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2. Soft tissue problems in slim adults: Only implants with low profile
should be used in the thoracic spine.
3. Inadequate instrumentation in unstable spines: A cross-connector
should be used.
4. To avoid flatening of the thoracic spine, the rods are bent following the
normal kyphotic profile.
5. If a penetration of the medial wall of the pedicle is noticed, a
laminectomy should be done to visualize the dura. If the dura is torn,
the leakage has to be sutured and corticosteroids should be given (Fortecortin initially 50 mg, on the first postoperative day 8 mg every 4
hours, on the second postoperative day 4 mg every 8 hours).
6. A lateral fracture of the pedicle normally leads to loss of screw stability. An unstable screw should be removed and the adjacent segment
should be instrumented. If this is not possible, the screw should be replaced by a pedicle hook, or pedicle hook with a transverse process
hook to construct a claw. Sublaminar wiring of the rod to the spine
could be done alternatively to hook implantation.
Postoperative Care
1. AP and lateral x-ray before the patient leaves the operating room.
2. Mobilization during the next 3 days, depending on the patient’s
general condition, without external support.
3. Physical activities are restricted for the first 3 months; no limitation
after 1 year postoperation (Fig. 17–6).
Suggested Readings
Ebraheim NA, Xu R, Ahmad M, Yeasting RA. Projection of the thoracic
pedicle and its morphometric analysis. Spine 1997;22:233–238.
Philips JH, Kling TF, Cohen MD. The radiographic anatomy of the thoracic
pedicle. Spine 1994;19:446–449
von Strempel A. Correction of remote posttraumatic gibbusity and of re-
sulting functional disturbances of the thoracolumbar spine. Oper Orthop Traumatol 1996;8:202–211.
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SECTION II THE THORACIC SPINE
Eurostile
18
Extrapedicular Screw Placement in the
Thoracic Spine
Peter Metz-Stavenhagen and Walter Morgenstern
Goals of Surgical Treatment
Posterior correction and stabilization of various spinal disorders (especially Scheuermann’s kyphosis, global kyphosis in ankysosing spondylitis,
congenital kyphosis, and fracture treatment).
Diagnosis
Pathological thoracic kyphosis is defined as a sagittal deformity between
T1 and T12. The diagnosis is established on clinical and radiologic examination. The patient is inspected laterally and sagittal hyperkyphosis is recognized in a standing position as well as in forward bending. Radiologic
diagnosis is made with measurement on standing anteroposterior (AP) and
lateral x-rays of the spine on a long cassette. Hyperextension films are
made to assess the flexibility of the curve and compensatory behavior of
the adjacent lumbar or cervical spine. It is important to describe the structural and destructive changes of the vertebrae (wedge vertebra) and congenital malformations.
Indications for Surgery
1. Hyperkypyhosis (i.e., Scheuermann’s disease, ankylosing spondylitis)
2. Congenital kyphotic deformities
3. Fracture treatment
4. Posttraumatic kyphosis
5. Scoliosis
6. Tumors
7. In cases with osteoporotic bone or dysplasias in which hook insertion
is difficult or impossible
Contraindications
1. Severe rotation and dysplasia.
2. In fixed deformities it is necessary to release anteriorly.
3. Generally there is no contraindication compared to interpedicular
screw placement in the thoracic spine.
Advantages (Fig. 18–1)
1. Decreased risk due to increased distance to the spinal canal
2. Decreased risk of lateral screw break-out compared to intrapedicular
screws
3. Improved fixation of the vertebral body with the option of anterior cortex penetration
4. Improved fixation due to multiple cortex penetration
5. Increased pullout strength due to longer screws
6. Improved fixation secondary to a greater screw diameter (5 to 7 mm)
7. Possibility of crossing over of screw tips (Fig. 18–1)
8. Compared to hooks, screws are out of the spinal canal
9. Safe zone higher variability of insertion angle (20 to 45 degrees-safe)
(Fig. 18–2)
Procedure
Screw Insertion
The entry-point is at the tip of the transverse process, in the transverse
midline. A small hole is made with an awl. Protrusion of the awl is
directed so as to intersect the facet joint of the instrumented vertebra at its
lateral border. Thereby a variable angle of insertion of 25 to 40 degrees is
produced. The angle of insertion increases from T12 towards the upper
segments. After the awl has penetrated the transverse process it will partially go through the rib between the costotransverse and costovertebral articulation and will re-enter the vertebral body lateral to the radix of the
pedicle. (Fig. 18–3) If the awl is always kept lateral to the lateral edge of the
facet joint (Fig. 18–4), then spinal canal penetration is impossible. In the
region between the transverse process, the vertebral body and the lateral
wall of the pedicle has no vascular or neural structures, so there is no risk
for injuries. With the use of an image intensifier, the exact position of the
awl or a probe can be documented. Screw length in an average adult is between 40 mm at T1, 45 mm at T5, and 45 to 50 mm at T10-T12.
Exposure Secrets
It is helpful to choose the entry-point of all screw placements in one line to
facilitate rod insertion. The safe zone (Fig. 18–2) of the screw within the
vertebral body is large enough to compensate variable entry-points. When
the spine is exposed for screw insertion, it is important to visualize the
transverse processes entirely on both sides to get a three-dimensional impression of the vertebral body and its rotational situation. Also, it is important to expose all segments in this manner to get an impression of the frontal and sagittal plane deformity. It is also important to identify dysplastic,
degenerative, or ankylosed structures.
Insertion of the Rod
After placement of all screws, rod insertion can be performed. In larger and
stiff curves it is important to avoid pedicle screw pullout. Therefore it is
recommendable to use smaller and flexible rods. With these rods it is
possible to accomplish a step-by-step compression towards the apex of the
curve. It is very important to visualise all screws during correction. As
soon as the screw head starts to move in the bone, correction should be
continued at the next level. With this technique the correction forces are
distributed on all instrumented levels and a forceful “all at once” correction with the risk of screw pullout is avoided. A solid rod has to be pre-bent
in a profile that you wish to achieve with the correction. Rod insertion
might be difficult and powerful forces must be applied to insert the rod.
Therefore there is an increased risk for screw pullout.
Pitfalls
1. A pedicle-screw pullout in rigid curves and osteoporotic bone (see
above)
2. Insufficient correction in rigid curves using pre-bent solid rods
Complications
Compared to intrapedicular screws, the risk for spinal canal volition is less
due to the distance of the screw to the canal (as mentioned above).
Postoperative Care
Postoperative care depends on the operation, length of fusion, bone material, and patient. In Scheuermann’s kyphosis, a postoperative immobilisation in a TLSO for four to six months is recommended. In cases with anterior release and fusion, immobilisation can be reduced. After four months,
x-rays (AP and lateral, as well as lateral tomogramms) are taken to assess
fusion and correction (Fig. 18–5).
Suggested Readings
Belmont PJ Jr, Klemme WR, Dhawan A, Polly DW Jr. In vivo accuracy of
thoracic pedicle screws. Spine 2001;26:2340–2346.
Cinotti G, Gumina S, Ripani M, Postacchini F. Pedicle instrumentation in
the thoracic spine: a morphometric and cadaveric study for placement
of screws. Spine 1999;24:114–119.
Dvorak M, MacDonald S, Gurr KR, Bailey SI, Haddad RG. An anatomic,
radiographic, and biomechanical assessment of extrapedicular screw
fixation in the thoracic spine. Spine 1993;18:1689–1694.
Panjabi MM, O’Holleran JD, Crisco JJ III, Kothe R. Complexity of the
thoracic spine pedicle anatomy. Eur Spine J 1997;6:19–24.
Suk SI, Kim WJ, Lee SM, Kim JH, Chung ER. Thoracic pedicle screw fixa-
tion in spinal deformities: are they really safe? Spine 2001;26:2049–
2057.
Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixa-
tion in the treatment of thoracic idiopathic scoliosis. Spine
1995;20:1399–1405.
Ugur HC, Attar A, Uz A, Tekdemir I, Egemen N, Genc Y. Thoracic pedicle:
surgical anatomic evaluation and relations. J Spinal Disord
2001;14:39–45.
Vaccaro AR, Rizzolo SJ, Allardyce TJ, et al. Placement of pedicle screws in
the thoracic spine. Part I: morphometric analysis of the thoracic vertebrae. J Bone Joint Surg Am 1995;77:1193–1199.
Vaccaro AR, Rizzolo SJ, Balderston RA, et al. Placement of pedicle screws
in the thoracic spine. Part II: an anatomical and radiographic assessment. J Bone Joint Surg Am 1995;77:1200–1206.
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18 EXTRAPEDICULAR SCREW PLACEMENT
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A
Figure 18–1
Entry point in the extra- (A) and intrapedicular (B) technique, top view and horizontal plane. Note “crossing over” of the screw tips with the extrapedicular technique.
B
Figure 18–2
The variability of the insertion angle (safe zone) in the intrapedicular vs. extrapedicular technique.
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SECTION II THE THORACIC SPINE
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Figure 18–3
The extrapedicular technique demonstrated on a cadaver specimen. Costotransversal and costovertebral articulations are indicated (blue). (See Color Plate
18–3.)
Figure 18–4
Computed tomography (CT) scan demonstrating extrapedicular screw placement
at T4. Note that the screw is lateral to the facet joint.
Xu R, Ebraheim NA, Ou Y, Yeasting RA. Anatomic considerations of
pedicle screw placement in the thoracic spine: Roy-Camille technique
versus open-lamina technique. Spine 1998;23:1065–1068.
Xu R, Ebraheim NA, Shepherd ME, Yeasting RA. Thoracic pedicle screw
placement guided by computed tomographic measurements. J Spinal
Disord 1999;12:222–226.
Figure 18–5
X-ray and clinical result pre- and postoperative in a 16-year-old girl with
Scheuermann’s disease. Preoperative 87 degrees; physiological profile of the
entire spine 2 years postoperatively.
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18 EXTRAPEDICULAR SCREW PLACEMENT
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19
Thoracic Disc Disease
Retropleural Approach
John M. Gorup and David H. Donaldson
Goals of Surgical Treatment
1. Decompress the spinal canal in the face of myelopathic symptoms or
progressive neurologic deficit
2. Relieve mechanical pain after a failure of an appropriate course of nonoperative treatment
Diagnosis
1. Requires a high index of suspicion.
2. Symptoms can vary from profound neurologic deficit to localized back
pain with mechanical symptoms.
3. Magnetic resonance imaging (MRI) has supplanted all other imaging
studies as the study of choice.
4. Discography is recommended to an asymptomatic, control level when
performing a fusion for mechanical back pain.
Indications for Surgery
1. Myelopathy: absolute indication
2. Progressive neurologic deficit: absolute indication
3. Radicular pain unresponsive to an appropriate course of nonoperative
treatment
4. One- or two-level degenerative disc disease unresponsive to a prolonged period of nonoperative treatment (쏜 1 year), working patient,
appropriate discographic study.
Contraindications
1. Insufficient pulmonary status: relative contraindication
2. Poor psychological patient profile
3. Unrealistic patient expectations
4. Nonconcordant findings on discography
Advantages
1. Minimal manipulation of spinal cord and nerve roots
2. Improved visualization
3. Decreased blood loss
4. Rarely need chest tube
Disadvantages
1. Learning curve
2. Previous experience with transthoracic approaches mandatory
Procedure
Positioning
General anesthesia is obtained. Our preference is to use a double-lumen
tube to allow one to drop the ipsilateral lung during the procedure, if
needed. The patient is then positioned in a true lateral decubitus position,
at the flex point of the operative table. The side of the herniation is the side
that is up. With central herniations the left-side-up position is preferred, as
it is easier to deal with the aorta and its branches, if one inadvertently enters the chest cavity. All bony prominences are well padded; an axillary roll
and sequential compression boots are placed. The patient is prepped and
draped from anterior to posterior midline and symphysis to nipple.
Incision
Level is determined by the rib that leads to the involved disc space (i.e., the
eighth rib is removed for a T7–8 exposure) (Fig. 19–1A). We always use
radiographs prior to incision to verify the position. If there is any question,
a spot lateral radiograph is obtained. The incision is started at the lateral
border of the paraspinal musculature and is carried obliquely across the rib
approximately 3 inches. Muscle is transected as necessary. The periosteum
is incised with cautery and then elevated using a periosteal elevator. Care
is taken to maintain contact with the rib at its inferior border, thereby protecting the neurovascular bundle. A Doyen is then used to remove the periosteum on the underside of the rib, taking care not to violate the parietal
pleura. This segment of rib is then resected and saved for later interbody
fusion. Sharp ends are rounded off using a rongeur or rasp.
Exposure
A finger is inserted posteriorly and the parietal pleura is bluntly dissected
away from the ribs, vertebral bodies, and remaining portion of rib (Fig. 19–
1B). If the pleura is violated, it can be reapproximated primarily at this
time. The rib head is then removed with a rongeur to give access to the
posterolateral corner of the disc; no cautery is used here. Segmental vessels
are identified, ligated, and transected.
Discectomy
Magnification and good lighting are mandatory at this stage. The disc is incised in its posterior one third to two thirds, just anterior to the disc herniation. Disc is removed away from the spinal cord using curets and pituitary
rongeurs. The posterior annulus and longitudinal ligament must be removed to ensure adequate decompression of the cord.
Interbody Fusion
Using a high-speed bur, a slot is cut into the caudad and cephalad vertebral
bodies, to the depth of one’s discectomy. End plates are decorticated with
curets or a burr. Rib strut graft is inserted; the remaining rib is morselized
and used to fill in the remaining graft site (Fig. 19–2). Postoperative x-rays
show proper placement of the rib graft with preservation of sagittal alignment (Fig. 19–3).
Pitfalls
1. Avoid wrong-site surgery by using fluoroscopy and spot radiographs
prior to incision to confirm proper rib selection.
2. Avoid neurologic injury by using loupe magnification with headlight
or operative microscope.
3. Confirm adequacy of decompression by removing posterior longitudinal ligament.
Complications
1. Vascular complications can generally be avoided by good knowledge
of the local anatomy. Should a segmental injury occur, it could be
safely tied off. Damage to the great vessels requires direct repair.
2. Neurologic injury is best avoided with careful surgical technique, magnification, and good lighting. Should a cord injury occur, immediate IV
steroid infusion should be started. Postthoracotomy pain from intercostal neuritis is alleviated with steroid blocks or Neurontin.
3. Good patient selection, appropriate diagnostic workup, and good technique limited to two or fewer levels can lessen the chance of poor results.
Postoperative Care
1. The intercostal nerves are blocked using bupivacaine to offer improved postoperative pain control.
2. The patient is mobilized the evening or morning following surgery
without restrictions.
3. Jewett braces are employed for comfort and are discarded as tolerated,
except for two-level fusions and one-level fusions below T10, which
are braced for 3 months.
Suggested Readings
Brown CW,Deffer PA Jr, Akmajian J, Donaldson DH, Brugman JL. The natu-
ral history of thoracic disc herniations. Spine 1992;17(suppl):S97–
S102.
Ogilvie JW. Thoracic disc herniation. In: Bridwell K, DeWald R, eds. The
Textbook of Spinal Surgery. 2nd ed. Philadelphia: Lippincott-Raven;
1997:1495–1502.
Otani K, Yoshida M, Fuji E, Nikai S, Shibasaki K. Thoracic disc herniation:
surgical treatment in 23 patients. Spine 1988;13:1262–1267.
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SECTION II THE THORACIC SPINE
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6
Strut
covered
with bone
(morselized)
7
Rib 8
and 3-inch
skin incision
Rib 9
A
Rib 8
partially
resected
Parietal pleura
bluntly dissected
away from ribs
then remove rib head
Parietal
pleura
Intercostal
muscle divided
Figure 19–1
(A,B) The incision is started at the lateral border of the paraspinal musculature and is
carried obliquely across the rib approximately 3 inches.
B
Segmental vessels
ligated
Cut edge
pleura
Rib 8
thoracotomy
Rib
strut in
place
Ganglion
under
periosteum
Cut edge of periosteum
T7
E
Ao
T8
B
Lung
Figure 19–2
A
Anterior longitudinal
ligament
Eurostile
19 THORACIC DISC DISEASE: RETROPLEURAL APPROACH
(A) Rib strut graft is inserted. (B) Remaining rib is morselized and used to fill in the
remaining graft site.
95
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T7
T8
T6
T9
T7
T8
T9
A
Figure 19–3
Postoperative standing anteroposterior (AP) (A) and lateral (B) radiographs of the spine 8 months after successful retropleural discectomy and auto-
logous rib strut fusion at T6-T8.
B
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20
Vertebral Corpectomy for Thoracic Tumor or
Infection
Robert F. McLain and Ranjith R. Kuzhupilly
Goals of Surgical Treatment
1. To decompress the spinal cord, reduce tumor bulk, stabilize the spine,
and confirm diagnosis and staging in unresectable tumors
2. To achieve curative, en bloc excision in isolated resectable tumors
Diagnosis
Pain and weakness are the most common presenting complaints in both
thoracic tumors and infection. Pain is usually constant and unremitting,
worse at night, and segmental in location. Radicular symptoms may result
in “girdle” pain in the thoracic spine or mimic herniated nucleus pulposus
in the lumbar segments. Neurologic deficits are rarely the first symptoms to
present, but are common by the time the diagnosis is made. Examination
occasionally reveals spinal deformity or mass.
Plain films show bone destruction, including the classic “winking-owl”
sign, when bone loss of 30 to 50 % is present. Technetium-99 m bone scans
are very sensitive, but not specific. Computed tomography (CT) scans and
CT myelograms offer improved sensitivity and accuracy. When CT scans
show destruction of more than 40 % of the vertebral body, there is an 80 to
90% chance of vertebral collapse. Magnetic resonance imaging (MRI) is
the gold standard imaging study for detecting spinal neoplasms and for
evaluating neural compromise and soft tissue mass. Sclerotic tumors give
low-intensity signals on T1- and T2-weighted images, whereas lytic lesions give lowintensity signals on T1- and high-intensity signals on T2-
weighted images. MRI also provides the most definitive imaging of vertebral osteomyelitis or abscess.
Biopsy is the last step in preoperative diagnosis and staging. Although
some posterior lesions may be amenable to excisional biopsy, most lesions
require either needle or an incisional biopsy.Biopsies should be performed
by the surgeon who will do the definitive excision, and should take into account future incisions needed for definitive surgery. Transverse incisions
must be avoided.
Indications for Surgery
Surgery is considered in those with at least 6 weeks‘ life expectancy with
the following:
1. Severe, unremitting pain
2. Progressive neurodeficits in the face of, or following, appropriate
radiation therapy
3. Instability or progressive deformity of the spine
4. Unknown histologic diagnosis
5. Pathologic fracture of the spine, with bony compression of neural ele-
ments
6. Isolated lesion or solitary site of relapse offering hope of extended sur-
vival
Contraindications to Surgery
1. Very limited life expectancy (i.e., less than 6 weeks)
2. Diffuse spinal involvement
3. Compromised medical status
4. Lack of facilities/resources for definitive management
Procedure
Choice of procedure is determined by location of tumor or lesion (Fig. 20–
1) (McLain and Weinstein, 1990, 1999). Zone I lesions are best approached
posteriorly; zone II lesions can be approached either posteriorly or posterolaterally; zone III lesions should be approached anteriorly; and zone IV
lesions require a combined anterior and posterior approach for complete
excision.
Video-Assisted Posterolateral Approach
The video-assisted transpedicular approach is indicated for:
1. Intralesional resection of thoracic spinal metastasis causing cord com-
promise and instability
2. Debridement and stabilization of radiosensitive tumors
3. Decompression and stabilization of spine infections
This approach is particularly useful for tumors of the upper thoracic
spine (T1-T4), and for patients with established pulmonary disease who
cannot tolerate thoracotomy (McLain, 1998). It provides extrapleural
access to the thoracic vertebral body for intralesional vertebrectomy. Position the patient prone, and make a midline longitudinal incision centered
over the spinous processes at the appropriate level. Dissect the paraspinal
muscles off the spine and transverse processes and retract them laterally.
The costotransverse ligaments are divided, the rib excised lateral to the
vertebral body, and the transverse process resected close to its junction
with the lamina. The pedicle lies anterior to the stump of the resected
transverse process, with the neural foramina above and below. Below the
transverse process and medial to superior costotransverse ligaments are
vessels that should be cauterized or tied. After costotranversectomy the
pedicle is taken down flush with the vertebral body using a bur and rongeurs. Progressively debulk the anterior tumor under direct vision to create
a cavity within the vertebral body. Introduce the 30-degree, 4-mm endoscope into the cavity to help visualize the posterior vertebral cortex, posterior longitudinal ligament, and dura, thereby ensuring safe and complete
decompression (Fig. 20–2). Angled Epstein curets and pituitary rongeurs
are used for intralesional removal of all tumor tissue ventral to the cord,
across to the far pedicle, and to prepare the end plates for reconstruction. A
small shell of the far lateral cortex is left to protect the lateral structures as
well as to provide some stability to the reconstruction. After completing
the vertebrectomy, reconstruct the anterior defect with a titanium cage or
allograft fibula. Posterior instrumentation is then completed through the
same dorsal incision at the same sitting. Take a chest x-ray to rule out
pneumothorax, and close without a chest tube. This approach considerably reduces the morbidity associated with thoracotomy approaches to the
upper thoracic levels.
Closure
The fascia is closed with No. 1 absorbable suture, the subcutaneous tissue
with 2-0 interrupted sutures, and the skin with a subcuticular 4–0 absorbable suture.
Anterior Approach
This approach is suitable for intralesional or en-bloc resections (Webb,
1994). The patient is placed in a lateral decubitus position, usually left side
up unless tumor site dictates otherwise. The patient is secured with either
a beanbag or lateral supports. The relevant rib space is planned from x-rays
based on which vertebra is affected. Make an oblique incision from the
lateral border of the paraspinal muscles posteriorly along the selected rib
to the anterior axillary line. Cut the latissimus dorsi and trapezius in line
with the incision. The serratus anterior is cut in line with the incision if required. Incise and elevate the periosteum over the rib and resect it. Alternatively, the approach can be through the intercostal space, the incision
being made nearer the superior margin of the inferior rib to avoid the intercostal vessels.
The chest is entered through the parietal pleura after deflating the ipsilateral lung through a double-lumen endotracheal tube. The vertebral
column can now be seen. The overlying pleura is incised vertically lateral
to the anterior longitudinal ligament and dissected off the vertebral body
bluntly, ligating any segmental vessels in the way. Resect the rib head for
better exposure of the vertebral body and disc space (Fig. 20–3). This approach is most suitable for T5-T11 lesions, but can be extended proximally
or distally with care.
Combined Thoracoretroperitoneal Approach
This approach is indicated for access to the thoracolumbar junction. The
patient is placed in the lateral decubitus position as above. The incision is
similar to that above, but carried out along either the 10th or 11th rib depending on the access required. The anterior portion of the incision curves
distally along the abdomen as it nears the rectus sheath. Divide the external oblique, internal oblique, and transversalis fascia in layers along the incision. Incise the rib bed to enter the pleural space, exposing the superior
surface of the diaphragm. Starting at the cartilaginous tip of the resected
rib, the diaphragm is cut along its periphery toward the medial crus, using
silk tags to mark the edges for later repair. Incise the parietal pleura and excise the rib head as before. Enter the retroperitoneal space distal to the tip
of the resected rib by blunt dissection and develop the retroperitoneal in-
Eurostile
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1
Spinous process
Facet joint
2
Transverse process
4
3
Figure 20–1
Axial representation of a vertebral body showing the four anatomic zones.
Figure 20–2
Video-assisted posterolateral approach. Midline skin incision, paraspinal muscles dissected off, transverse process resected, and anterior tumor debulked through the
pedicle. The endoscope is introduced into this cavity and further corpectomy carried out under endoscopic guidance.
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SECTION II THE THORACIC SPINE
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Cross-section of
tricortical graft
Figure 20–3
Anterior approach to thoracic spine, approach through the rib bed after rib resection. The spine is exposed after deflating the ipsilateral lung. Allograft reconstruction after
corpectomy.
Eurostile
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