability has been reported in the anatomy of the segmental vasculature, including originating off an intercostal vessel, and its complete absence.
n
The nerve root exiting cephalad to and crossing the body of the involved ver-
tebra must be identified and ligated to facilitate the en bloc corpectomy (Figure
24-1, A and B).
Positioning
n
Position the patient prone on the operating table (Figure 24-2).
n
Bolsters should be placed longitudinally on each side of the patient such that
the anterior chest wall and abdominal wall clear the operating table.
A
B
FIGURE 24-1, A-B
Procedure 24 | Complete Vertebral Resection for Primary Spinal Tumors 233
FIGURE 24-2
234 Procedure 24 | Complete Vertebral Resection for Primary Spinal Tumors
P O RTA L S / E X P O S U R ES
P E A R LS
• Dissection must be wide enough to
fully expose the transverse processes
bilaterally and extend well onto the ribs
at the involved level.
P O RTA L S / E X P O S U R ES
P I T F A L L S
• If the patient underwent percutaneous
biopsy, the biopsy tracts must be
débrided at this time to prevent tumor
contamination.
FIGURE 24-3
P O RTA L S / E X P O S U R ES
C O N T RO V E R S IE S
• Some authors recommend a second,
anterolateral approach and thoracotomy
to facilitate the ventral release in
tumors with soft tissue extension.
• Alternatively, thoracoscopy has been
used to facilitate ventral release and
anterior column reconstruction with less
morbidity than traditional thoracotomy.
Portals/Exposures
n
This procedure is ideally performed through a single, posterior approach.
n
Make a vertical midline incision centered over the involved spinous process,
extending one to three vertebrae caudal and cephalad.
n
Dissect the paraspinal muscles from the spinous processes and lamina at all
levels, and retract laterally.
S T E P 1 P EA R L S
• Because of the unique threedimensional anatomy of the spine, a
thread-wire saw or Gigli saw is a critical
instrument in making the pedicle cuts.
• Use of a malleable thread-wire saw
guide to pass the saw will protect the
neural elements.
S T E P 1 P IT FA L L S
• Once the spinal canal is breached,
bleeding can be brisk. It is therefore
imperative that all instrumentation
is applied in advance so that the
procedure can proceed with speed and
efficiency.
S T E P 1
I N S T RU M E N T A T I O N /
I M P L AN TAT IO N
• The rods used for provisional fixation
should have a large lateral bend so as
not to obstruct the operative field.
Procedure
Step 1: En Bloc Laminectomy
n
Place pedicle screws in the vertebrae caudal and cephalad to the involved
vertebra in preparation for posterior instrumentation (Figure 24-3). Additional
levels may be instrumented at the surgeon’s discretion, based on bone quality,
spinal level, and body habitus.
n
Transect the ribs of the involved vertebra 3 to 4 cm lateral to the costotransverse
joint, and bluntly dissect the pleura from the vertebra.
n
Remove the spinous process and inferior articular processes of the cephalad
vertebra to expose the superior articular process of the involved vertebra.
n
Pass the thread-wire saw from the medial cortex of the lamina through the
intervertebral foramen in a cephalocaudal direction (Figure 24-4, A).
n
Place the lateral end of the thread-wire saw beneath the superior articular
process and the transverse process to wrap the saw around the pedicle.
n
While applying force in a cephalad direction, use a reciprocating motion of the
saw to cut the pedicle from caudal to cephalad (Figure 24-4, B).
n
Repeat the above process to cut the contralateral pedicle, and remove the
posterior elements (spinous process, superior articular processes, inferior articular processes, transverse processes, and pedicles) as a single unit (Figure 24-5).
n
Apply provisional posterior fixation.
Step 2: En Bloc Corpectomy
n
Bluntly dissect around the vertebral body, identifying the segmental arteries
bilaterally.
n
Ligate and divide the spinal branch of the segmental artery of the involved
vertebra (Figure 24-6).
n
Cut the nerve root, crossing the involved vertebral body on the side from which
the vertebral body will be removed.
Procedure 24 | Complete Vertebral Resection for Primary Spinal Tumors 235
A
FIGURE 24-4, A-B
B
FIGURE 24-5
FIGURE 24-6
236 Procedure 24 | Complete Vertebral Resection for Primary Spinal Tumors
FIGURE 24-7
S T E P 2 P IT FA L L S
• Be sure to fully release all soft
tissue structures, especially on the
contralateral side of the nerve root
transection.
• Because the vertebral body cuts are
made directed at the spinal cord, it is
imperative to protect the spinal cord
with instruments such as spatulas or
malleable retractors.
FIGURE 24-8
n
Bluntly dissect laterally and anteriorly to develop the plane between the verte-
bral body and the pleura.
n
Dissect the aorta from the anterior aspect of the vertebral body.
n
Pass thread-wire saws anterior to the vertebral body.
n
Mobilize the spinal cord by blunt dissection.
n
Make vertebral body cuts with the thread-wire saws through the inferior end
plate of the cephalad vertebra and the superior end plate of the caudal vertebra
(Figure 24-7).
n
Rotate the vertebral body around the spinal cord and remove it en bloc
(Figure 24-8).
Step 3: Anterior Reconstruction and Posterior Stabilization
n
Insert cage to reconstruct the anterior column (Figure 24-9).
n
Remove rods used for provisional fixation and apply rods to previously inserted
pedicle screws for final fixation.