entry
10. Identify the carotid pulse and retract carotid sheath laterally
11. Cut through the pretracheal fascia
12. Localize superior and inferior thyroid arteries, tying them off if necessary
13. Split longus colli muscles and anterior longitudinal ligament
14. Subperiosteally dissect to identify anterior vertebral body, utilizing retractors and an operating microscope
15. Retract longus colli muscles laterally, forming a deep plane
16. Dissect thin layer of fibrous tissue covering vertebra away from disk space
17. Once the bone 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
18. Perform the diskectomy over segments needed based on preoperative imaging of levels that are compressed due to tumor:
a. Using Leksell rongeurs and hand-held high-speed drill, remove the appropriate disk(s) or perform a complete corpectomy for added exposure
b. Identify location of tumor and resect tumor as needed if epidural or within the spinal canal/cord (with care not to injure the vertebral artery)
i. Use operative microscope and open the spinal cord dura midline with 11 blade and tack up the dural leaflets with suture (see ▶Fig. 1.24)
ii. If tumor is intradural and extramedullary, the tumor can then be resected carefully with microdissection technique without cord injury (neuromonitoring needed in these cases)
iii. If tumor is intradural and intramedullary, with microdissection technique the cord must be entered midline and the tumor must be identified and resected starting centrally first, then around the edges (neuromonitoring needed in these cases)
19. After appropriate tumor resection, there may be need for additional stabilization to prevent kyphosis if the resection caused multiple segment decompression. Therefore, instrumentation with anterior cage and plate can be performed.
20. 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
• Loss of neck mobility (minimal, unless fusion extended to occiput and C1)
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
Fig. 1.24 (a–c) Intraoperative image of surgical exposure for cervical midline intramedullary tumor resection. A laminoplasty was performed beforehand to visualize the dura. (Source: Operative considerations and surgical pearls. In: Baaj A, Kakaria U, Kim H, eds. Surgery of the Thoracic Spine: Principles and Techniques. 1st ed. Thieme; 2019).
• 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
• Injury to trachea or esophagus (from anterior approach)
• Injury to vertebral or carotid arteries
Prognosis
• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• PT and OT will be needed postoperatively, immediately and as outpatient to regain strength
• Brace/Collar is used for 8 weeks after discharge to immobilize to increase rate of healing
Bibliography
Rangel-Castilla L, Russin JJ, Zaidi HA, et al. Contemporary management of spinal AVFs and AVMs: lessons learned from 110 cases. Neurosurg Focus 2014;37(3):E14
2 Thoracic
Christ Ordookhanian and Paul E. Kaloostian
2.1 Trauma
2.1.1 Thoracic Decompression/Thoracic Fusion
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
