Minimally Invasive Thoracic Corpectomy




Indications




  • •

    Conditions requiring ventral decompression of the spinal cord with removal of one to two vertebral bodies at any level of the thoracic spine



    • •

      Extradural tumors


    • •

      Infection (e.g., diskitis, osteomyelitis)


    • •

      Fractures or trauma


    • •

      Degenerative disease or focal deformity



  • •

    Patients for whom open thoracotomy or traditional open lateral extracavitary approaches may present excessive morbidity





Contraindications




  • •

    Need for en bloc or marginal spondylectomy


  • •

    Greater than two-level corpectomy required


  • •

    Severe deformity requiring significant intraoperative manipulation for correction


  • •

    Patient characteristics unfavorable for surgery, such as inability to tolerate general anesthesia, uncorrected coagulopathy, life expectancy too short for palliative surgical resection (<3 months), and severe osteoporosis





Planning and positioning





Figure 82-1:


The patient is placed prone on a radiolucent Jackson table with proper padding for dependent areas. An open-frame table facilitates the use of anteroposterior and lateral fluoroscopy during the procedure. The arms can be positioned toward the head for thoracic levels as high as T6 depending on individual patient anatomy.



Figure 82-2:


Axial computed tomography (CT) scan from a patient with T9 lung cancer metastasis. A measurement is used to estimate the distance needed from the midline to achieve the desired approach trajectory. Analysis of preoperative imaging is crucial to determine the side of approach or need for bilateral approach (e.g., circumferential epidural tumor involvement) and to plan the distance from the midline at which to place the incision to achieve a favorable approach trajectory.




Procedure





Figure 82-3:


After appropriate preparation and draping, the operative level is identified on intraoperative fluoroscopy, and a paramedian incision is marked out on the skin. The distance of the incision from the midline varies based on patient anatomy and approach trajectory desired, but on average it is approximately 6 cm off the midline. Local anesthesia is injected, and the skin is incised sharply. The thoracodorsal fascia may be incised separately if desired. Tubular dilation is performed over the transverse process using a commercially available minimally invasive surgery (MIS) retractor system ( A ). An expandable MIS retractor is placed over the dilators and fixed into place using a table-mounted arm ( B ).



Figure 82-4:


After removal of the dilators, the retractor is expanded to enlarge the working field. Additional retractor blades may be inserted as available. Retractors that expand in rostral-caudal and medial-lateral directions are most useful in this procedure ( A ). Position of the retractor is confirmed on lateral fluoroscopy ( B ).

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Jun 15, 2019 | Posted by in NEUROSURGERY | Comments Off on Minimally Invasive Thoracic Corpectomy

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