and Techniques. 1st ed. Thieme; 2019).
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
Fig. 2.7 Surgical trajectories to addressing a thoracic disk herniation (image demonstrates giant calcified herniation in central canal). Line A is a costotransversectomy approach, Line B is a lateral transthoracic/retropleural approach, and Line C is an anterior transthoracic approach. Both transthoracic approaches do not require cord retraction. (Source: Surgical management. In: Baaj A, Kakaria U, Kim H, eds. Surgery of the Thoracic Spine: Principles and Techniques. 1st ed. Thieme; 2019).
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:
a. Perform rib resection
b. Incise endothoracic fascia, dissecting off the parietal pleura
c. 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:
a. Using hand-held curved high-speed drill, remove the posterior wall of vertebral bodies
b. Remove the vertebral bodies and disks associated with the trauma
c. Introduce hemostatic agents, if necessary, to control bleeding
d. Achieve hemostasis
11. Perform spinal fusion
a. Perform reconstruction with expandable cage and autograft
b. Perform ventrolateral screw-plate fixation
c. 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:
a. Using hand-held curved high-speed drill, remove the posterior wall of vertebral bodies
b. Remove the vertebral bodies and disks associated with the trauma
c. Introduce hemostatic agents, if necessary, to control bleeding
d. Achieve hemostasis
9. Perform spinal fusion:
a. Perform reconstruction using titanium mesh, autograft, and/or expandable cages
i. Supplement with vertebral body screws and rods if deemed necessary
b. 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
