(expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal
– Thoracic Decompression/Fusion Approaches:
• Anterior transthoracic (see ▶Fig. 2.8):
– Excellent exposure to anterior thoracic spine, vertebral bodies, intervertebral disks, spinal canal, and nerve roots
– Posterior elements and contralateral pedicle inaccessible
– No extensive bone resection or corpectomy
– Can freely use hemostatic agents in locus of bone removal since lateral fusion is performed
– Do not perform if there is displacement of posterior bone elements into spinal canal or when posterior penetrating injury exists (unless as part of a combined procedure)
– T2–T9 is preferentially approached from the right side to avoid injury to heart, aortic arch, and great vessels
Fig. 2.8 Illustration of different approaches to the thoracic spine. The transsternal approach allows anterior access to the upper thoracic. (Source: Thoracic spine. In: Vialle L, ed. AOSpine Masters Series, Volume 1: Metastatic Spinal Tumors. 1st ed. Thieme; 2014).
– T10–L2 is preferentially approached from the left side to avoid injury to liver
• Anterior transsternal (see ▶Fig. 2.9):
– Direct anterior exposure of thoracic spine
– Excellent for upper thoracic access and cervicothoracic exposure
Indications for Surgical Intervention
• Spinal stenosis
• No improvement after nonoperative therapy (physical therapy, pain management)
• Partial paraplegia
• Residual spinal compression
• Existence of blunt chest trauma or potential hemorrhagic lesions
• Unstable patterns of fracture
• Sufficient disruption of supporting ligaments
• Transthoracic/Transsternal approaches:
– Partial injury of thoracic cord
– Anterior compression
– No intraspinal displacement of posterior bone elements
– Anterior spinal cord syndrome with partial or complete myelographic spinal block
– Thoracic disk disease
– Vertebral osteomyelitis of diskitis
Surgical Procedure for Anterior Transthoracic Decompression/Fusion
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. Large bore (16–14 gauge) intravenous (IV) access for blood loss during operation
4. Patient placed in left/right lateral decubitus position with all pressure points padded (depending on whether left or right lateral thoracotomy will be performed)
5. Neuromonitoring may be required to monitor nerves (if necessary and indicated)
6. Intraoperative fluoroscopy used as deemed appropriate
Fig. 2.9 (a) Patient orientation for the anterolateral transthoracic approach to thoracic decompression and fusion. (b) Surgical steps for anterolateral transthoracic approach, from incision and retractor placement to muscular dissection, rib visualization, electrocautery, and rib resection. (c) Following initial thoracotomy, either retropleural or transpleural approaches are viable. This image demonstrates the next steps in a retropleural approach. (d) Intraoperative image of a lateral transthoracic approach to a thoracic vertebrectomy and fusion with instrumentation. (Source: Open lateral transthoracic approach. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).
7. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed
8. Make posterior incision starting from appropriate level of spine, curving down the line of the rib
9. Divide the latissimus and trapezius muscles:
a. Divide the rhomboids and both teres as well for T1–T4 exposure
10. Mobilize scapula from chest wall and elevate using scapula retractor
11. Enter chest through intercostal space or the bed of the rib at the level of vertebrae of interest:
a. Make incision in intercostal space to enter thoracic cavity
b. Resect proximal rib as bone graft will be used
c. Mobilize erector spinae superiorly and inferiorly, or divide it transversely at the level of intercostal incision
d. Retract ribs and scapula using Finochietto or Burford retractor
e. Retract the intercostal space
12. Expose the vertebrae of interest:
a. Mobilize superior and posterior hilum (T1–T4)
b. Mobilize the pulmonary ligament and hilar pleura
c. Divide the mediastinal pleura posterior to the hilum from the inferior pulmonary vein to just above the mainstem bronchus (T5–T8)
d. Displace the lung anteriorly and move it out of the way using wet lap pads
e. Open the mediastinal pleura anterior to the vertebral bodies vertically from the thoracic inlet to the level of the carina. Dissect and mobilize the mediastinal structures. Mobilize the azygos vein with tributaries and the esophagus using blunt and sharp dissection (right thoracotomy), or mobilize the descending thoracic aorta (left thoracotomy) (T1–T8)
