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15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
163
as calcified (22–65%). A small number of these
discs are intradural (~6%) [26] and can only be
treated safely using an anterior/lateral approach.
While occurring predominantly in the cervical
region, OPLL can occur at any level of the spine
[33–35]. Long-term longitudinal studies of OPLL
have shown myelopathy-free survival at 30-year
follow-up to be 71% [36]. Despite these results,
there are reports of rapid progression of symptoms [37, 38]. Further studies have shown that
spinal canal stenosis of over 60% and lateral calcification are radiographic risk factors for the
development of myelopathy [39–41]. Anterior
decompression and reconstruction within the cervical spine for OPLL have been shown to be safe
and effective [42–44]. Surgery on thoracic OPLL
is potentially morbid, with recent studies showing a 14.7–34.6% rate of postoperative neurological deterioration [45–47]. Therefore, for the
young asymptomatic patient, deferring surgery
while closely following the physical exam with
imaging correlates is appropriate [44].
Neoplastic
Surgery for malignancy is indicated for tissue
diagnosis, neurological decompression, and spinal stabilization (Fig. 15.2). Operative interven-
tion is also appropriate when neoplasms are
resistant to radiation therapy and for removal of
isolated recurrences. Surgery has been shown to
improve quality of life for metastases [48–51],
but the improvements may be compromised if
there are postoperative complications [52, 53].
Preoperative considerations about whether
patients are surgical candidates include preoperative functional status, medical comorbidities, life
expectancy, and need for tissue diagnosis [54–
56], while new evidence suggests that age is not
an absolute contraindication [57].
Trauma
Thoracic spinal fractures occur most frequently
at the thoracolumbar junction, with 50–80%
between T10 and L2 [58, 59]. This area is more
susceptible to injury because the thoracic spine
has additional mechanical stability via the rib
cage, while the more caudal junctional levels
undergo transitioning from kyphosis to lordosis
in conjunction to a change in orientation of the
facet joints [60, 61]. The most common fracture
types are compression and burst [61, 62], with
the traditional teaching being that surgery is considered for patients with more than 40% height
loss, 50% compromise of the spinal canal without
Fig. 15.2 Example of a metastatic lesion to the T3/T4
disc space causing spondylolisthesis and spinal column
instability. Surgery only for tissue sampling and decompression would be inappropriate, as there is risk for spinal
cord injury with worsening spondylolisthesis. Placement
of an interbody with fusion would restore spinal alignment and provide stability for arthrodesis
164
H.M. Zakaria and V. Chang
neurological deficits, or a kyphotic deformity
greater than 300 degrees [63–65].
Deformity
Thoracic spine deformity may be congenital,
idiopathic, degenerative, and as a sequelae of previous trauma, infection, neoplasm, or surgery.
Again, it is appropriate to perform surgery on
symptomatic deformity, including intractable
axial or radicular pain and progressive neurological deficits. Often, surgery is deferred until
kyphosis is greater than 30 degrees or if there is
progression of deformity on serial imaging.
Infectious
With the advent of modern antibiotics, vertebral
osteomyelitis and discitis without mechanical
instability or a neurological deficit can be primarily treated nonsurgically [66–69]. Surgery is warranted to identify the causative organism, for
neurological progression, or osseous deformity
causing pain. Recent evidence has shown that
spinal instrumentation within an infected locus,
including from an anterior approach and with
tuberculosis, is safe and warranted to confer
additional stability [70–75].
Imaging
Adequate imaging is vital before surgery on the
thoracic spine. Plain radiographs are a versatile
and fairly inexpensive imaging modality. They
are sensitive enough to identify vertebral body
alignment/deformity, fractures, evidence of discitis or spondylosis, osteolytic/blastic lesions
(malignancy), and calcifications within the spinal canal that are indicative of posterior osteophytes and calcified discs. They can be used
preoperatively to count the number of ribs and
vertebral bodies for correlation with intraoperative fluoroscopy and can be helpful for accurate
intraoperative localization to minimize the risk
of surgery at an incorrect level. Plain radiographs
are also useful to assess pulmonary function and
to identify possible risk factors for complications, including COPD/emphysema, heart failure, and pulmonary metastasis. In addition, 36″
standing radiographs can be used to assess for
alignment under physiological loads as well as
with bending to illustrate whether a deformity is
fixed or mobile. One caveat with plain radiographs is that it may be ineffectual in patients
with a large body habitus, as bony anatomy may
be obscured.
MRI functions as the mainstay imaging
modality, with sufficient sensitivity and specificity to differentiate disc disease from infectious,
neoplastic, traumatic, or demyelinating pathologies [
76–78]. CT can also be useful and in some
cases is superior to MRI when imaging bony
anatomy, calcified discs, and OPLL. It may also
be used to define bony architecture for surgical
approaches and instrumentation [23, 79, 80]. CT
myelography is useful to assess bone anatomy in
relation to neural structures.
It is important to note that both CT myelography and MRI have a relatively high false-positive
rate when it comes to identifying symptomatic
disc disease, about 14% for both [23, 81, 82]. In
rare cases where the pain generator cannot be
identified, or if there are multiple sites of disc disease, or no clear pathology at all, provocative discography has been useful in localizing the
specific site of axial back pain [83–85]. This procedure should not be used when there is large
disc prolapse with cord deformity, as the saline
injection may cause further disc herniation and
increase the risk of spinal cord injury.
Medical Optimization
Patients should be medically optimized before
any open anterior or lateral approach to the
spine. These procedures are potentially morbid
with a risk for major blood loss and can place
considerable physiological stress on the patient
in the perioperative period. Plain chest AP and
lateral radiographs are part of routine screening for any patient undergoing elective surgery
and are a useful screening modality for COPD/
15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
165
emphysema, heart failure, and pulmonary metastasis. Echocardiography is indicated for those
patients who may have elements of heart failure.
Pulmonary function testing is useful to quantify
pulmonary disease and identify patients whose
lung capacities may be insufficient to tolerate surgery; this is especially important if the operative
plan is to deflate a lung and to ventilate with only
one lung. Marginal surgical candidates should
undergo these additional tests and excluded if
there is clinical indication that they may not tolerate the procedures. These approaches are known
to produce severe pain from rib resection, soft tissue retraction, and chest tube placement, which
is necessary when entering the thoracic cavity.
Many of these approaches require preoperative
coordination with an access surgeon, who will
provide spinal exposure. However, in the case of
acute neurological deficit, such considerations
are not feasible, and therefore it is imperative
that the treating surgeon weigh the potential risks
of a morbid approach with the potential benefits.
It is also critical that the surgeon discusses these
considerations with the patient, if possible, prior
to undergoing surgery.
this vessel, which normally arises from the left
side from T9–L2, may be achieved using modern
imaging modalities [
Ultimately, the specific monitoring modality
used, whether SSEP, MEP, or EMG, is contentious, as currently there is no universal standard
of care [
time feedback about injury to the spinal cord, but
its utility to prevent injury is still uncertain. A
baseline reading should be obtained before initiation of surgery, which is used for intraoperative
comparisons. Changes from this baseline indicate injury, and the surgeon should correlate
these changes with intraoperative findings. Some
aberrations from baseline may be caused by
physiologic changes, anesthetic parameters, or
technical problems, which are outside the scope
of this chapter [103–105].
by the location of pathology. As a general rule,
T1 to T3 requires an anterior transmanubrial
approach, T4 to T10 a lateral transthoracic
approach, and T10 to T12 a lateral thoracoabdominal approach, which may be used for upper
lumbar pathology as well.
101, 102]. It may be able to provide real-
The exact approaches utilized will be dictated
98–100].
Neuromonitoring
Intraoperative neuromonitoring has efficacy to
detect spinal cord injury, but its ability to prevent
injury remains controversial [
specific reports of poor sensitivity and specificity
of neuromonitoring for thoracic spine surgery
[92, 93]. Neuromonitoring may be used to identify and avoid potential ischemic injury to the spinal cord, which may occur during ligation of
radicular arteries [94]. Recent literature has
shown that three levels of bilateral arterial sacrifice are safe without evidence of cord ischemia or
compromise [
where just a single artery ligation caused spinal
cord ischemia [96]. The number of segmental
vessels ligated is proportional to the risk of cord
ischemia and should therefore be minimized if
possible [97]. This may be more pronounced if
the artery of Adamkiewicz (great anterior radicu-
95], although there are case reports
86–91]. There are
T1–T3: Transmanubrial (Possibly with Clavicular Resection)
As compared to the remainder of the thoracic spine,
surgical pathology in this area is uncommon. In
patients with long and thin necks, the C7/T1 and
T1/T2 discs are potentially approachable via the
standard anterior cervical discectomy approach.
However, in most patients, a transmanubrial
approach is necessary and will allow access up to
the T3/T4 disc space. The transmanubrial corridor
requires dissection and manipulation of the superior mediastinum, including the left brachiocephalic vein, subclavian veins, aortic arch, and great
vessels, putting these structures at risk. Other structures at risk include the carotid sheath and contents,
trachea, esophagus, recurrent laryngeal nerves,
sympathetic trunk and stellate ganglion, and pleural apices. There are several variations to this
approach [106–108], but this section will cover the
most commonly used technique.
166
H.M. Zakaria and V. Chang
The patient is positioned supine with a towel
roll or bolster between the scapulae to allow for
head and shoulder extension. Additional extension can be achieved by lowering the head of the
operating table. The shoulders are pulled down
using adhesive tape to allow for lateral fluoroscopy, but placing too much tension on the shoulders puts the patient at risk for brachial plexus
injury. Trendelenburg positioning may allow for
enhanced venous drainage from the operative
site. An orogastric tube should be placed to help
identify the esophagus intraoperatively.
An incision through the skin and subcutaneous layer is performed along the medial border of
the right sternocleidomastoid (SCM) muscle or
along the superior border of the clavicle if a clavicular resection is planned. The incision should
extend caudally to the sternal notch and then
down the midline of the manubrium to the sternal
angle. Platysmal flaps are then elevated while
ensuring the safety of the anterior jugular vein
underneath; however, this vessel may be ligated
if necessary to aid in exposure. The strap muscles
and the SCM are dissected, and their insertions
onto the clavicle and manubrium are identified
and elevated subperiosteally proximally and laterally. Subperiosteal exposure of both the clavicle and the manubrium is performed, which
requires elevation of the pectoralis major muscle.
Subperiosteal exposure should also be accomplished along the posterior aspect of the manubrium with finger dissection. At this point, if
necessary, the clavicle may be sectioned with
care, as the subclavian vein is in close proximity
underneath. Up to the middle of the clavicle may
be taken, with greater removal improving exposure. After sectioning, it is disarticulated from
the manubrium and stored for reimplantation
during closure.
The manubrium is split longitudinally along
its midline while being careful not to injure the
mediastinal structures. Sternal retractors are
placed to help exposure, and the major vessels,
the pericardium, and the thymus are identified.
The inferior thyroid artery and vein may be
ligated to assist in exposure. The thymus and
surrounding fat are reflected to the right, and the
trachea, esophagus, and carotid sheath are identified. The left innominate vein may be sacrificed
to enhance the exposure. The approach to the
spine is between the left common carotid and the
right innominate (brachiocephalic) artery, trachea/esophagus, and thyroid (Fig. 15.3). The
recurrent laryngeal nerve lies posterior to the trachea and anterior to the esophagus, and so to
avoid injury, care should be taken to avoid dissection or manipulation of this area, including
during placement of the retractor. The brachio-
Fig. 15.3 The vascular anatomy encountered during the
transmanubrial approach to the spine. The final corridor to
the vertebrae during this approach is between the left
common carotid artery and the right innominate (brachio-
cephalic) artery. This pathway yields a relatively avascular plane, which upon careful and blunt dissection will
yield the vertebral column
15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
167
cephalic and subclavian veins can be displaced
inferolaterally to approach the prevertebral fascia, which can be thinned by using a Kitner to
visualize the longus colli muscles [106, 109].
The thoracic duct lives in close proximity and to
the left of the esophagus from around T4 to
where it joins with the internal jugular or subclavian vein, and care must be taken to not injure it.
The remainder of the procedure should be performed in a similar fashion as a cervical spine
anterior cervical discectomy. Briefly, osteophytes
that narrow the access to the disc space should be
cleaned away using rongeurs or a high-speed
drill. A sharp knife is used to incise the anterior
longitudinal ligament and the annulus fibrosis,
allowing access into the interbody space. The
bulk of the disc should be removed with pituitary
forceps. The superior and inferior aspects of the
end plates should be prepared by cleaning away
any residual disc material: an osteotome or various curettes are excellent tools for this task. Once
all the residual disc material has been cleared
away, the desired interbody device can be placed.
Additional instrumentation and fusion are often
required to ensure stability of the interbody
device (Fig. 15.4). Hemostasis is achieved with
bipolar cautery and hemostatic agents.
Closure is performed in layers. The sternum
and manubrium should be wired to approximate
the split halves. If the clavicle was disarticulated
and removed, it should be fixed back into place.
The strap muscles and SCM are reattached to
their insertion sites and repaired. A drain is
placed, and the platysma and skin are closed in
the usual fashion.
T4–T12: Transthoracic (Possibly with Scapula Mobilization)
The transthoracic approach to the spine allows
for straightforward access from T6 to T12.
Access to T4 and T5 is possible but requires elevation of the scapula to reach this height.
The patient is intubated with a double lumen
endotracheal tube to allow for deflation of the
lung and is subsequently placed in a lateral
decubitus position. An axillary roll is often necessary to prevent pressure on the brachial
plexus. The laterality of the surgery should be
ipsilateral to the pathology. However, the leftsided approach avoids potential injury to the
thoracic duct as well as the fragile azygos vein
and vena cava, and the view is not obstructed by
Fig. 15.4 (a) Computed tomographic scan of the cervi-
cothoracic junction illustrating a T3 vertebral body fracture with retropulsion into the spinal canal. The dotted
lines show the rostral and caudal limits to a transmanu-
brial approach to the spinal column. (b) Postoperative
imaging after a T3 corpectomy with instrumentation and
fusion was performed on this lesion (Reprinted with permission from Lam and Groff [
109])
168
H.M. Zakaria and V. Chang
the dome of the liver in the lower thoracic
spine. For the upper thoracic spine, a rightsided approach avoids the heart, carotid, and
subclavian vessels. Scoliosis may prompt an
approach from the convexity, instead of being
confined within the concavity. A final consideration is if the patient has had previous surgery
or pulmonary disease which would make access
to a specific thoracic cavity preferable. The
patient should be placed at the break of the
table such that a mild convex curve is created,
which assists in opening of the rib interspaces.
The location of the incision is determined
with fluoroscopy; it should be located two rib
levels cranial to the pathology, and the incision
itself is oblique along the superior aspect of the
rib and should reach past the anterior axillary
line for adequate exposure. The skin is incised,
and there are often several layers of musculature
that need to be divided in a layered fashion and
overlying the rib, including the trapezius, latissimus dorsi, rhomboid major, rhomboid minor,
serratus anterior, and serratus posterior. At the
rib, a subperiosteal plane is used to dissect away
the neurovascular bundle from the inferior
aspect of the rib using an Alexander-Farabeuf
periosteotome and a Doyen elevator. The rib is
then cut at the costal junction anteriorly and the
costotransverse junction posteriorly; it should
be harvested and used as autograft to enhance
arthrodesis.
Within the upper thoracic spine, the scapula
limits exposure, and so additional rib resections
may be necessary. Alternatively, the scapula may
be mobilized. If this is the plan, then the incision
should start from the T1 spinous process and
travel along the medial/inferior border of the
scapula. At the most inferior aspect of the scapula, the incision should curve anteriorly along the
sixth or seventh rib to end at the costal cartilage
of the third rib. Dissection is performed in a layered fashion through the musculature (i.e., trapezius, latissimus dorsi, rhomboids, serratus
posterior), which mobilizes the scapula and
allows it to be retracted proximally and away
from the operative site. The removal of the rib is
similar to the procedure described previously,
with a subperiosteal dissection and harvesting at
the desired rib being performed while sparing the
neurovascular bundle.
The lung is then deflated, and the parietal
pleura incised, allowing access to the thoracic
cavity. It is possible to dissect the pleura away
from the chest wall after rib removal, which
allows for an extrapleural approach to the
spine and thus no need for a chest tube [110].
Extrapleural dissection also has a theoretically
decreased risk of perioperative morbidity. A rib
spreader provides rib retraction and eases entry
into the thoracic cavity, and the lung may be protected with a malleable retractor covered with a
sponge.
At this time, it is prudent to again use fluoroscopy to identify the correct interspace.
Alternatively, the surgeon may count the ribs by
palpation within the thoracic cavity. The neurovascular structures should also be identified,
including the aorta, parietal pleura, azygos veins,
vena cava, and sympathetic plexus, and avoided
if possible. The parietal pleura is dissected to
expose the subperiosteal plane on the interspace,
with care taken to avoid the segmental vessels if
possible; these vessels may be ligated but should
be tied or clipped away from the aorta to avoid
bleeding. The vertebral bodies and disc space are
exposed subperiosteally to enhance visualization
(Fig. 15.5). If necessary, the sympathetic chain
can be displaced dorsally. The intercostal neurovascular bundle can be used to localize the neural
foramen. The rib head is removed with a rongeur
or a drill, allowing full exposure and access to the
disc space. Additional rib resections may be performed if greater exposure is needed to approach
multiple levels. The surgeon should be able to see
clearly the disc margins, the intervertebral foramen, and the pedicle above and below the operative site.
The pedicle below the disc space may require
removal using a burr and Kerrison rongeurs to
enhance exposure of the exiting nerve root and
the thecal sac, as well as osteophytes which
may crowd the disc space. The disc annulus is
incised sharply, and the disc material can be
removed with a pituitary rongeur, a Kerrison
rongeur, or a drill. The goal at this stage should
be decompression and preparation of the inter-
15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
169
Fig. 15.5 This illustration shows the operative view of
the bony and vascular anatomy after exposure of a leftsided transthoracic approach to the spinal column. The
descending aorta partially obscures the view, but this ves-
space for arthrodesis, which requires removal
of as much of the disc as possible. For calcified
central discs, decompression is ensured if the
entirety of the thecal sac is visualized and the
contralateral pedicle can be palpated with a
blunt instrument. After removal of the disc,
bleeding of the epidural veins can be treated
with hemostatic agents or careful bipolar cautery at a low setting. An interbody is placed,
and the vertebral bodies are instrumented to
allow for fusion.
Calcified discs with dural adhesions are at the
highest risk for CSF leak [26, 111]. If a CSF leak
is encountered, primary approximation for watertight closure is always the most ideal treatment
choice. However, this is often not possible due to
the narrow working space, or the tear may be so
large that it is better classified as a dural defect.
Subsequently, other standard methods of dural
closures should be attempted, including the muscle, fat, or fascia onlay to plug the hole. The use
of fibrin glue sealants is common in these situations. For large CSF leaks or inadequate repairs,
a subarachnoid drain for CSF diversion should be
placed as cranial to the dural defect as possible.
Drains should undergo attempted wean by POD57, and patients who have a persistent CSF leak
sel may be mobilized with relative ease if necessary. The
sympathetic chain and ganglia lay just lateral to the vertebral bodies, and, if necessary, subperiosteal elevation is
possible
through the incision despite prolonged drainage
perhaps need permanent shunting.
At the time of closure, irrigation of the thoracic cavity allows for removal of bone fragments
and dust as well as identification of air leaks
within the visceral pleura. A chest tube is placed
along the posterior aspect of the thoracic cavity
via a separate incision. The parietal pleura should
be closed, with visual confirmation of lung reinflation afterward. The ribs are reapproximated
with nonabsorbable suture or wire, with the assistance of a rib reapproximator. The overlying
musculature should be closed in layers and the
skin closed in the usual fashion. The chest tube
should be set to water suction and monitored for
air leakage.
T10–L2: Thoracoabdominal Approach
This versatile approach allows for spinal access
from T10 to L2 by partial mobilization of the diaphragm to give access to the thorax and retroperitoneum. It is important to note that extending the
incision to the iliac crest does allow for exposure
of the lower lumbar disc spaces. This approach
does carry with it unique risks, including injury
170
H.M. Zakaria and V. Chang
to the abdominal viscera, splanchnic nerves,
sympathetic trunk, thoracic duct, and great vessels, as well as postoperative ileus. It should not
be performed on patients with respiratory compromise or those with adhesions from previous
retroperitoneal surgery.
The patient is intubated with a double-lumen
endotracheal tube. A nasogastric tube should be
placed to assist with intraoperative identification
of the esophagus. The patient is placed in a lateral
decubitus position. The approach may be from
the left or right side, but a left-sided approach is
advantageous because the liver will not obscure
the view and the thin-walled vena cava does not
need to be mobilized. The table should be broken
to spread out the operative field, with the center
of break positioned over the site of the incision.
Fluoroscopy is used to confirm the operative
level, and an incision is made along the 9th,
10th, or 11th rib, depending on the location of
the pathology. Its course starts from the posterior
angle of the rib and continues anteriorly along the
rib past the costal cartilage, and once at the anterior surface of the abdomen and before the rectus
abdominus, it should curve inferiorly to end at
the level of the pathology. The muscles and fascia are divided in a layered fashion to reach the
surface of the rib, which is exposed to the costal
cartilage. The rib is raised subperiosteally, avoiding damage to the neurovascular bundle, and cut
at the costal junction and the costotransverse
junction. It may be used as autograft to enhance
fusion.
The lung is deflated and the pleura is identified. The retropleural space is entered by blunt
dissection through the cartilaginous portion of
the rib. The peritoneum is then swept off the rectus abdominus and the diaphragm with the use of
fingertip or a sponge stick. The internal oblique,
external oblique, and transversus abdominis muscles are cut in a layered fashion. Further exposure
and dissection allow visualization of the psoas
muscle, and the peritoneum should again be
swept off of it carefully. The peritoneum often
covers the diaphragm posteriorly, and after
sweeping it off it can be clearly visualized. Entry
into the thoracic cavity is performed by opening
the rib bed, and the collapsed lung may be further
retracted with a malleable covered with a sponge.
At this time, the diaphragm may be sectioned and
released circumferentially from within the chest
cavity, being sure to maintain at least 1 cm to
allow for reattachment of this muscle. If access to
L1 and L2 is necessary, then the diaphragmatic
crus may also need to be incised. Suture may be
placed in the diaphragm remnant to aid closure at
the end of procedure.
Access to the disc space and placement of an
interbody is performed as described previously,
making sure to respect the great vessels and sympathetic plexus. If mobilization of the great vessels is required to access the vertebral body, then
the intercostal vessels may need to be ligated
safely and away from their origin. If the psoas
muscle needs to be mobilized, a subperiosteal
dissection should be performed to avoid injury of
the lumbar plexus.
At the time of closure, a chest tube is placed
using a different entry site. Closure of the wound
should be performed in layers, including the diaphragm, the pleura, and the intra-abdominal muscles. Careful closure of this area is crucial, as any
defect may allow for the development of a hernia.
Visual confirmation of lung reinflation should be
performed before closing the superficial muscular layer. The skin is closed in the usual fashion.
Choice of Interbody Device
Depending on whether a discectomy or discectomy with corpectomy is necessary, a variety of
instrumentation and grafting options are available (Fig. 15.6). Iliac crest graft either as autograft from the patient or as an allograft from
cadaveric donor bone is viable. One consideration with iliac crest graft is the potential harvest
site morbidity. Other structural allografts such as
a fibular strut or femoral ring allografts can be
used. As technology has evolved, a variety of
other synthetic strut grafts have been developed,
ranging from static titanium cages to expandable
cages with modular end caps made either out of
titanium or polyether ether ketone (PEEK).
Traditionally, these strut grafts were used in conjunction with an anterior plate secured by screws.
15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
Minimally Invasive Anterior Thoracic Approaches
More recently minimally invasive approaches,
which were initially developed for the lumbar
spine, have been also adapted for the thoracic
spine. These techniques most often utilize a modular expandable retractor which can be used in
conjunction with a fiber optic light source to
allow for visualization through a relatively small
opening. However, these approaches are outside
the scope of this chapter.
Illustrative Case
A 59-year-old man with diabetes mellitus and
hypertension presented to clinic with a 2-month
history of “pins and needles” in his feet. He
reported that the sensation traveled up his legs
and ended in his lower back. He reported axial
mid-back pain, which was made worse with
movement. He denied any bowel or bladder
incontinence, weakness, or numbness. He was
able to perform his normal activities of daily living without difficulty. On examination, his
strength was intact in both his upper and lower
Fig. 15.6 This AP radiograph is an example of instrumentation options. The patient has a T8–L2 pedicle fixation with a T12 corpectomy and placement of an
expandable cage
extremities, and rectal tone was intact. He had
diminished light touch in a stocking distribution
in his bilateral lower extremities. His reflexes
were 1+ in his upper extremities and 3+ in his
patellar and Achilles tendons with cross adduction. A test of pathological reflexes revealed three
Newer implants have emerged with integrated
plating systems that allow for securing of the
cage to the bone without the use of a plate. Bone
grafting options range from locally harvested and
morselized autografts to a variety of allograft
products that are available on the market. Other
biologic extenders such as recombinant human
bone morphogenetic protein and silicone-based
bioglasses are also available to help facilitate
arthrodesis. More recently, a number of allograft
preparations enriched with mesenchymal stem
cells have also emerged as grafting options. A
detailed discussion of all these options is outside
the scope of this chapter, but numerous options
exist to promote arthrodesis, and surgeons must
familiarize themselves with the potential risks
and benefits of each [112].
beats of clonus in his bilateral lower extremities,
as well as positive Babinski’s sign bilaterally.
MRI of the thoracic spine revealed a large
gadolinium- enhancing mass that was centered at
the right T10 pedicle; the mass encroached into
the vertebral body of T10 and caused impingement of the spinal cord at that level (Fig.
Due to need for tissue sampling for pathology,
the clear myelopathy on physical exam, and the
potential for spinal column destabilization due to
erosion of the vertebral body, the decision for
operative intervention was made. The operative
plan was to perform a two-stage surgery. The first
stage was a posterior approach T9–T11 laminectomy and right facetectomy with resection, followed by T9–T11 pedicle screw instrumentation
and fixation. The second stage of the surgery was
171
15.7).
172
H.M. Zakaria and V. Chang
Fig. 15.7 Preoperative MRI of a 59-year-old man who
presented to the clinic with signs of myelopathy. The
Fig. 15.8 Postoperative imaging for the patient in
Fig. 15.7. The patient underwent a two-stage operation.
The first stage was a T9–T11 laminectomy, right facetectomy, and pedicle screw fixation. The second stage was a
lesion is centered at the right pedicle and is causing erosion of the vertebral body. There is significant stenosis of
the spinal canal with impingement on the spinal cord
right transthoracic T10 corpectomy and placement of an
expandable PEEK cage. The patient continued to do well
1 year postoperatively
a right lateral transthoracic approach for T10 corpectomy and resection of tumor. The vertebral
body defect was repaired with an expandable
PEEK cage with T9–T11 anterior fusion.
The patient tolerated surgery without any intraoperative complications. His postoperative course
was benign; his chest tube was removed on postoperative day 3, and he was discharged to inpatient
rehabilitation on postoperative day 5. Postoperative
anterior/posterior and lateral x-rays showed good
placement of hardware and stable construct
(Fig. 15.8). Final pathology revealed the tumor to be
a schwannoma. Imaging performed at 1-year follow-up showed gross total resection of the lesion.
Technical Pearls
• A double-lumen ET tube should be used to
facilitate lung collapse.
• An access often surgeon is recommended to
safely reach the desired spinal cord level.