Indications
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Unstable burst fractures with anterior spinal cord compression
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Primary or metastatic vertebral tumors
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Osteomyelitis or diskitis
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Severe spinal deformities
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Sequestered thoracic disk herniation with migration dorsal to the vertebral body, leading to spinal cord impingement and neurologic deficits
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Failed previous stabilization surgery (anterior or posterior) resulting in pseudarthrosis or instability or both
Contraindications
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Limited life expectancy (<3 months)—protracted recovery period and hospitalization after thoracotomy and corpectomy may not be justified for a patient with a short life span
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Medical comorbidities such as severe pulmonary or cardiac disease, which may prohibit a safe thoracotomy or prevent successful weaning from the ventilator postoperatively
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Extensive disease involving several spinal levels in which case full exposure through the anterior approach may be not feasible
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Posterior tension band injury and translational or rotational injury without the explicit intent of a concomitant posterior procedure
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Severe osteopenia or osteoporosis—should include additional posterior stabilization
Planning and positioning
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Preoperative work-up should include multiple imaging modalities such as x-rays and magnetic resonance imaging (MRI) that include the entire thoracic and lumbosacral spine. Radiographs must be correlated with MRI before surgery to scrutinize for transitional levels and other bony anomalies; this allows the surgeon to identify the exact level of pathology for excision or decompression intraoperatively and minimizes the risk for wrong site surgery.
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Preoperative angiography may be considered to identify the artery of Adamkiewicz and to evaluate the vascular flow to a tumor and allow for embolization when appropriate.
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The patient is usually positioned in the right lateral decubitus position, and a left-sided thoracotomy is performed for access below T5. The primary reason for this approach is the ease of mobilizing the aorta versus the vena cava and the absence of the liver on the left side. The location of the pathology and the characteristics of the surrounding vascular anatomy can alter the side of the approach, however.
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The upper thoracic spine (T1-3) is best approached through a midline sternotomy or a posterior lateral extracavitary approach. The lower thoracic spine (T11 and T12) often necessitates a combined thoracoabdominal approach.
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Double-lumen endobronchial intubation is often preferred because it allows for selective lung ventilation. The deflated lung can be easily retracted away from the operative field.
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The patient should be placed in the lateral decubitus position by the surgeon. A beanbag can be deflated in place to help ensure that the patient remains at 90 degrees to the floor throughout the case.
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The arms can be positioned on a double arm board with an axillary role under the dependent arm to reduce the risk of a brachial plexus palsy. Both elbows must be well padded (protecting the ulnar nerve) and gently flexed up and away from the surgical field.
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The lower leg is positioned relatively straight on a pillow (protecting the peroneal nerve). The upper leg is also positioned on a pillow with the knee and the hip flexed and taped down so as to relax the ipsilateral psoas muscle for easier retraction during the case.
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The desired level should be placed on the break of the bed, and the table should be flexed for optimal access to the intercostal interval.
Figure 65-1:
The patient is positioned in the right lateral decubitus position with the elbows padded and slightly flexed out of the way. An axillary roll is placed one hand’s-breadth caudal to the dependent axilla to minimize brachial plexus injury.
Procedure
