Extended posterior circumferential approach to thoracic and thoracolumbar spine.

OBJECTIVE

Posterior spinal surgical approach to achieve a retropleural/ retroperitoneal corpectomy with circumferential spinal cord decompression following subtotal vertebrectomy, posterior instrumentation and interbody spacer placement under compression as well as kyphosis correction with spinal column shortening.

INDICATIONS

Infective, traumatic or neoplastic lesions of the vertebral body that lead to vertebral body destruction, instability and neurologic deficit. Need for immediate postoperative loading stability to permit ambulation and rehabilitation.

CONTRAINDICATIONS

Multiple contiguous vertebral disease. Instances where the graft bed preparation and stable interbody spacer placement may be suboptimal due to the limited access offered by this approach.

SURGICAL TECHNIQUE

Posterior midline exposure two to three levels above and below lesion, dissection at level of lesion extended bilaterally exposing transverse processes, costotransverse articulations and medial 5-8 cm of ribs. Placement of pedicle screws at proximal and distal levels; in case of osteoporotic bone augment screws with cement. Bilateral costotransversectomy at one or more levels to drain prevertebral abscess and expose diseased vertebral bodies. After temporary stabilization, laminectomy and corpectomy are carried out from both sides to permit circumferential decompression. A temporary rod is placed on the contralateral side in the position of deformity to prevent any inadvertent translatory movements during the subsequent surgical step. After completion of the procedure an appropriately contoured rod is placed. The interbody spacer is positioned. Kyphosis correction by spinal column shortening and compression along the posterior implant is performed.

POSTOPERATIVE MANAGEMENT

By day 3 ambulation and rehabilitation are initiated.

RESULTS

22 patients were operated in the last 8 years with tuberculosis (18 patients - twelve paraplegics), osteoporotic fractures (two patients), congenital kyphosis and Ewing's sarcoma (one patient each). All patients were followed up at 3, 6, 9, and 12 months and then annually. At each followup, clinical, hematologic and radiologic parameters were assessed. All interbody grafts and cages incorporated without significant loss of correction. Ten of twelve tuberculous paraplegics recovered. No patient had postoperative infection, interbody spacer- or implant-related complications.