47 Lumbar Corpectomy 1. Decompression of spinal canal 2. Removal of pathologic tissue (tumor, infection, fracture fragments) 3. Restoration of lumbar lordosis 4. Direct stabilization of the anterior column of the lumbar spine 1. Primary or metastatic disease 2. Infection 3. Fracture 4. Posttraumatic kyphotic deformity 5. Congenital or acquired spinal deformity 6. Multilevel upper lumbar disc herniation Anterior release; decompression and anterior column reconstruction for tumor (primary or metastatic); fracture; deformity; or degenerative disease. 1. Pelvic or abdominal tumor 2. Multiple prior abdominal surgeries 1. Prior radiation 2. Significant aorta or femoral vascular disease 3. Prior abdominal surgery 4. Obesity 1. Sutton’s law: direct removal of offending tissue 2. Mechanical advantage for maintaining restoration of anterior column and lumbar lordosis 3. Improved wound healing 1. Anterior exposure of the upper lumbar spine may require a thoracotomy. 2. Familiarity with approach. 3. Requires knowledgeable assistant. In the preoperative planning of an anterior lumbar corpectomy, the surgeon should divide the operation into the three essential parts: approach, decompression, and stabilization. Ultimately the patient’s unique anatomy and pathology, along with the individual surgeon’s skill, will determine the most appropriate technique. There are two essential variations of the surgical approach for lumbar corpectomy: anterior lateral and straight anterior. The anterior lateral approach provides easier access to the upper lumbar spine (L1, L2, and L3) via a retroperitoneal approach. It provides a more lateral orientation for decompression and anterior column reconstruction. The straight anterior approach is a more user-friendly approach for the lower lumbar spine (L4, L5, S1). It provides a straightforward anterior/posterior orientation to the spine. I find the direct anterior approach more suitable for placement of structural grafts when I am attempting to improve lumbar lordosis. This approach does not utilize a thoracotomy or rib incision. I have not been able to get adequate exposure higher than the L2-L3 disc with this approach (even in very thin patients!). The incision for the anterior lateral approach can be extended into a direct anterior incision and ultimately can help you get anywhere in the lumbar spine. Exposure of L1 or L2 usually requires a rib excision with a T10, T11, or T12 being excised. L3 and L4 can be exposed with a flank incision without thoracotomy. The anterior lateral approach is more user friendly if you plan to utilize an anterior lateral plate for the anterior column reconstruction. Anterior: The patient is supine. The skin incision may be longitudinal, oblique, or transverse, and is dependent on the surgeon’s choice, patient’s size, and cosmetic concerns (Fig. 47–1A). Classically the anterior rectus sheath is opened on the patient’s left side two to three fingerbreadths from the midline (Fig. 47–1B). The lateral border of the rectus abdominus muscle is delineated and then retracted toward the midline (note: some surgeons prefer to delineate the medial border of the rectus and retract laterally). Once the rectus is retracted, the posterior sheath is identified. At the inferior border of the posterior sheath (about midway between the umbilicus and the symphysis pubis) is a thickening called the arcuate ligament. Immediately below the arcuate ligament is the entry to the retroperitoneal space. With a moist lap or sponge stick, sweep away the transversalis fascia, retroperitoneal fat, and peritoneum. Start lateral and go medial to avoid tearing the peritoneum. After clearing off the undersurface of the arcuate ligament and the posterior rectus sheath, divide the sheath laterally to gain full exposure. Initially use hand-held retractors (beaver or Harrington) and identify the psoas. The psoas is the key; once it is identified, sweep with a moist lap the peritoneal contents. The ureter almost always is swept along with the peritoneum. Identify the great vessels and then place the appropriate blades for the Bookwalter retractor. Note: Do not use the self-retaining retractors to retract the great vessels. Identify the bifurcation of the aorta, which is usually at the L4–5 disc space. Underneath the aortic bifurcation, usually just a little lower at the level of the superior half of L5 vertebral body, is the bifurcation of the vena cava. A vessel loop around the left common iliac artery aids in the retraction and dissection, so place this first. Mobilize the artery using 2-0 silk ties, vessel clips, or bipolar electrocautery. After the artery has been mobilized, mobilize the vein. At this point, to fully mobilize the vessels to perform a corpectomy of L5, do the following:
Goals of Surgical Treatment
Diagnosis
Indications
Absolute Indications
Relative Indications
Advantages
Disadvantages
Procedure
Approach
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