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15 Open Anterior and Lateral Thoracic Interbody Approaches and Techniques
173
• For the lateral decubitus position, a beanbag
or foam bolster may be used to assist in
placement, with an axillary roll used to prevent brachial plexus injury.
• Placing the incision over the break in the table
helps to improve exposure by spreading out
the operative field.
• If the table is broken during surgery, then it
should be returned to flat position before instrumentation to prevent iatrogenic scoliosis.
• Flexion of the patient’s hips and knees helps
relax the abdominal musculature.
• For approaching the cervicothoracic junction,
the recurrent laryngeal nerve has a more reliable course on the left, and a left-sided
approach may be favored.
• For patients with extreme kyphosis, the transmanubrial approach may not be successful to
allow for access to the disc space, and there
are radiological methods to predict whether
patients are amenable to this approach [108].
• Preoperative recognition of a calcified disc is
important for planning of the surgical approach
and techniques and can be identified with
plain radiographs or CT myelogram.
• The transthoracic approach is best for treatment
of calcified disc, and partial corpectomies may
be needed to ensure safe exposure of the disc.
• The best way to avoid a durotomy is to limit
manipulation of the thecal sac if possible.
• For the transabdominal approach, a gauzecovered finger or a Kitner may be used to dissect out the peritoneum as well as the parietal
pleura without violating the peritoneum.
• When splitting muscles, their ends should be
tagged to allow for anatomic approximation
during repair, especially for the diaphragm.
• Psoas muscle should be mobilized subperiosteally to avoid injury to the lumbar plexus.
• Due to the potential for blood loss, an intraoperative blood salvage device may be useful in
patients without a history of malignancy or
infection.
• When it is necessary to ligate segmental arteries, they should be sectioned away from the
aorta, but ligation should be avoided in general to prevent spinal cord ischemia.
• If vessels are taken, prevent hypotension to
ensure perfusion, especially in the setting of
severe cord compression, where the cord may
already have compromised blood flow.
• An intraoperative test occlusion can also be
performed to assess whether a segmental
artery is safe to ligate; the vessel can be temporarily clamped for a few minutes to see if
any signal changes develop on either SSEP or
MEPs. If no changes are observed, then the
vessel can be ligated safely and divided.
Complications and Strategies for Avoidance
These procedures are potentially morbid, medically as well as surgically. The best way to avoid
a medical complication after surgery is to ensure
preoperative optimization as well as the appropriate level of postoperative care. Patients should be
screened to see if they can tolerate the procedure,
including potentially major blood loss as well as
lung collapse. Adequate pain management postoperatively is essential to promote ventilation
and inflation of the lung, especially with a chest
tube in place. Thoracic rib blocks by anesthesia
can provide excellent localized pain control and
may be safely repeated as necessary. Pulmonary
toilet using cough, deep breathing exercises, and
incentive spirometry is important to prevent atelectasis and pneumonia. For the patient with multiple medical comorbidities, ICU monitoring is
appropriate.
Accurate and precise localization of a thoracic
spine lesion is important to prevent surgery at the
incorrect level. Intraoperative fluoroscopy is used
to count ribs or vertebral body pedicles superiorly until the correct level is reached. However,
in a small but clinically relevant number of
patients, variations from normal anatomy in the
number of ribs and vertebral bodies may potentially lead a surgeon to localize at the wrong level
if unnoticed preoperatively. Preoperative anterior/posterior and lateral radiographs may be
used to establish a baseline and correlate with
intraoperative fluoroscopy. Consultation prior to
surgery with the radiologist who will be aiding in
determination of disc level can aid identification
of correct level. Preoperative marking of the correct level with a radiopaque dye by interventional
radiology is also another option. When palpating
ribs to check the operative level, the second rib is
174
H.M. Zakaria and V. Chang
often the most caudal rib that can be easily palpated. The first rib lies inside the second rib and
may not be easily felt. Fluoroscopy should be
used to confirm the correct operative level.
Dural openings causing CSF leaks have the
potential of becoming CSF fistulas, which are
difficult to treat. Primary, tension-free, and
watertight repair of any dural opening is ideal,
but this may be technically difficult to achieve,
especially with ventral tears. When this is not
possible, a muscle graft or a pleural flap may be
used. Processed allograft or xenograft is another
option. Fibrin glue is useful as an adjunct to reinforce the suture line [113, 114]. If these techniques are not successful, then the use of a lumbar
drain for CSF diversion until the dural tear heals
may be required to prevent a CSF-pleural fistula.
If there is concern regarding a CSF leak, then the
chest tube should be removed early before discontinuation of the lumbar drain.
Conclusion
Surgery for thoracic spine disease should be
offered for symptomatic lesions that have failed
conservative therapy, compromise spinal stability, and/or cause progressive neurological symptoms. Preoperative assessment of the specific
pathology, with evaluation of calcified discs, is
essential to minimize morbidity. Patients should
be critically assessed for fitness for surgery and
medically optimized preoperatively. Approaches
to the T1–T4 disc spaces frequently require an
anterior transmanubrial approach, to T4–T10 a
lateral transthoracic approach, and T10–T12 and
below a lateral thoracoabdominal approach. An
access surgeon is often necessary to reach the
desired level. Postoperative mobilization and
pain control are needed to minimize morbidity.
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Thoracic Lateral Extracavitary Decompression and Fusion
Christopher D. Witiw and Richard G. Fessler
Introduction
The lateral extracavitary approach (LECA) was
first described by Capener in 1954 and then modified by Larson et al. in 1976 [1, 2]. The approach
affords access to all three columns of the spine,
and the primary indication of this posterolateral
intervention is resection of ventral compressive
pathology on the spinal cord [3]. Anterior decompression and circumferential reconstruction of the
integrity of the spinal column may be performed
all through a single incision, and all steps of the
operation can be accomplished without the need
for any substantial manipulation of patient positioning. Moreover, efforts to minimize the invasiveness of the operation and reduce the likelihood
of complications have led to advances in mini-
C.D. Witiw, MD
Department of Neurological Surgery, Rush University
Medical Center, 1725 W. Harrison St., Suite 855,
Chicago, IL 60612, USA
Division of Neurosurgery, Department of Surgery,
University of Toronto, Toronto, ON, Canada
e-mail:
christopher.witiw@mail.utoronto.ca
R.G. Fessler, MD, PhD (*)
Department of Neurological Surgery, Rush University
Medical Center, 1725 W. Harrison St., Suite 855,
Chicago, IL 60612, USA
rfessler@rush.edu
e-mail:
16
mally invasive techniques. Now, similar decompression and reconstruction may be accomplished
with limited muscular disruption [4].
The LECA is one of the numerous options to
address ventral compressive pathology in the
thoracic spine, leaving the spinal surgeon with
numerous considerations. With this chapter, we
will describe appropriate indications for the
LECA to assist with decision-making. This will
be followed by essential preoperative considerations, a detailed review of the surgical steps for
the classic open LECA, and more recent modifications to make the operation minimally invasive. This is supplemented by a discussion of the
essential details of the costotransversectomy and
transpedicular approaches to the vertebral body.
These allow for ventral decompression with less
invasive access, albeit at the expense of a
decrease in ventral visualization. Following this,
we will outline the modifications needed for a
posterolateral approach to the upper thoracic vertebrae (T1–T4) through the lateral parascapular
extrapleural approach. The chapter concludes
with technical pearls, a case illustration and a discussion of potential complications along with
strategies for avoidance.
Indications and Patient Selection
The LECA may be employed for posterolateral
access to compressive thoracic pathology from
T5 to T12. Lesions from the cervicothoracic
© Springer International Publishing AG 2017
L.T. Holly, P.A. Anderson (eds.), Essentials of Spinal Stabilization,
DOI 10.1007/978-3-319-59713-3_16
179
180
C.D. Witiw and R.G. Fessler
junction down to T4 may be approached by the
lateral parascapular extrapleural approach
(LPEA) which will also be described within this
chapter [5]. The LECA or LPEA is certainly not
the sole option, and spine surgeons are often
challenged to decide which of the myriad of techniques for decompression of ventral spinal
pathology is optimal. Broadly these may be
divided into anterior intracavitary, anterolateral,
and posterolateral.
The anterior thoracotomy based and modifications for the upper thoracic spine such as
trans- sternal, trans-manubrial, and trans-clavicular exposure approaches allow a direct visualization of the anterior and middle columns of
the spine for decompression and reconstruction
[6]. However, visualization often comes at the
cost of approach-specific complications such as
pulmonary contusions, pleural effusions, atelectasis, and hemothoracies [7]. Less invasive, thoracoscopic technologies hold some promise to
reduce complications, but these techniques are
less familiar to spine surgeons, and the steep
learning curve reduces its practicality for surgeons who do not perform them routinely [8].
An alternative to the intracavitary approach is
the retropleural approach [9, 10]. This affords
the benefit of avoiding entrance into the thoracic
cavity and provides excellent exposure to the
anterior spinal column. However, challenges
include an ongoing risk of pleural breach along
with obtaining appropriate angulation to sufficiently decompress the spinal cord and a risk to
the segmental arteries. For these reasons and
more, this approach has yet to garner widespread acceptance.
The posterolateral approaches offer more
familiarity and are the preferred method for
many surgeons. These include the transpedicular
approach, the costotransversectomy, or the
LECA. Of these three, the LECA affords greater
exposure and allows for excellent visualization
[11]. The only anatomical structures of the spi-
nal column falling outside of surgeon visualization are the contralateral edge of the vertebral
body and contralateral pedicle, and, if needed,
these may often be approached from the contralateral side [
12].
The specific pathological indications for a
posterolateral approach are quite broad. Most
conditions of the thoracic spinal column that
result in ventrally oriented compressive forces on
the spinal cord are amenable to this approach. A
recent systematic review of the literature conducted by Foreman et al. identified multiple
series describing the approach to address numerous pathological conditions and include trauma,
intervertebral disc herniation, tumor, and infection [
3]. A summary of the typical indications for
LECA may be found in Table 16.1. We strongly
advocate for the consideration of a LECA where
a thoracic corpectomy is mandated to achieve
sufficient decompression and/or resection of
pathological tissue. We also suggest a LECA for
cases of calcified, central intervertebral disc herniations. Soft laterally oriented thoracic disc herniations are most often amenable to treatment by
a posterolateral microendoscopic thoracic discectomy [13]. In cases where ventral decompression is required but patient comorbidities may
limit LECA as an option, then a transpedicular or
costotransversectomy approach may be
considered; however, more recent modifications
to the traditional LECA to make it less invasive
generally make it appropriate even in these
scenarios.
Table 16.1 Indications for lateral extracavitary approach
for thoracic spinal decompression and fusion
Trauma
Vertebral body fracture
Spinal cord compression
Painful progressive deformity
Intervertebral disc herniation
Calcified centralized disc herniations
Tumor
Extradural
Vertebral body metastases
Primary osseous lesions of the spinal column
Intradural extramedullary
Meningioma
Peripheral nerve sheath tumors
Infection
Osteomyelitis
Epidural abscess
Spinal tuberculosis
16 Thoracic Lateral Extracavitary Decompression and Fusion
181
Preoperative Considerations
Accurate intraoperative localization of the correct surgical level is of paramount importance for
any surgical intervention involving the thoracic
spine. While the ultimate localization occurs in
the operating room, the preoperative steps ensure
success. It is thus imperative that the presurgical
imaging includes sufficient anatomical features
to allow the surgeon to determine that correct
level of the thoracic pathology. Imaging should
include the second cervical vertebra to allow for
a downward count of the vertebral levels or the
sacrum to allow for an upward count. An upward
count from the sacrum is preferred because intraoperatively, it is easier to count in a cranial direction from the sacrum or from the lowest rib
because the anatomical relation of the musculoskeletal structures of the pectoral girdle can
obstruct radiographic visualization of the lower
cervical and upper thoracic spine. All patients
must also have a preoperative chest radiograph to
account for the possibility of an additional rib as
well as a lateral lumbosacral radiograph to assess
for the presence of a lumbosacral transitional vertebra. Further consideration may be given to
implementation of an institution level protocol to
ensure availability of radiology expertise during
surgical intervention to confirm interpretation of
level localization. Taking these steps prior to surgical intervention will serve greatly to mitigate
the risk of operating at an incorrect thoracic level.
We also suggest that somatosensory evoked
potentials and motor evoked potentials should be
arranged preoperatively to ensure they are available at the time of surgery. These should be initiated once the patient is positioned and then
monitored throughout the operation to detect any
changes during the intervention.
approach; however, both will be described as
many surgeons prefer the open approach. This
will be followed by a discussion of the essential
technical surgical considerations for the costotransversectomy and transpedicular approaches.
This section will conclude with a description of
the LEPA which may be used to address upper
thoracic (T1–T4) pathology and afford similar
access to this region as the LECA does for the
more caudal thoracic levels.
Open Lateral Extracavitary Approach
Surgical Exposure
The patient is positioned prone on a Wilson frame
or a Jackson table. The side of approach should
be dictated by side of pathology. The skin incision may be oriented in a number of ways but two
often predominate. The first is a long midline
“hockey-stick” incision with the apex of the curvature located at the level of the pathology
(Fig. 16.1a) [14]. The other is a curvilinear
incision beginning at the midline three levels
above the pathology and ending at the midline
three levels below with the apex of the arc 7.5 cm
off the midline on the ipsilateral side of the
approach (Fig. 16.1b) [3]. Both afford access to
the posterior aspect of the contralateral side if
posterior instrumentation is needed. With the
Surgical Technique
There have been numerous modifications to the
LECA since its early description, but these can be
generally classified as traditional open approaches
and minimally invasive approaches. The senior
author exclusively uses the minimally invasive
Fig. 16.1 Options for cutaneous incision. (a) “Hockey-
stick” incision with apex of the curve at the level of
pathology; (b) curved incision with apex of the curve
approximately 7.5 cm lateral to the level of pathology
182
C.D. Witiw and R.G. Fessler
curvilinear incision, the initial dissection is carried down to the thoracodorsal fascia, and the
cutaneous flap is mobilized across midline. Then
the spinous processes and lamina are exposed
through midline subperiosteal dissection at the
level of the pathology and a level above and
below. Then dissection is carried laterally at the
affected level to identify the angle of the ipsilateral rib. Following this, the latissimus dorsi muscle is identified at the lateral edge of the cutaneous
incision, and a vertical incision is carried down to
the ribs. The muscle is dissected to free the muscle from the rib cage which facilitates mobilization of the ipsilateral latissimus muscle. With the
“hockey-stick” incision, the skin flap is raised
with the plane of dissection immediately above
the thoracodorsal fascia, and the fascia is opened
in a linear fashion over the spinous processes.
The fascial incision is then carried out laterally at
the level of interest, exposing the erector spinae
muscles. The erector spinae muscles are elevated
from lateral to medial and then retracted medially. This may necessitate splitting all or part of
the erector spinae muscle to achieve sufficient
exposure. Surgeon preference and familiarity
will generally dictate the technique selected.
The rib resection is initiated by opening the
posterior periosteum with monopolar electrocautery. A periosteal elevator is used to strip the
periosteum from the posterior aspect of the rib
and then carried further to elevate the periosteum from the cranial and caudal aspects of the
rib. The cranial rib edge is easiest to strip from
medial to lateral, and the inferior edge is easiest
to strip from lateral to medial. Caution is needed
to preserve the neurovascular bundle when dissecting the caudal aspect of the rib. A curved
periosteal elevator such as a Doyen rib raspatory
should be employed to complete the circumferential periosteal dissection. A guillotine-type rib
cutter should be used to transect the rib 5–10 cm
from the costovertebral joint. Remove the transverse process with a Leksell rongeur back toward
the pedicle and lamina. Incise the costotransverse and costovertebral ligaments with a scalpel. Elevate the rib and disarticulate it at the
costotransverse and costovertebral joints using a
Kerrison rongeur. If properly dissected, the peri-
osteum, endothoracic fascia, and retropleural fat
should provide protection against a breach of the
pleura. Then the rib is transected 5–10 cm from
the costovertebral joint and removed. The neurovascular bundle is identified, and the intercostal
nerve is followed to the neural foramen. The thoracic nerve root and vasculature may be ligated
with silk ties followed by sharp division if it is
felt that additional exposure is needed at this
stage. The laminofacet on the ipsilateral side
should be removed with an osteotome, and this
will be followed by removal of the ipsilateral
pedicle using a high-speed burr. An inside-out
method for the pediculectomy will help prevent
injury to the exiting nerve root by leaving a thin
rim of cortical bone. This can be carefully
resected using a Kerrison punch. At this stage,
there is excellent visualization of the intervertebral disc, lateral spinal canal, and vertebral body
at the pathological level, and attention may be
turned to the ventral decompression (Fig. 16.2).
The segmental artery should be identifiable at
the caudal limit of the concavity corresponding
to the vertebral body. If it is felt that the intercostal vessel cannot be spared, then intraoperative
neuromonitoring should be used to monitor for
potential disruption of a major supply to the spinal cord. A temporary vascular clip should be
applied and then somatosensory evoked potentials monitored for a few minutes. If there is no
significant change, then this suggests the vessel
can be ligated; otherwise, the vessel should be
spared. The sympathetic chain, located on the
lateral vertebral surface, should be identified and
the rami communicantes transected.
Ventral Decompression
If the nature of the pathology requires corpectomy, the intervertebral discs above and below
the involved vertebral body are identified and
resected with sharp dissection. Disc material is
cleared with curettes and pituitary rongeurs. The
adjacent endplates should be completely free of
disc or cartilaginous material to optimize bony
fusion. A high-speed burr should be used to
decompress the center of the vertebral body with
the inside-out method. A thin cortical shell
should be maintained at the ventral, dorsal, and