Symptoms and Signs

• Chest tenderness and ecchymoses
• Paraplegia
• Diminished control of bowel/bladder function
• Moderate/severe back pain
• Respiratory distress
• Difficulty maintaining balance and walking
• Loss of sensation in hands
• Inability to conduct fine motor skills with hands

Surgical Pathology

• Thoracic spine benign/malignant trauma

Diagnostic Modalities:

• CT thoracic spine
• MRI thoracic spine
• CT or X-ray chest
• Ultrasonography

Differential Diagnosis

• Blunt trauma (complete and incomplete Spinal cord injury [SCI])
  • Pneumohemothorax, pulmonary contusion, cardiac contusion
• Penetrating trauma (complete and incomplete SCI)
• Wedge/compression fracture
• Burst fracture
• Chance fracture
• Fracture-dislocation

Treatment Options

• Acute pain control with medications and pain management
• Physical therapy and rehabilitation
• If symptomatic with cord compression:
  • Urgent surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery
  • If poor surgical candidate with poor life expectancy, medical management recommended
  • Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
  • May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal

Indications for Surgical Intervention

• Spinal stenosis
• No improvement after nonoperative therapy (physical therapy, pain management)
• Partial paraplegia
• Residual spinal compression (see ▶Fig. 2.1)
  

  

• Existence of blunt chest trauma or potential hemorrhagic lesions
• Unstable patterns of fracture
• Sufficient disruption of supporting ligaments

Surgical Procedure for Posterior Thoracic Spine

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed prone on Jackson Table with all pressure points padded
4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make an incision down the midline of back
7. Subperiosteal dissection of muscles bilaterally exposing the spinous process and paraspinal muscles
8. Dissect tissue planes along spinous process and laminae using rongeurs
9. Move paraspinal muscles laterally to expose the laminae
10. Once the locus of interest is exposed, it is best to localize and verify the correct vertebra via X-ray or fluoroscopic imaging and confirming with at least two people in the room
11. Perform the decompression procedure over segments needed based on preoperative imaging of levels that are compressed due to trauma:
    1. Using Leksell rongeurs and hand-held high-speed drill, remove the bony spinous process and bilateral lamina as indicated for specific procedure (laminectomy)
    2. Or, remove bone of lamina above and below spinal nerves to create a small opening of lamina, relieving compression (laminotomy)
    3. If compression is diagnosed to be from spondylolisthesis, a diskectomy is performed (remove portion of slipped disk)
    4. Remove the thick ligamentum flavum and any bone spurs with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding cerebrospinal fluid (CSF) leak
    5. Perform appropriate foraminotomy with Kerrison rongeurs as needed for appropriate decompression of nerve roots
12. Perform spinal fusion with instrumentation (often needed in trauma cases):
    1. Place pedicle screws over segments involved with connecting rods bilaterally, in addition to bone grafting, to fuse these segments (see ▶Fig. 2.2 and Fig. 2.3)
       

       

       

13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative drains that can be removed after 2 to 3 days

Pitfalls

• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control

Prognosis

• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• Pain medications for postsurgical pain
• Catheter placed in bladder and removed 1 to 2 days postsurgery
• Physical therapy and occupational therapy will be needed postoperatively, immediately and as outpatient to regain strength
• Brace placed after discharge to immobilize to increase the rate of healing

Symptoms and Signs

• Chest tenderness and ecchymoses
• Paraplegia
• Diminished control of bowel/bladder function
• Moderate/severe back pain
• Respiratory distress
• Difficulty maintaining balance and walking
• Loss of sensation in hands
• Inability to conduct fine motor skills with hands
• Pain, weakness, numbness on either side of back, chest, or from bicep to wrist of one arm

Surgical Pathology

• Thoracic spine benign/malignant trauma

Diagnostic Modalities

• CT thoracic spine
• MRI thoracic spine
• CT or X-ray chest
• Ultrasonography

Differential Diagnosis

• Blunt trauma (complete and incomplete SCI)
  • Pneumohemothorax, pulmonary contusion, cardiac contusion
• Penetrating trauma (complete and incomplete SCI)
• Wedge/Compression fracture
• Burst fracture
• Chance fracture
• Fracture-dislocation

Treatment Options

• Acute pain control with medications and pain management
• Physical therapy and rehabilitation
• If symptomatic with cord compression:
  • Urgent surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery

• If poor surgical candidate with poor life expectancy, medical management recommended

  • Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
  • May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal
• Corpectomy approaches:
  • Anterior (Thoracoscopic): Pleural entry to access anterior thoracic; broadest canal decompression, satisfactory visualization of thecal sac; easy graft insertion; anterolateral screw-plate fixation (see ▶Fig. 2.4 and ▶Fig. 2.5)
    

    

    

  • Anterolateral (Retropleural): Most direct anterior approach requiring retropleural dissection; canal decompression; anterolateral screw-plate fixation
  • Posterolateral (Lateral Extracavitary): Satisfactory visualization of thecal sac; anterior stabilization; posterior tension band preservation; unilateral decompression (see ▶Fig. 2.6)
    

    

  • Posterior (Transpedicular): Circumferential decompression; difficult graft insertion; unideal thecal sac positioning (see ▶Fig. 2.7)
    

    

Indications for Surgical Intervention

• Spinal stenosis
• No improvement after nonoperative therapy (physical therapy, pain management)
• Partial paraplegia
• Progressive cord compression
• Progressive kyphosis/deformity
• Existence of blunt chest trauma or potential hemorrhagic lesions
• Unstable patterns of fracture
• Sufficient disruption of supporting ligaments
• Compression places thoracic spine at risk of permanent damage

Surgical Procedure for Retropleural Thoracic Corpectomy

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed in left/right lateral decubitus position with padding of upper and lower extremities, held in place with tape over upper and lower extremities
4. Fluoroscopy is used to confirm that no vertebral movement has occurred
5. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
6. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
7. Make 6 cm incision from posterior axillary line to 4 cm lateral of midline
8. Dissect toward the rib head:
   1. Perform rib resection
   2. Incise endothoracic fascia, dissecting off the parietal pleura
   3. Dissect areolar tissue until endothoracic fascia is opened over rib head
9. Take down costovertebral ligaments and proximal rib head, exposing vertebral body

10. Perform corpectomy in a pedicle-to-pedicle fashion, preserving anterior shell of bone and anterior longitudinal ligament:

    1. Using hand-held curved high-speed drill, remove the posterior wall of vertebral bodies
    2. Remove the vertebral bodies and disks associated with the trauma
    3. Introduce hemostatic agents, if necessary, to control bleeding
    4. Achieve hemostasis
11. Perform spinal fusion
    1. Perform reconstruction with expandable cage and autograft
    2. Perform ventrolateral screw-plate fixation
    3. Perform midline posterior incision and place posterior percutaneous screws
12. Place chest tube if significant pleural tear occurs (can be removed in 2–3 days)
13. Remove retractor and inspect wound for further bleeding and pleural violations
14. Place red rubber catheter between endothoracic fascia and parietal pleura
15. Close fascia with suture
16. Catheter under water seal; the patient is made to valsalva with help of anesthesia
17. Remove catheter and tighten last facial suture
18. Close the muscle, subcutaneous layers, and skin

Surgical Procedure for Lateral Extracavitary Thoracic Corpectomy

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed prone on Jackson Table with all pressure points padded
4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make 4 cm incision, 4 cm laterally from midline
7. Remove proximal rib, costovertebral ligaments, rib head, intercostal vessels, and ipsilateral pedicle
8. Perform corpectomy, preserving ventral body, anterior longitudinal ligament, and contralateral vertebral margins:
   1. Using hand-held curved high-speed drill, remove the posterior wall of vertebral bodies

   2. Remove the vertebral bodies and disks associated with the trauma

   3. Introduce hemostatic agents, if necessary, to control bleeding
   4. Achieve hemostasis
9. Perform spinal fusion:
   1. Perform reconstruction using titanium mesh, autograft, and/or expandable cages
      • i. Supplement with vertebral body screws and rods if deemed necessary
   2. Place posterior percutaneous screws and rods above and below the level of corpectomy
10. Place chest tube if significant pleural tear occurs (can be removed in 2–3 days)
11. Remove retractor and inspect wound for further bleeding
12. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

Surgical Procedure for Transpedicular Thoracic Corpectomy

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed prone on Jackson Table with all pressure points padded
4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. C-arm fluoroscopy equipment set up in operation zone
7. Make midline incision two levels above and below the level of trauma, preserving the fascia
8. Perform dissection to lateral edge of transverse processes
9. Remove posterior elements and bilateral facets, exposing thecal sac and pedicles
10. Remove pedicles with drill, exposing vertebral body bilaterally
11. Perform corpectomy:
    1. Using Pituitary rongeurs and hand-held curved high-speed drill, remove the posterior wall of vertebral bodies
    2. Remove the vertebral bodies and disks associated with the trauma
    3. Introduce hemostatic agents, if necessary, to control bleeding
    4. Achieve hemostasis
12. Place posterior pedicle screws and rods two levels above and below the level of corpectomy

13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

Pitfalls

• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Pulmonary contusion, atelectasis, pleural effusion, chylothorax, hemothorax
• Lumbar plexus damage, segmental artery damage
• Muscle dissection-related morbidity
• Pleural damage

Prognosis

• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• Pain medications for postsurgical pain
• Catheter placed in bladder and removed 1 to 2 days after surgery
• Physical therapy and occupational therapy will be needed postoperatively as outpatient to regain strength
• External back brace placed after discharge

Symptoms and Signs

• Chest tenderness and ecchymoses
• Paraplegia

• Diminished control of bowel/bladder function

• Moderate/severe back pain
• Respiratory distress
• Difficulty maintaining balance and walking
• Loss of sensation in hands
• Inability to conduct fine motor skills with hands
• Trachea deviates away from side of tension pneumothorax

Surgical Pathology

• Thoracic spine benign/malignant trauma

Diagnostic Modalities

• CT thoracic spine
• MRI thoracic spine
• CT or X-ray chest
• Ultrasonography

Differential Diagnosis

• Blunt trauma (complete and incomplete SCI)
  • Pneumohemothorax, pulmonary contusion, cardiac contusion
• Penetrating trauma (complete and incomplete SCI)
• Wedge/Compression fracture
• Burst fracture
• Chance fracture
• Fracture-dislocation

Treatment Options

• Acute pain control with medications and pain management
• Physical therapy and rehabilitation
• If symptomatic with cord compression:
  • Urgent surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery
  • If poor surgical candidate with poor life expectancy, medical management recommended
  • Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
  • May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal

  • Thoracic Decompression/Fusion Approaches:

• Anterior transthoracic (see ▶Fig. 2.8):
  

  

  • Excellent exposure to anterior thoracic spine, vertebral bodies, intervertebral disks, spinal canal, and nerve roots
  • Posterior elements and contralateral pedicle inaccessible
  • No extensive bone resection or corpectomy
  • Can freely use hemostatic agents in locus of bone removal since lateral fusion is performed
  • Do not perform if there is displacement of posterior bone elements into spinal canal or when posterior penetrating injury exists (unless as part of a combined procedure)
  • T2–T9 is preferentially approached from the right side to avoid injury to heart, aortic arch, and great vessels

  • T10–L2 is preferentially approached from the left side to avoid injury to liver

• Anterior transsternal (see ▶Fig. 2.9):
  

  

  

  • Direct anterior exposure of thoracic spine

  • Excellent for upper thoracic access and cervicothoracic exposure

Indications for Surgical Intervention

• Spinal stenosis
• No improvement after nonoperative therapy (physical therapy, pain management)
• Partial paraplegia
• Residual spinal compression
• Existence of blunt chest trauma or potential hemorrhagic lesions
• Unstable patterns of fracture
• Sufficient disruption of supporting ligaments
• Transthoracic/Transsternal approaches:
  • Partial injury of thoracic cord
  • Anterior compression
  • No intraspinal displacement of posterior bone elements
  • Anterior spinal cord syndrome with partial or complete myelographic spinal block
  • Thoracic disk disease
  • Vertebral osteomyelitis of diskitis

Surgical Procedure for Anterior Transthoracic Decompression/Fusion

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Large bore (16–14 gauge) intravenous (IV) access for blood loss during operation
4. Patient placed in left/right lateral decubitus position with all pressure points padded (depending on whether left or right lateral thoracotomy will be performed)
5. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
6. Intraoperative fluoroscopy used as deemed appropriate
7. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
8. Make posterior incision starting from appropriate level of spine, curving down the line of the rib
9. Divide the latissimus and trapezius muscles:
   1. Divide the rhomboids and both teres as well for T1–T4 exposure
10. Mobilize scapula from chest wall and elevate using scapula retractor
11. Enter chest through intercostal space or the bed of the rib at the level of vertebrae of interest:
    1. Make incision in intercostal space to enter thoracic cavity
    2. Resect proximal rib as bone graft will be used
    3. Mobilize erector spinae superiorly and inferiorly, or divide it transversely at the level of intercostal incision
    4. Retract ribs and scapula using Finochietto or Burford retractor
    5. Retract the intercostal space

12. Expose the vertebrae of interest:

    1. Mobilize superior and posterior hilum (T1–T4)
    2. Mobilize the pulmonary ligament and hilar pleura
    3. Divide the mediastinal pleura posterior to the hilum from the inferior pulmonary vein to just above the mainstem bronchus (T5–T8)
    4. Displace the lung anteriorly and move it out of the way using wet lap pads
    5. Open the mediastinal pleura anterior to the vertebral bodies vertically from the thoracic inlet to the level of the carina. Dissect and mobilize the mediastinal structures. Mobilize the azygos vein with tributaries and the esophagus using blunt and sharp dissection (right thoracotomy), or mobilize the descending thoracic aorta (left thoracotomy) (T1–T8)
    6. Mobilize the thoracic duct anteriorly (T5–T8)
    7. Retract diaphragm using sponge stick. Mobilize posterior attachments of diaphragm. Mobilize posterior mediastinal structures for anterior retraction (T9–T12)
13. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma:
    1. Using Leksell rongeurs and hand-held high-speed air drill, resect the adjacent disk material immediately ventral to the posterior cortical bone of the vertebral bodies
    2. Leave a thin shelf of bone immediately adjacent to posterior longitudinal ligament and dura intact:
       • i. This step avoids the cord falling ventrally, which can result in cord injury during the resection process
    3. Remove adequate portion of subcortical bone, using high-speed air drill, across midline for decompression of ventral cord surface
    4. Remove thin shelf of bone adjacent to posterior longitudinal ligament with rongeur
    5. Control bone bleeding with bone wax
14. Perform posterior thoracic fusion with instrumentation (if necessary, as most often anterior approach is all that is needed):
    1. Place and secure bone graft with cancellous screws to bridge the vertebra above and below the midpoint of the fracture, avoiding injury to vital structures
15. Achieve hemostasis
16. Drain the chest and inspect posterior mediastinum for lymph leak
17. If previously mobilized, reattach the diaphragm to the fascia of the posterior chest wall with sutures
18. Close muscle and skin incisions in appropriate fashion, often with placement of postoperative chest tube that can be removed after 2 to 3 days

Surgical Procedure Anterior Transsternal Decompression/Fusion

1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks
2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist
3. Patient placed in supine position with all pressure points padded
4. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
5. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
6. Make an incision on medial border of right sternocleidomastoid, extending down over manubrium
7. Perform median sternotomy with sternal saw (see ▶Fig. 2.10)
   

   

8. Mobilize sternocleidomastoid laterally and trachea/esophagus medially, exposing anterior cervicothoracic spine
9. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma:
   1. Using Leksell rongeurs and hand-held high-speed drill, remove disk material at the affected level
   2. Remove the thick ligamentum and any bone spurs with Kerrison rongeurs with careful dissection beneath the ligament to ensure no adhesions exist to dura mater below and thus avoiding CSF leak

   3. Perform complete decompression of anterior cord with Kerrison rongeurs as needed for appropriate decompression of nerve roots

   4. Irrigate surgical site
10. Perform spinal fusion with instrumentation (if necessary, most often not needed):
    1. Perform reconstruction with expandable cage and autograft
    2. Perform screw-plate fixation
11. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion, often with placement of postoperative Jackson-Pratt drains:
    1. Achieve closure of sternum with sternal wires

Pitfalls

• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• Postoperative weakness or numbness or continued pain
• Postoperative wound infection
• Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life
• Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Injury to artery of Adamkiewicz (generally originating from the left T8–L1) resulting in cord ischemia, radicular arteries (typically during dissection around intervertebral foramina), thoracic duct, chylothorax, and/or esophagus (from transthoracic approach)
• Vascular complications
• Atelectasis and pneumonia
• Hemothorax and empyema (managed with drainage and antibiotics)
• Injury to carotid sheath, trachea, esophagus, recurrent laryngeal nerves, great vessels, vertebral arteries, and/or sympathetic trunk (from transsternal approach)

Prognosis

• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities

• Pain medications for postsurgical pain

• Catheter placed in bladder and removed 1 to 2 days after surgery
• Physical therapy and occupational therapy will be needed postoperatively as outpatient to regain strength
• Brace (i.e., Jewett or Taylor type) placed after discharge (patient can be mobilized after 2 to 3 weeks of transthoracic decompression/fusion operation)

Symptoms and Signs

• Moderate back pain
• Muscle weakness and reduction of mobility from pain (as opposed to from nerve impairment, which typically requires emergent treatment, particularly if it relates to bladder function)
• Pain and discomfort derived from consistent nerve irritation
• Difficulty maintaining balance and walking
• Tingling numbness in arms/legs/hands
• Abnormal spinal curvature
• Spinal instability

Surgical Pathology

• Thoracic spine benign/malignant trauma
• Thoracic spine benign/malignant tumor
• Thoracic vascular benign/malignant lesion

Diagnostic Modalities

• Clinical examination
• CT of thoracic spine with and without contrast
• MRI of thoracic spine with and without contrast
• CT or X-ray chest
• Ultrasonography
• Angiography
• PET scan (search for tumor foci)
• Biopsy (determine severity of tumor and possible type of cancer)

Differential Diagnosis

• Thoracic disk herniation
• Spinal stenosis (narrowing of the spine)

• Scoliosis

• Bulging thoracic disk
• Presence of bony spurs
• Tumor:
  • Metastatic (malignant, requiring emergent treatment)
  • Primary (benign or malignant)
• Vascular lesion (typically requiring supplemental embolization):
  • Fibromuscular dysplasia (FMD)
  • Spinal arteriovenous malformation (AVM)
  • Spinal dural arteriovenous fistula (AVF)
  • Thoracic outlet syndrome (TOS)
• Vertebral fracture:
  • Blunt trauma (incomplete SCI)
  • Penetrating trauma (incomplete SCI)
  • Wedge/compression fracture
  • Burst fracture
  • Chance fracture
  • Fracture-dislocation