Corpectomy for vertebral body metastasis restores thoracic spine alignment and stability, in addition to providing decompression in the case of spinal cord compression. In addition, optimal gross debulking of tumor mass can also be performed in preparation for adjuvant treatment and lastly, can provide tissue for diagnosis in the case of an undiagnosed metastasis.

Advantages of the transthoracic approach include direct anterior decompression of the spinal cord, reduction of tumor burden, restoration of spinal column alignment, and possibly improving fusion rates across the decompressed segment owing to larger surface area available for engraftment.

Disadvantages include the risks of injuring major vascular structures, thoracic duct, and sympathetic chain. Risks also include pneumothorax, hemothorax, chylothorax, pulmonary contusions, and post-thoracotomy pain. There is increased risk for thromboembolic complications with delayed postoperative mobilization. Other potential complications include injury to the spinal cord directly or from vascular interruption of the segmental arterial supply, both of which are rare. ¹

Posterior element involvement with tumor pathology, sometimes contributing to the stenosis, would mandate a combined posterior–posterolateral approach in addition for decompression with or without transpedicular instrumentation.

32.2 Patient Selection

Patients with good systematic control of the primary tumor, an expected life span of at least 3 to 6 months, and tumor limited to one or two thoracic vertebral bodies are candidates for this procedure. Significant spinal cord compression, spinal instability, and progressive neurologic deficits are considered indications for expedited surgical intervention. This option, however, must be weighed against radiation or Stereotactic Radiosurgery (SRS) in the case of the neurologically intact patient with thoracic vertebral body metastasis and no fractures or deformity or with intractable spinal pain. ²

Contraindications to transthoracic vertebrectomy include patients with chronic pulmonary disease with suboptimal lung function, involvement by the tumor of one or both chest walls, and for systemic prognosis of the primary tumor of less than 3 months.

32.3 Preoperative Preparation

Preoperative preparation for a patient who is to undergo a thoracotomy includes appropriate counseling of the patient and family as to the nature of the disease and the goals of the procedure. Detailed imaging studies are necessary for appropriate planning, and these may include any of the following: magnetic resonance imaging (MRI) scan of the thoracic spine with and without contrast, computed tomography (CT) scans with bone windows of the thoracic spine with sagittal and coronal reconstructions, or CT myelography. Pulmonary function testing is also often indicated.

Decadron or Solu-Medrol should be administered intravenously in all patients with spinal canal compromise, in addition to preoperative antibiotic prophylaxis. Finally, the availability of long-handle instrumentation to carry out the procedure is verified before the start of the operation.

32.4 Operative Procedure

32.4.1 Anesthesia

Double-lumen intubation is rarely necessary because the lung can be gently retracted without deflation to provide sufficient access to the posterior chest wall and vertebral bodies. If the patient is neurologically intact at baseline, intraoperative neurophysiological monitoring may be performed.

32.4.2 Positioning

Positioning is probably one of the most important steps in ensuring smooth progress of the operation. Patients are placed in the lateral decubitus position with the side of predominant tumor involvement facing up. If the tumor involves the body in a symmetric fashion, a left-sided approach (right lateral decubitus positioning) is recommended to facilitate easy and early dissection of the aorta away from the vertebral body. The use of a Jackson lateral table (Orthopedic Systems, Inc., Union City, California) is highly recommended. Extreme care should be taken that the patient is exactly aligned in the lateral position to assist in proper orientation of anatomical landmarks. It is recommended that anteroposterior (AP) and lateral fluoroscopy be used in this situation to ensure marking of the correct operative level and also to confirm placement of the patient in a true lateral decubitus position. Fixating the arms in front of and slightly above the patient maximizes access to the lateral thoracic wall. Appropriate measures are taken to pad pressure points such as the placement of an axillary roll, keeping the hips and knees slightly bent, and placing a pillow between the knees.

32.4.3 Surgical Technique

Thoracotomy and access to the spinal column may be performed by the spinal surgeon alone or with the help of a thoracic surgeon, depending on the comfort level of the individual surgeon in performing this procedure. The surgeon can stand anterior or posterior to the patient, although the former is generally easier.

The skin incision should approximately parallel the ribs from the midaxillary line laterally and curving posteriorly toward the midline. Subcutaneous bleeding points are controlled. Muscle dissection of the latissimus dorsi and serratus anterior is performed to expose the ribs. It is a good working policy to expose the ribs corresponding to the level of the involved pedicle as well as the ribs above and below. The rib at the involved level must be removed, but additional ribs can also be excised to both yield potential bone graft material and to minimize rib retraction ( ▶ Fig. 32.1).

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