Transthoracic Approach

47 Transthoracic Approach

Brian Kwon and David H. Kim

I. Key Points

– The transthoracic approach places the major vessels of the thoracic cavity at risk and threatens injury to the lungs and heart.

– An injury to the spinal cord at this level may result in paraplegia.

– Mark levels carefully, and make frequent use of radiographs or fluoroscopy.

II. Indications

– Thoracic myelopathy resulting from spinal cord compression¹

• Herniated nucleus pulposus (HNP), stenosis, or ossification of the posterior longitudinal ligament (OPLL)

• Cervical and lumbar pathology ruled out

– Infections

• Discitis or osteomyelitis

– Trauma

– Tumors

– Not for axial thoracic spine pain

III. Technique

– Position lateral decubitus.²

– Alert anesthesia staff to use double-lumen endotracheal tube so that deflation of lung can be performed if necessary.

– Confirm level(s)

• If using open technique, manually palpate ribs (enlist help of thoracic surgeon).

• Live fluoroscopy: use fixed markers, such as spinal needles placed into facet joints (to mark pedicles or ribs).

• Count ribs on anteroposterior (AP) view (take note of males with missing twelfth rib).

• Lower thoracic vertebrae can be counted from sacrum.

• Confirm as many times as necessary (thoracic vertebrae look alike!).

– Make skin incision over disc or vertebral body based on imaging.

• Semilinear or linear

– Upper thoracic discs (T2 to T5) may require mobilization of scapula.

• Cut latissimus dorsi, serratus anterior, and teres major muscles midsubstance—allows scapula to be deflected cephalad and dorsally.

– For lower thoracic discs (T9 to T12), hemidiaphragm may need to be released from the vertebrae.

– Resect rib for visualization (Fig. 47.1A–C).

• Preserve nerve root if possible; otherwise sacrifice by ligating a segment of nerve to prevent painful neuromas. Tell patient about post-op paresthesia.

• Excellent source of structural or morselized autograft

– Can get to discs and vertebrae via transpleural or retropleural approach

• Incise parietal pleura.

• Lifts off lateral side of vertebral body

– Deflate lung.

– Ligate segmental vessels close to azygous vein/aorta.

• Necessary for corpectomies

– Follow nerve root into foramen.

– Rib head resection is necessary above T9-T10.³

• May not be necessary at T11 or T12

• Helpful to see pedicle, the primary landmark for performing discectomy

Fig. 47.1 (A,B) A window is made through the parietal pleura over the vertebral body. (C) The corpectomy is performed all the way to the contralateral pedicle. (From Anterior thoracic decompression. In: Spine Surgery: Tricks of the Trade 2nd ed. Vaccarro AR, Albert TJ, eds. Thieme; pg. 108, Figs. 31.2, 31.3.)

IV. Complications

– Spinal cord injury

• Spinal neuromonitoring necessary

• Direct spinal cord trauma

• Vascular insufficiency

Note ligation of multiple segmental vessels for multilevel surgery.