Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6033_Библиотеки_им_академика_М_И_Перельмана.pdf
122
a
bc
de
C. Gragnaniello and K. Seex
Fig. 15.13 A 76-year-old male with a history of a previous
laminectomy at L4/5 for radicular symptoms at the presence
of a canal stenosis at L4/5 from which he had good relief of
his symptoms for 2 years. He represented after 2 years with
worsening symptoms from a worsening stenosis at the L3/4
level that was initially managed with steroid injections and
subsequently with an L3/4 interlaminar decompression that
only gave him 9 months of relief. The patient medical
fi xed blade anteriorly and a novel self-retaining
posterior retractor (G clamp, Relax Retractors,
Sydney, Australia). Other blades maybe added
but are not usually needed.
15.6.3.1 Neuromonitoring
Generally agreed to be mandatory with transpsoas [ 2 ], surgeons using both of the above
oblique lateral approaches do not routinely use
neuromonitoring although this is described in the
Medtronic technique. (Dr Richard Hynes,
Melbourne, Florida personal communication).
The muscle retraction both superfi cial and deep
is likely to be easier with the use of muscle relaxants, which would otherwise need to be reversed
if neuromonitoring was being used.
history included a BMI of 31, HTN, hyperlipidemia, and
gout. Upon the last recurrence, he had severe LBP and pain
bilaterally in L4 when standing or walking. A sagittal T2WI
MRI scan showed a stenosis at L3/4 and disc degeneration
at L4/5 with instability ( a ). A sagittal CT reconstruction of
the same midsagittal cut ( b ). Early postoperative lateral and
AP x-ray fi lms ( c , d ). Coronal CT reconstruction showing a
solid fusion after 12 months ( e )
15.6.4 Psoas Retraction
A theoretical concern with the anterior to psoas
approach is that the lumbar plexus maybe stretched
or compressed against the Transverse processes. In
order to avoid this we limited the psoas retraction at
L4/5 to mid body, in addition to periodic release of
psoas retraction during surgical delays. As this
proved uneventful, we now routinely retract psoas
up to the posterior 1/3 of the L4 body.
15.6.5 Levels
The ideal levels for ATP are L4/5 and L3/4. No
advantage over transpsoas has been noted at
15 Anterior to Psoas (ATP) Fusion of the Lumbar Spine
123
a
c
b
d
e
Fig. 15.14 A 65-year-old man with a history of MI and
placement of four coronary stents. Upon presentation was still
a smoker of a pack/day and was on aspirin. He was limited by
severe back pain with bilateral S1 pain (L > R) that persisted
despite conservative measures. Lateral x-ray demonstrating
and L5/S1 disc degeneration ( a ). Intraoperative lateral and AP
x-ray ( b , c ). Postoperative CT reconstruction at 12 months
demonstrating good alignment and solid fusion ( d , e )
124
C. Gragnaniello and K. Seex
L2/3. An isolated L 1/2 is easier with a direct lateral approach. L 2/3 is straightforward below or
anterior to the 12th rib but L 1/2 access varies
with individual anatomy.
15.6.6 Vascular Injuries
Vascular injuries are a theoretical risk during an
ATP approach. However, a left side approach is
usually free from vascular structures and the
natural corridor, well seen on MRI, makes
possible an approach without any vascular
dissection [ 5 ]. In Davis’s paper there was a mean
space of 15 mm between edge of left psoas and
vessels, (without psoas retraction) [ 5 ].
However, surgeons should be prepared to recognize and be able to divide the iliolumbar vein
as rarely this may overlie the L4/5 disc.
The miniopen approach described here anticipates direct visualization of any intra-abdominal
structures in the approach.
In comparing the ATP approach to ALIF at
L4/5, the absence of vascular dissection and vascular retraction is a major advantage particularly
in elderly patients.
By contrast access to the L5/S1 disc space,
going anterior to psoas and lateral to the vessels
requires the same degree of vascular expertise as
for an L4/5 ALIF.
15.6.7 Nerve Injuries
The sympathetic trunk has to be mobilized and
our experience has been that this tolerates
mobilization and compression by smooth retractor
blades quite well, even sacrifi ce generally only
produces warming of the affected leg that is
usually unnoticed by the patient and resolves in
the fi rst 12 weeks. However in younger patients
(and particularly women), the sympathectomy
effect can lead to unilateral swelling and much
unhappiness.
The genitofemoral nerve is the sensory nerve
most obviously at risk, being on the psoas and
immediately under the psoas retractor blade, and
its injury can produce unpleasant groin neuralgia.
Careful placement of the G clamp retractor blade,
care to preserve psoas fascia, limited duration of
psoas retraction, and retractor stability are all
recommended to reduce potential for nerve injury
(Fig. 15.10 ).
15.7 ALL Section
Although only recently reported, anterior column realignment ( ACR ) is a technique that is
proving very powerful in aiding deformity correction with minimal blood loss compared to
posterior osteotomy techniques [ 18 ]. This ACR
technique exposes the lateral annulus and the lateral edge of the ALL and then divides the ALL
from the traditional direct lateral approach within
psoas [ 18 , 19 ]. ATP however with its oblique
approach provides direct vision of more of the
critical structures, namely, the anterior surface of
the spine, ALL, and adjacent major vessels.
These theoretical advantages have been confi rmed
by the relative simplicity of sectioning ALL
using this approach (Fig. 15.11a, b ). A full dis-
cussion of this technique including the use of
hyperlordotic cages is beyond the scope of this
chapter, but a very good reason to learn ATP is to
gain familiarity with the approach to perform a
controlled release of the anterior annulus and/or
ALL under direct vision, achieving 20° plus segmental corrections at a single level.
Conclusions
The left-sided anterior to psoas approach
offers the most natural corridor to the disc
space. The novel instruments and methods
described here allow for insertion of large lateral cages from L2 to L5, without the problems associated with the transpsoas approach,
particularly at L4/5. Once comfortable with
the technique, it can be applied equally well
on the right although the IVC must be mobilized. It is more logical to perform release of
the anterior annulus and ALL by an approach
anterior to psoas and anterior oblique to the
spine rather than transpsoas and direct lateral.
15 Anterior to Psoas (ATP) Fusion of the Lumbar Spine
125
References
1. Acosta FL, Liu J, Slimack N, Moller D, Fessler R,
Koski T. Changes in coronal and sagittal plane alignment following minimally invasive direct lateral interbody fusion for the treatment of degenerative lumbar
disease in adults: a radiographic study. J Neurosurg
Spine. 2011;15:92–6.
2. Berjano P, Lamartina C. Minimally invasive lateral
transpsoas approach with advanced neurophysiologic
monitoring for lumbar interbody fusion. Eur Spine J.
2011;20:1584–86. Brier-Jones JE, Palmer DK, Inceoglu
S, Cheng WK. Vertebral body fractures after transpsoas
interbody fusion procedures Spine J. 2011;1:1068–72.
3. Cummock MD, Vanni S, Levi AD, Yu Y, Wang MY.
An analysis of postoperative thigh symptoms after
minimally invasive transpsoas lumbar interbody
fusion. J Neurosurg Spine. 2011;15:11–8.
4. Dakwar E, Le TV, Baaj AA, Le AX, Smith WD,
Akbarnia BA, Uribe JS. Abdominal wall paresis as a
complication of minimally invasive lateral transpsoas
interbody fusion. Neurosurg Focus. 2011;31(4), E18.
5. Davis TT, Bae HW, Mok JM, Rasouli A, Delamarter RB.
Lumbar plexus anatomy within the psoas muscle: implications for the transpsoas lateral approach to the L4–L5.
Disc J Bone Joint Surg Am. 2011;93(16):1482–7.
6. Guerin P, Obeid I, Gille O, Bourghli A, Luc S,
Pointillart V, Cursolle JC, Vital J-M. Safe working
zones using the minimally invasive lateral retroperitoneal transpsoas approach: a morphometric study. Surg
Radiol Anat. 2011;33:665–71.
7. Kepler CK, Sharma AK, Huang RC. Lateral trans-
psoas interbody fusion (LTIF) with plate fi xation and
unilateral pedicle screws: a preliminary report.
J Spinal Disord Tech. 2011;24:363–7.
8. Lowitz EH, Yanni DS, Chwajol M, Starke RM, Perin
NI. Evaluation of indirect decompression of the lumbar
spinal canal following minimally invasive lateral transpsoas interbody fusion: radiographic and outcome analysis. Minim Invasive Neurosurg. 2011;54(5–6):201–6.
9. Le TV, Smith DA, Greenberg MS, Dakwar E, Baaj
AA, Uribe JS. Complications of lateral plating in the
minimally invasive lateral transpsoas approach.
J Neurosurg Spine. 2012;16:302–7.
10. Le TV, Vivas AC, Dakwar E, Baaj AA, Uribe JS. The
effect of the retroperitoneal transpsoas minimally
invasive lateral interbody fusion on segmental and
regional lumbar lordosis. Sci World J. 2012;2012:
Article ID 516706, 7 pages.
11. Mayer HM. A new microsurgical technique for minimally invasive anterior lumbar interbody fusion.
Spine. 1997;22:691–700.
12. Moller DJ, Slimack NP, Acosta FL, Koski TR, Fessler
RG, Liu JC. Minimally invasive lateral lumbar interbody fusion and transpsoas approach-related morbidity. Neurosurg Focus. 2011;31(4), E4.
13. Sharma AK, Kepler CK, Girardi FP, Cammisa FP,
Huang RC, Sama AA. Lateral lumbar interbody
fusion: clinical and radiographic outcomes at 1 year: a
preliminary report. J Spinal Disord Tech. 2011;24:
242–50.
14. Silvestre C, Mac-Thiong JM, Hilmi R, Roussouly P.
Complications and morbidities of mini-open anterior
retroperitoneal lumbar interbody fusion: oblique lumbar interbody fusion in 179 patients. Asian Spine J.
2012;6:89–97.
15. Sofi anos DA, Briseno MR, Abrams J, Patel AA.
Complications of the lateral transpsoas approach for
lumbar interbody arthrodesis: a case series and literature
review. Clin Orthop Relat Res. 2012;470:1621–32.
16. Malham GM, Ellis NJ, Parker RM, Seex KA. Clinical
outcome and fusion rates after the fi rst 30 extreme lateral interbody fusions. Sci World J. 2012;2012:Article
ID 246989, 7 pages. doi:
17. Gragnaniello C, Seex KA. Anterior to psoas fusion of
the lumbar spine. Neurosurg Focus. 2013;35(2 Suppl):
Video 13. doi:
18. Akbarnia BA, Mundis Jr GM, Moazzaz P, Kabirian N,
Bagheri R, Eastlack RK, Pawelek JB. Anterior column
realignment (ACR) for focal kyphotic spinal deformity
using a lateral transpsoas approach and ALL release.
J Spinal Disord Tech. 2014;27(1):29–39.
19. Pimenta L, Forti F, Oliveira L, Marchi L, Jensen R,
Coutinho E, Amaral L. Anterior column realignment
following lateral interbody fusion for sagittal deformity correction. Eur J Orthop Surg Traumatol.
2015;25 Suppl 1:S29–33.
20. Malham GM, Ellis NJ, Parker RM, Blecher CM,
White R, Goss B, et al. Maintenance of segmental lordosis and disc height in Standalone and Instrumented
Extreme Lateral Interbody Fusion (XLIF). Clin Spine
Surg. 2016 May 26 (Epub ahead of print).
10.3171/2013.V2.FOCUS13207 .
10.1100/2012/246989 .
Thoracic MIS Retropleural Access
Jay Rhee , C. Rory Goodwin , and Daniel M. Sciubba
1 6
Key Points
1. It is critical to position the patient in a
90° true lateral decubitus position with
high-quality AP and lateral fl uoroscopic
images.
2. Injury to the underlying parietal pleura
should be avoided during the dissection
of the rib and while sweeping the lung
anteriorly to expose the lateral vertebral
column to prevent a postoperative
pneumothorax.
3. The side of approach will be signifi cantly infl uenced by the levels being
treated and the anatomy on axial
imaging.
4. The segmental vessel must be carefully
dissected and sectioned at least 2 cm
from the aorta to prevent substantial
bleeding.
J. Rhee , MD • C. R. Goodwin , MD, PhD
Department of Neurosurgery ,
The Johns Hopkins University School of Medicine ,
Baltimore , MD 21287 , USA
D. M. Sciubba , MD (*)
Johns Hopkins University , Baltimore , MD , USA
dsciubb1@me.com
e-mail:
16.1 Introduction
Surgical approaches to the thoracic spine can
occur via anterior, posterior, or the combination of anterior and posterior approaches. The
surgical technique employed is typically determined based on the pathologic lesion, location of the lesion, and surgeon’s preference.
Posterior approaches (e.g., laminectomy) were
preferred initially for the treatment of thoracic
pathologies, such as thoracic disk herniation;
however, unacceptable poor outcomes were
key in the development and use of alternative
surgical approaches [ 1 ]. Transthoracic tho-
racotomies were employed for the treatment
of various pathologies because this approach
offers excellent visualization of the ventral
spinal column without spinal cord manipulation for anterior-based pathologies [
Unfortunately, the combination of the large
skin incision, need for collapse of the lung,
rib resection, and muscle dissection led to signifi cant postoperative pulmonary dysfunction,
pain, and morbidity associated with open thoracotomies [ 5 – 7 ]. Thoracoscopic approaches
were developed to reduce the drawbacks of
the open thoracotomy approach; however, the
need for collapse of the lung (similar to open
thoracotomy), lack of three-dimensional visualization, steep learning curve, and need for
postoperative chest tube were seen as disadvantages of this approach. The advent of minimally
2 – 4 ].
© Springer International Publishing Switzerland 2017
M.Y. Wang et al. (eds.), Lateral Access Minimally Invasive Spine Surgery,
DOI 10.1007/978-3-319-28320-3_16
127
128
J. Rhee et al.
invasive techniques over the past decades has
led to a decrease in the postoperative morbidity
associated with the treatment of ventral thoracic
pathologies and improved clinical outcomes
[ 3 , 8 – 10 ]. These minimally invasive approaches
range from mini open, percutaneous, and endoscopic approaches via transpedicular, transfacet, and transforaminal approaches [ 11 – 13 ].
McCormick described a lateral retropleural
thoracotomy to avoid the morbidity associated
with the traditional open thoracotomy and thoracoscopic approaches [ 14 ]. The retropleural
approach for thoracic pathologies has become
more common in its use because it allows for a
minimally invasive anterior exposure, gives
excellent visualization similar to the thoracoscopic and open thoracotomy techniques, and
avoids the spinal cord manipulation associated
with posterior approaches. The technique also
allows for reduced risks of great vessel injury,
damage to the sympathetic plexus, or development of a duropleural CSF fi stula because of
the extrapleural feature of the approach [ 14 –
16 ]. Additionally, this technique commonly uti-
lizes a single small incision, allows the use of
the operative microscope if the surgeon is
inclined, and includes less pain postoperatively
secondary to paucity of muscle and ligamentous disruption/manipulation. The main disadvantages of this operative approach are the
longer operative corridor, which require longer
instruments, and make it more diffi cult to control bleeding or other complications should
they arise [
17 ].
16.2 Anterior-Based Approaches
For anterior only pathology or as an adjunct in
cases requiring 360° decompression, the thoracic
spine can be treated via an anterior approach. The
fi rst and rarely the second thoracic levels may be
accessed without a sternotomy or manubriotomy
in select cases. Access up to T4 can often be
achieved with a sternotomy, which typically
requires an approach surgeon. The great vessels
are at risk in anterior approaches and will limit
pathologies extending below T4.
16.3 Posterior-Based Approaches
Posterior approaches to the thoracic spine allow
access to the posterior elements as well as the
lateral and anterolateral aspects of the vertebrae. These include laminectomy, transpedicular,
costotransversectomy, and lateral extracavitary
approaches that may be performed unilaterally
or bilaterally. Full anterior decompression can
be performed through bilateral posterolateral
access. Pedicle screws and an anterior cage can
be placed allowing 360° stabilization and fi xation across multiple segments through a single
approach. Limitations to posterior and posterolateral approaches include the need for extensive
muscular dissection especially for cases requiring anterior decompression and instrumentation,
high postoperative pain, risk of spinal cord injury,
high volume blood loss, and risk of injury to the
pleura and neurovascular bundles when resecting
ribs. A thoracic nerve root is often sacrifi ced for
access when placing an anterior cage following
a corpectomy, which is typically well tolerated.
Removing calcifi ed midline herniated disks from
a posterior approach can be challenging and has
been associated with high rates of thoracic cord
injury.
16.4 Lateral-Based Approaches
Traditional lateral-based techniques involve a
thoracotomy and provide excellent exposure of
the lateral vertebral column caudal to T4. Above
this level, the scapula obstructs access to the ribs.
For upper thoracic levels (T5-T6), right-sided
approaches are preferred to avoid injury to the
aortic arch. Levels below T6 may be approached
on either side taking care to thoroughly review
preoperative axial images to assess the location
and proximity of the aorta and mediastinum to
the vertebral column. Levels near the thoracolumbar junction may be more easily approached
from the left to avoid retracting the liver [
Lateral transthoracic access involves dissection through the latissimus dorsi and trapezius
muscles, resection of up to 15 cm of the rib, and
distraction of the rib cage for visualization. For
18 ].
16 Thoracic MIS Retropleural Access
129
T8 and above, the rib one level caudal to the target level is typically resected, while more caudal
segments may require resection of the rib two
levels caudal. Defl ation of the ipsilateral lung
may be required in cases involving rostral thoracic vertebrae. Open lateral access will place the
patient at risk for injury to the pleura, lung, intercostal neurovascular bundle, aorta, and/or azygous vein depending on laterality and increase
the potential for postoperative thoracotomy pain.
16.5 Surgical Technique and Anatomic Considerations
16.5.1 Preoperative Planning
A full preoperative workup including medical,
neurologic, and radiographic assessments is performed and tailored for each individual patient.
MRI and CT scans of the spinal segments of interest are critical for evaluation of the neural and
osseous anatomy. Scoliosis and dynamic X-rays
may be helpful for Cobb angles and alignment
measurements in cases involving spinal deformity.
For patients with risk factors for osteoporosis,
bone mineral density studies are often obtained.
The side of approach may be dictated by the
pathology, but in equivocal circumstances, the
anatomy will infl uence laterality. On axial imaging, a laterally positioned descending aorta may
make exposing the left side of the thoracic spine
diffi cult. In the lower thoracic spine, a left-sided
approach is often easier and safer as this will
avoid working around the liver as well as potential injury to the thin-walled inferior vena cava.
16.5.2 Preparation and Patient Positioning
Standard single-lumen general endotracheal
intubation is performed and neuro-monitoring
leads are inserted. The patient is placed in a 90°
true lateral decubitus position onto a radiolucent
table using intraoperative fl uoroscopy taking
care to properly pad all pressure points and
joints. The bed is oriented such that anesthesia is
toward the patient’s head, the C-arm fl uoroscopy
positioned anteriorly, and the surgeon(s) positioned behind the patient. The surgical scrub is
positioned behind the patient beside the surgeon
toward the foot of the patient with the Mayo
stand in between the scrub and surgeon. It is
critical to obtain high-quality true AP and lateral
images of the target vertebral segments prior to
incision. Once an AP image of the vertebrae is
obtained, the patient is secured to the bed with
2-in. silk tape and straps (Fig. 16.1 ).
ab
Fig. 16.1 ( a ) Patient placed in a 90o true lateral decubitus
position with pre-operative surgical marking of ribs and
index level. ( b ) Fluoroscopic X-Ray image of the
vertebrae is obtained with the patient is secured to the bed
with two inch silk tape and straps
130
J. Rhee et al.
16.5.3 Surgical Approach
The C-arm is adjusted for a true lateral view and
a radiopaque marker is placed above the disk
space of interest. For single-level fusions, a 4–5cm incision is marked at the level of the disk
space. For two-level fusions or a single-level
corpectomy, an incision is marked along the midvertebra between the two disk spaces of interest.
The skin is incised and the underlying muscles
are bluntly dissected to expose the rib overlying
the target interspace(s). It is prudent to make the
incision over an underlying rib to prevent plunging into the intercostal space. Approximately
4 cm of the rib are dissected from their muscular
attachments as well as the parietal pleura and
resected with a rongeur or a bone scalpel. Care
must be taken to avoid injury to the pleura, inter-
a
costal vessels, and nerves on the caudal surface
of the ribs.
A fi nger is inserted into the retropleural space
hugging the posterior chest wall, and the lung is
swept anteriorly with a sponge stick until the lateral vertebral column is exposed. Appropriately
sized retractor blades are chosen and placed onto
the correct target disk space under direct visualization. The position of the retractor can be confi rmed with an AP fl uoroscopic image. The
authors use the SynFrame retractor system
(DePuy Synthes, Raynham, MA) which employs
a table-mounted ring directly above the incision
attached to articulated retractor blade holders.
Three blades are typically used: one for anterior
retraction of the lung and two for rostral and caudal retraction (Fig. 16.2 ) . Alternatively, the table-
mounted retractors used for lateral retroperitoneal
c
b
Fig. 16.2 ( a ) Synframe retractor system (Depuy Synthes,
Raynham, MA) which employs a table mounted ring
directly above the incision attached to articulated retractor
blade holders. ( b ) Visualization of thoracic plate through
Synframe retractor system. ( c ) Antero-posterior X-ray
image of the T8 cage and plate after corpectomy
16 Thoracic MIS Retropleural Access
131
lumbar access may be used in the thoracic spine
in similar fashion (Fig. 16.3 ).
Once the exposure is complete and the selfretaining retractor is in place, fl uoroscopy is used
to confi rm that the correct level has been exposed.
From the lateral view, the disk spaces are elevated
compared to the vertebral bodies. The disk space
can be palpated with a Penfi eld dissector for confi rmation and the surgeon may commence the diskectomy. For a corpectomy, a diskectomy is
performed above and below before the removal of
the vertebral body. The segmental artery courses in
an anteromedial to posterolateral direction at the
mid-position of the vertebral body. This vessel
should be dissected, clipped, and cauterized with
bipolar electrocautery before sectioning. As the
segmental artery arises directly off of the descending aorta, it is critical to section the vessel at least
2 cm distal to the aorta. If the artery is cut too close
to the aorta and was not suffi ciently clipped or cauterized, it may retract and bleed profusely from
aortic back pressure. The anterior border of the vertebral body can be palpated with a Penfi eld dissector. The neural foramen provides a useful landmark
for the posterior border. The rostral/caudal boundaries have been defi ned by the diskectomies, and
the surgeon may commence with the corpectomy.
Once the main procedure is complete, the
pleural surface is inspected thoroughly. If the
pleura is compromised or there is signifi cant
residual bleeding, a 10-French chest tube is
placed in the wound and tunneled subcutaneously over several ribs from the incision. The
retractor blades are carefully removed allowing
the lung to expand to the posterior chest wall.
The muscles overlying the rib resection are reapproximated with 0-Vicryl interrupted sutures,
and the rest of the incision is closed in standard
fashion.
16.5.4 Postoperative Care
If a chest tube is in place, it is connected to a
reservoir on water seal or −20 cm of H2O depending on the severity of the pleural injury. All
patients undergo a postoperative chest X-ray
shortly after the arrival to the postanesthesia care
unit. If a chest tube was placed or a pneumothorax is discovered on the postoperative chest
X-ray, a follow-up X-ray is performed on postoperative day 2 for surveillance. The chest tube is
weaned and removed as tolerated.
Patients are encouraged to sit in a chair and
ambulate on the fi rst postoperative day. All
patients have sequential compression devices and
are started on heparin prophylaxis for prevention
of deep vein thrombosis.
ab c
Fig. 16.3 ( a ) Table mounted retractors used for lateral
retroperitoneal lumbar access used in the thoracic spine.
( b ) Magnifi ed view of retractor system intra-operatively.
( c ) Antero-posterior X-ray image of the cage placement
after corpectomy
132
J. Rhee et al.
16.6 Outcomes Using a Minimally Invasive Anterolateral Approach
Two studies reporting outcomes and complications of MIS retropleural access are available for
review at the time this chapter was written. In
2011, Karikari et al. reported their series of 22
patients who underwent MIS thoracic and thoracolumbar lateral interbody fusions for a variety
of pathologies using the MaXcess retractor
(NuVasive, San Diego, CA) [ 19 ]. They report a
95.5 % successful fusion rate among 47 levels
treated with three complications, none of which
involved neural, vascular, or pulmonary injuries.
In another study, Meredith et al. reported a series
of 18 patients who underwent MIS lateral
thoracic and thoracolumbar interbody fusions
with the MaXcess retractor with only one patient
failing to fuse [ 20 ]. Seven non-pulmonary com-
plications occurred in six patients with none
involving neural elements or vessels. Although
large-scale studies are required for further evaluation, these early reports show that the MIS
anterolateral approach can be used to treat a variety of thoracic pathologies safely with high rates
of successful fusion.
16.7 Advantages of the Minimally Invasive Lateral Approach
Currently, there are no large cohort reports comparing outcomes of minimally invasive lateral thoracic
vertebral approaches to classic open thoracotomies. However, some potential advantages of the
lateral retropleural thoracic approach include:
No approach surgeon
Smaller incision
Less rib resection or muscle dissection
Less rib retraction
Avoidance of single-lung ventilation
Less lung retraction and postoperative atelectasis
Less pain
Shorter hospitalization
Less blood loss
16.8 Limitations of the Minimally Invasive Lateral Approach
More radiation exposure from increased intraop-
erative fl uoroscopy use
Learning curve
Smaller exposure
Longer working corridor necessitating longer
instruments
16.9 Summary
For anterior and anterolateral pathologies limited
to one to three thoracic levels, an MIS lateral
approach provides ample exposure while limiting
morbidity.
References
1. Logue V. Thoracic intervertebral disc prolapse with
spinal cord compression. J Neurol Neurosurg
Psychiatry. 1952;15(4):227–41.
2. Anand N, Regan JJ. Video-assisted thoracoscopic
surgery for thoracic disc disease: classifi cation and
outcome study of 100 consecutive cases with a 2-year
minimum follow-up period. Spine. 2002;27(8):
871–9.
3. Burke TG, Caputy AJ. Treatment of thoracic disc
herniation: evolution toward the minimally invasive
thoracoscopic technique. Neurosurg Focus. 2000;
9(4), e9.
4. Dickman CA, Mican CA. Multilevel anterior thoracic
discectomies and anterior interbody fusion using a
microsurgical thoracoscopic approach. Case report.
J Neurosurg. 1996;84(1):104–9.
5. Currier BL, Eismont FJ, Green BA. Transthoracic
disc excision and fusion for herniated thoracic discs.
Spine. 1994;19(3):323–8.
6. Fessler RG, Sturgill M. Review: complications of sur-
gery for thoracic disc disease. Surg Neurol. 1998;
49(6):609–18.
7. Mulier S, Debois V. Thoracic disc herniations: trans-
thoracic, lateral, or posterolateral approach? A review.
Surg Neurol. 1998;49(6):599–606; discussion -8.
8. Chi JH, Dhall SS, Kanter AS, Mummaneni PV. The
mini-open transpedicular thoracic discectomy: surgical technique and assessment. Neurosurg Focus.
2008;25(2), E5.
9. Jho HD. Endoscopic microscopic transpedicular tho-
racic discectomy. Technical note. Neurosurg Focus.
1998;4(2), e7.