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. C-arm fluoroscopy equipment set up in operation zone
7. Make midline incision two levels above and below the level of trauma, preserving the fascia
8. Perform dissection to lateral edge of transverse processes
9. Remove posterior elements and bilateral facets, exposing thecal sac and pedicles
10. Remove pedicles with drill, exposing vertebral body bilaterally
11. Perform corpectomy:
a. Using Pituitary rongeurs and 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
12. Place posterior pedicle screws and rods two levels above and below the level of corpectomy
13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion
Pitfalls
• Reduction in range of motion and mobility of fused spinal segments
• Intraoperative CSF leak
• Blood clot (deep vein thrombosis, or more severe pulmonary embolism)
• Damage to spinal nerves and/or cord
• 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
• Loss of sensation
• Progressive kyphosis
• Residual spinal compression
• Problems with bowel/bladder control
• Pulmonary contusion, atelectasis, pleural effusion, chylothorax, hemothorax
• Lumbar plexus damage, segmental artery damage
• Muscle dissection-related morbidity
• Pleural damage
Prognosis
• Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities
• Pain medications for postsurgical pain
• Catheter placed in bladder and removed 1 to 2 days after surgery
• Physical therapy and occupational therapy will be needed postoperatively as outpatient to regain strength
• External back brace placed after discharge
2.1.3 Transthoracic Approaches for Decompression and Fusion/Transsternal Approaches for Decompression and 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
• Trachea deviates away from side of tension pneumothorax
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 SCI)
– Pneumohemothorax, pulmonary contusion, cardiac contusion
• Penetrating trauma (complete and incomplete SCI)
• Wedge/Compression fracture
• Burst fracture
• Chance fracture
• Fracture-dislocation
Treatment Options
• Acute pain control with medications and pain management
• Physical therapy and rehabilitation
• If symptomatic with cord compression:
– Urgent surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery
– If poor surgical candidate with poor life expectancy, medical management recommended
– Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization
– May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing
