Determine Appropriateness of Costotransversectomy

• Advantages of costotransversectomy
  
  
  
  
  • Less extensive than thoracotomy
    
  • Adequate for pathology along lateral canal up to midline
  
  
• Disadvantages of costotransversectomy
  
  
  
  
  • Cannot access pathology across midline of canal
    
  • Significant paraspinal muscle dissection

Imaging

• Plain x-rays
  
  
  
  
  • Determine number of ribs for localization
    
  • Assess deformity and/or instability
  
  
• Magnetic resonance imaging (MRI)
  
  
  
  
  • Determine extent of neural element compression
  
  
• Computed tomography
  
  
  
  
  • Evaluate bony anatomy
  
  
• Computed tomography/myelogram
  
  
  
  
  • If MRI is contraindicated

Operative Planning

• Patient counseling regarding risk, benefits, and postoperative course

Routine Equipment

• Basic spine tray including Kerrison rongeurs (2 to 4 mm)
  
• Cautery–monopolar and bipolar
  
• High-speed drill (e.g., Midas Rex)
  
• Headlight and loupe magnification
  
• Table-mounted retractor (Thompson-Farley [Thompson Surgical Instruments, Inc., Traverse City, MI] versus Omni-Tract [Omni-Tract Surgical, St. Paul, MN])

• Cell Saver–if significant blood loss is anticipated in the absence of infection/neoplastic disease
  
• Microscope for intradural pathology
  
• Spinal instrumentation if reconstruction is intended

Operating Room Set-up

• Prone table: Jackson table with Wilson frame or bolsters
  
• Make sure patient is secured well in case rotation of the table is required
  
• Mayfield head holder versus Gardner-Wells tongs with traction
  
• Intraoperative anteroposterior and lateral x-ray versus fluoroscopy

Anesthetic Issues

• Secure endotracheal tube for prone position
  
• Appropriate blood pressure monitoring
  
• Foley catheter for extended cases (beyond 3 hours)
  
• Perioperative antibiotics 30 minutes prior to skin incision
  
• Perioperative steroids for decompressive or intradural pathology
  
• Avoid any orbital compression if patient’s face is placed on cushioned mask

Positioning

• Options
  
  
  
  
  • Standard prone position
    
  • Three quarter prone with side of pathology elevated

Incision

• Options
  
  
  
  
  • Curvilinear incision, beginning and ending in the midline with apex centered over the rib to be resected, ~5 to 7 cm from midline
    
  • Midline incision: requires extended length to mobilize paraspinal muscles
    
  • Paramedian incision several centimeters from the midline

Planning of Sterile Preparation

• Standard scrub and prep

Exposure