Management considerations and strategies to avoid complications associated with the thoracoscopic approach for corpectomy

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The thoracoscopic approach to the anterior spine is a practical and valuable means of approaching ventral spinal lesions but demands advanced technical skills and fine hand-eye coordination that is usually acquired with experience. A mutual understanding of all the ventilatory and surgical steps allows for an organized orchestration between the anesthesiologist and surgeon, which ultimately helps minimize potential complications. Despite a concerted effort by all involved to avoid risks, thoracoscopic surgery is associated with complications for which the surgical team should be cognizant. In this paper, the authors detail the operative technique of vertebral corpectomy and interbody fusion via the thoracoscopic approach for the treatment of ventral spinal pathology involving the thoracic and lower lumbar spine, discuss complications known to occur with the thoracoscopic approach, and present means to help avoid them.

The thoracoscopic approach to the anterior spine is a practical and valuable means of approaching ventral spinal lesions but demands advanced technical skills and fine hand-eye coordination that is usually acquired with experience. A mutual understanding of all the ventilatory and surgical steps allows for an organized orchestration between the anesthesiologist and surgeon, which ultimately helps minimize potential complications. Despite a concerted effort by all involved to avoid risks, thoracoscopic surgery is associated with complications for which the surgical team should be cognizant. In this paper, the authors detail the operative technique of vertebral corpectomy and interbody fusion via the thoracoscopic approach for the treatment of ventral spinal pathology involving the thoracic and lower lumbar spine, discuss complications known to occur with the thoracoscopic approach, and present means to help avoid them.

The use of the thoracoscopic approach to the thoracic and upper lumbar spine for anterior corpectomy has increased since its introduction in the early 1990s. Jacobaeus10 was the first to describe the use of the thoracoscopic approach to the chest in 1910 (Fig. 1). By the late 1980s, cardiothoracic surgeons had developed the video-assisted thoracoscopy, which attracted the attention of spine surgeons Lewis and Obenchain, who ingeniously incorporated this technique to target ventral spinal disease.14,16 Compared with its predecessor (open thoracotomy), the thoracoscopic approach affords better cosmetic results, less postoperative pain, earlier mobilization, shorter hospital stays, and lower treatment costs.8,14 In addition, the commonly encountered perioperative morbidities associated with open thoracotomy, such as pneumothorax, pleural effusions, chylothorax, pneumonia, and intercostal neuralgia, are substantially reduced with the endoscopic method.8 Moreover, thoracoscopy avoids shoulder girdle dysfunction, which was commonly encountered with the open approach because of the need for large incisions and excessive and prolonged rib cage retraction.7

Fig. 1.
Fig. 1.

H. C. Jacobaeus of Stockholm using an early cystoscope to peer through a patient's pleural cavity. Reprinted with permission from Archives of Surgery 139 (1):100–112, 2004. Copyright 2004 American Medical Association. All rights reserved.

Despite the success of the thoracoscopic approach in reducing many of the problems associated with open thoracotomy, it is not without complications. Since thoracoscopic spine surgery is a challenging undertaking that calls on the surgeon to have excellent hand-eye coordination in an enclosed space where depth perception is hampered, complications can result from a lack of experience. There are also unavoidable complications that can arise in the hands of even the best-trained surgeons, and some complications are associated with anterior approaches in general and are not unique to thoracoscopic surgery. In this paper, we delineate the operative technique of thoracoscopic corpectomy and interbody fusion of the lower thoracic and upper lumbar spine in a step-by-step manner and emphasize its risks and present suggestions on how to avoid them.

Operative Technique

Proper operative technique starts with ensuring correct patient positioning and operative staff setup to afford a more efficient and comfortable working environment. The operating room should be arranged in a way that allows for effortless handling of instruments, comfortable working distance, and simple screen visualization for the surgeons while providing the anesthesiologist with easy and unhindered access to the patient's airway (Fig. 2). Typically, the room is set up with the main surgeon standing directly behind the patient and the operative site. The assistant operating the endoscope stands to the right of the main surgeon. The scrub nurse stands across from the main surgeon facing the patient. A video monitor displaying the endoscopic image is placed in front of the patient across from the main surgeon, and, when available, a second video monitor is placed behind the patient across from the scrub nurse or second assistant. A fluoroscopic monitor is placed beside the endoscopic monitor across from the main surgeon.

Fig. 2.
Fig. 2.

Ideal operative setup for a thoracoscopic approach to the spine. The anesthesiologist (A) stands at the patient's head. For a left-sided approach, the main surgeon (S1) stands behind the patient. The first assistant (S2) stands to the right of the main surgeon and operates the endoscope while the scrub nurse (SN) stands opposite the surgeons. Video monitors (M1 and M2) display the endoscopic image.

Highly specialized minimally invasive thoracoscopic instruments with appropriate length for easy maneuverability and nonreflective surfaces for thoracoscopic surgery have been developed. In addition, minimally invasive thoracoscopic instrumentation has been specifically developed for anterior column stabilization and preservation of spinal alignment after a corpectomy. The MACSTL anterolateral thoracolumbar spinal implant (Aesculap) was specifically designed for this purpose. It consists of a rigid plate that sits along the anterolateral aspect of the vertebra spanning 1 segment above and below the fractured level, with a ventral hole for an anterior stabilizing screw and a dorsal hole for a posterior polyaxial screw at the ends of the plate. The screws are implanted into the normal vertebrae below and above the diseased level. The posterior polyaxial screws are placed first, starting with the caudal end, to maintain adequate working visibility. The biomechanical properties of this plating system have been tested in single- and multilevel, partial and full corpectomy models with and without posterior ligamentous injury, and its efficiency has been demonstrated in many case series.11,12,20–23

After the patient has been positioned properly, the portals have been placed, and the diaphragmatic incision has been made to expose the pathological vertebra as detailed in the following sections of the paper, the screws are placed in preparation for the corpectomy and final interbody construct. Before the polyaxial screw is placed for the MACS-TL plating system, a short K-wire is inserted into the level caudal to the fractured vertebra 10 mm anterior to the spinal canal and 10 mm away from the superior endplate in the upper third of the vertebral body (Fig. 3A). It is inserted under fluoroscopic guidance perpendicular to the cortical surface with a radiolucent targeting device that has concentric rings that align once a perpendicular position is achieved. A mallet is used to impact the device attached to the K-wire until a depth of 25 mm is reached. Next, a cannulated decorticator is inserted over the K-wire to perforate the cortical surface and allow for subsequent screw placement. The polyaxial screw is inserted into a specialized polyaxial clamp. This assembly is then attached to a centralizer tube and inserted over the K-wire (Fig. 3B and C). The clamp is positioned so that the hole for the anterior stabilizing screw is ventral to the hole for the polyaxial screw. The polyaxial screw is then slowly inserted over the K-wire, which is removed after the screw is past the cortical surface. The screw is then slowly advanced to its full depth. The cranial polyaxial screw is inserted in a similar fashion. The anterior and posterior edges of the clamps help define the anteromedial and posterolateral extent of the corpectomy. The superior and inferior boundaries of the corpectomy are defined by intervertebral disc spaces above and below the diseased level. An anulectomy of the superior and inferior discs is then performed, followed by disc resection with the use of thoracoscopic rongeurs. As for the corpectomy, a thoracoscopic rongeur is used to remove the central bone. The space left behind after the bone resection is molded into a rectangular fashion with the use of osteotomes to accommodate the subsequent interbody cage. The final depth of the corpectomy is confirmed using fluoroscopy (Fig. 4).

Fig. 3.
Fig. 3.

Intraoperative photographs showing placement of the plating system. The K-wire is inserted into the level caudal to the fractured vertebra 10 mm anterior to the spinal canal and 10 mm away from superior endplate in the upper third of the vertebral body (A). The polyaxial screw–clamp assembly is then attached to a centralizer tube and inserted over the K-wire (B and C). After placement of the polyaxial screw–clamp assembly in the upper vertebral body superior to the fracture level and after completing the corpectomy and placement of an interbody cage with morcellized bone, the anterolateral interbody plate is placed (D and E). Finally, fixation nuts are placed on the polyaxial heads and tightened with a torque device (F).

Fig. 4.
Fig. 4.

Anteroposterior upright radiograph of the thoracolumbar junction showing a T-12 interbody cage following a T-12 corpectomy with lateral vertebral body plate and screw fixation. Reprinted with permission. Copyright Department of Neurosurgery, University of Utah.

For retropulsed bone or spinal disease extending past the posterior border of the vertebral body into the spinal canal, the spinal canal is decompressed. This may be done by resecting the pedicle on the involved end. The pedicle is accessed by following the rib head to its attachment to the anterolateral spine and resected using a high-speed drill. Removal of the proximal 2 cm of the rib exposes the underlying pedicle, which may be felt with a blunt hook. The pedicle is then resected using a high-speed drill and rongeurs to decompress the neural foramen and provide access to the dorsal epidural space to remove any retropulsed bone fragments or tumor.

For the interbody implant, we use an expandable titanium cage with appropriate dimensions based on careful measurements obtained using a caliper. At this stage, the operative portal is replaced with an expandable speculum to allow for ease of access when passing the expandable cage into the interbody cavity. Morcellized bone autograft is used in and around the cage to help promote fusion. The anterolateral interbody plate is placed after the interbody cage (Fig. 3D and E). The plate length is determined by measuring the distance between the screw heads on either end of the vertebral body and adding 30 mm. The plate is first placed on the centralizer and caudal screw–clamp assembly and then placed onto the cranial assembly. The posterior polyaxial screws are left slightly loose at first for easy plate manipulation to help facilitate plate positioning. The fixation nuts are then placed on the polyaxial heads and tightened with a torque device (Fig. 3F). Anterior stabilizing screws are inserted through the ventral hole after the bone is decorticated. The anterior screws should be 5 mm shorter than the posterior polyaxial screws to prevent contact of the 2 screws. Finally, lateral and anteroposterior fluoroscopic images help verify the final construct position.

Complications

The incidence of complications with thoracoscopic surgery is generally low and may be avoided with careful perioperative planning and consideration for the potential risks involved with every step from intubation to closure and extubation (Table 1).

TABLE 1:

Complications of thoracoscopic surgery and potential avoidance strategies*

Complication TypeComplicationsSuggested Complication Avoidance Strategies
anesthesiaincorrect ETT placementpreop PFT & ABG; CPAP on nonventilated lung; postop respiratory therapy; recheck position of double-lumen ETT w/ bronchoscope prior to op & any time oxygen saturation drops below 90%; ensure adequate inflation of bronchial & tracheal cuffs
inaccurate ETT size
over- or underinflation of bronchial cuff
CO2 embolism
pneumothorax
ventilation-perfusion mismatch
acidemia
accumulation of secretions
positioningbrachial plexopathyproper padding on all pressure points; U-shaped gel foam between legs
foot drop
pressure ulcers
muscle breakdown
rhabdomyolysis
instrumentsinjury to lungsdigital sweeping of portal site prior to port placement; fluoroscopic projection of op site onto skin for target portal incision & planning of remaining portal sites; initial placement of endoscopic port farthest away from diaphragm; K-wire insertion prior to screw placement; lunar diaphragmatic incision; adequate time for lung reinflation & evacuation of entrapped air prior to removal of portals
injury to large vessels
diaphragmatic injury
breakage of tools w/in chest cavity
skin burns
diaphragmatic hernia
pneumomediastinum & pneumoperitoneum
subcutaneous emphysema
hemodynamicexcessive intraop bleedinglimit use of suction when able; intraop hypotensive anesthesia; ensure adequate hemostasis; preop screening for primary lung disease; careful handling of instruments; limit retraction on spleen; experience (reduces op time)
prolonged op time
abundant use of suction
splenic rupture
tension pneumothorax
* ABG = arterial blood gas; CPAP = continuous positive airway pressure; ETT = endotracheal tube; PFT = pulmonary function test.

Pulmonary and Anesthesia-Related Complications

Single-lung ventilation is of crucial importance to the success of thoracoscopic spine surgery. Whereas in open, mini-open, or retropleural approaches, the ventilated lung can be retracted to expand the operative field, it is not possible to do so with thoracoscopy. In addition, the operating times and thus the length of time the lung is excluded from ventilation are frequently longer than for other thoracoscopic procedures.

Single-lung ventilation with a double-lumen endotracheal tube ventilating the contralateral lung while collapsing the ipsilateral one carries risks of which the operating team should be aware. For instance, incorrect tube placement, inaccurate tube size, and over- or underinflation of the bronchial cuff lodged in the mainstem bronchus of the ipsilateral lung can lead to air leaks into the operated lung. Inadvertent injury to a vein during positive-pressure insufflations can lead to carbon dioxide embolism with potentially fatal cardiac and neurological sequelae.18 Preoperative imaging, a detailed physical examination, and medical history can reveal important information about the patient's fitness for this surgery. For instance, the presence of blebs on a CT scan of the chest or a known history of a medical condition that increases the patient's risk of developing pneumothorax, such as chronic obstructive pulmonary disease or Marfan syndrome, can alert the anesthesiologist to the patient's heightened chance of experiencing such a complication. In the latter scenario, a pneumothorax caused by the rupture of an alveolar bleb could result in hypercarbia and hemodynamic instability. Another concern is the iatrogenically created ventilation-perfusion mismatch that can occur when both lungs are being perfused while only ventilating the nonoperative lung; this can lead to arterial desaturation over an extended period of time.3,16 In addition, the ventilation-perfusion mismatch may lead to inefficient CO2 clearance with subsequent CO2 retention and acidemia. This ventilatory practice of continuous prolonged nonventilation of the ipsilateral operative lung also allows for excessive accumulation of secretions in the airways resulting in atelectasis and pneumonia.3,16,18

Complications Related to Positioning

Proper patient positioning is important for ensuring a safe and unproblematic approach to the lateral aspect of the vertebral body and for preventing skin breakdown. The patient is usually placed in a right lateral decubitus position with his or her left side up, but ultimately the side of the approach is selected based on the pathological condition and the position of the aorta as determined from preoperative CT images. We favor approaching the spine through the left side to prevent injury to the inferior vena cava and to afford increased working space that is otherwise hindered by the presence of the liver on the right. With this positioning, liver injury from excessive retraction is also averted. The operating table is left in a flat position with the sagittal plane of the patient's body parallel to the ground. This latter position permits direct access to the vertebral body in question and minimizes anatomical errors. Despite its usefulness in providing excellent visualization and allowing for ease of work, the lateral decubitus position has its complications. Pressure can be exerted on the brachial plexus either directly on the side on which the patient is lying or by over-abducting the arm on the side of the operation. Similarly, the peroneal nerve may become compressed at the fibular head, resulting in a foot drop postoperatively. Also, prolonged operative time without appropriate padding may lead to the development of pressure ulcers and muscle breakdown with subsequent rhabdomyolysis and renal failure.18

The surgical staff arrangement in the operating room described above is just as important as the patient setup for ensuring an efficient and comfortable working environment.

Complications Related to the Use, Placement, and Removal of Instruments

Injury to large intrathoracic vessels can occur with instrumentation in a variety of ways. Endoscopic instruments placed in the intrapleural cavity can cause injury to the lung parenchyma and large vessels in the chest cavity, leading to air leaks postoperatively and excessive blood loss intraoperatively.3,16,18 The bleeding can come from epidural veins, tumor-feeding arteries, large segmental vessels, and intercostal vessels. In many instances, considerable blood loss is a result of poor coagulation due to inadequate exposure. The initial blind placement of the endoscope prior to placement of the instrument trocars also poses a risk of direct injury to the lung, diaphragm, and intercostal vessels. The latter complication may be a result of lung adhesions bringing the lung parenchyma closer to the skin surface than anticipated.16 The surgeon should place the trocars as gently as possible so as not to place pressure on the intercostal nerves, which could result in intercostal neuralgia. Once the trocars are placed, the surgeon should verify that they have crossed all tissue layers into the pleural cavity so as not to cause subcutaneous or mediastinal emphysema.7,9,18

Careful handling of the endoscope and endoscopic instruments is important. Surgical tools within the chest cavity can bend or break with forceful use. With the endoscope, the surgeon should keep in mind that the tip can get hot and should therefore be placed aiming upward when outside the thoracic cavity to prevent burns.16,18 The need for proper handling of instruments is exemplified by the gentle nerve root retraction necessary during nerve root decompression from a burst fracture when performing a corpectomy.24

The diaphragmatic incision necessary to gain access to the retroperitoneal section of the thoracolumbar junction, for instance, may predispose a patient to the development of a diaphragmatic hernia postoperatively, especially if the incision is made in a radial fashion. A radial incision in direct proximity to the orifices of the esophagus and aorta weakens the diaphragm fixation and causes the resected margins to separate with increased intraabdominal pressure. It is our preference to place a small semilunar incision into the diaphragm parallel to the disc space and not in line with the spine.13

Another interesting complication that can occur with the improper handling of instruments was discussed by Garcia et al.,5 who presented the case of a 73-year-old woman who developed bilateral pneumothoraxes, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema after thoracoscopic anterior stabilization of a T-12 compression fracture because of intraoperative air entrapment. The authors asserted that the diffuse spread of air within the viscera was not due to barotrauma since a pressure limitation of 22 cm H2O was maintained throughout mechanical ventilation. Animal studies have shown that a pressure of 50 cm H2O is required for the development of pneumomediastinum and pneumothorax.6 Upon insufflation of the collapsed lung at the conclusion of the case and with expansion of both lobes, the intrathoracic air is normally pushed out through the chest tube and the thoracoscopic portals. Garcia et al.5 noted, however, that in their case, the premature removal of the portals and a likely obstruction in the chest tube may have trapped air within the chest cavity, increasing intrathoracic pressure and allowing air to pass through the pleural incision and the diaphragmatic split.

Hemodynamic and Vascular Complications

Excessive intraoperative bleeding results from prolonged operative time and is usually due to oozing from the epidural venous plexus and segmental arteries, especially when treating burst fractures. The thoracoscopic approach has lessened the amount of intraoperative blood loss encountered. When Ragel et al.19 compared thoracoscopic procedures with open thoracotomy corpectomies, they demonstrated a statistically significant decrease in blood transfusion requirement. However, despite the dramatic decrease in the amount of blood loss afforded by the thoracoscopic approach, bleeding is inevitable and is of concern especially with prolonged operative time. Watanabe et al.24 noted the learning curve with thoracoscopic surgery whereby experience with the technique usually reduces operative time and blood loss, averting the need for blood transfusion. Extensive bleeding was reduced from 31.6% of cases to 3.0% after 4 years of experience. Interestingly, the volume of blood loss was directly related to the duration of operation. The average operative time and blood loss decreased from 540 to 300 minutes and from 4.0 to 1.5 L, respectively, over the 4-year period. Increased blood loss could lead to hemodynamic instability, necessitating intravascular expansion with crystalloids and blood transfusion. Being cognizant of the amount of actual blood loss is equally important for both the anesthesiologist and surgeon. Predicting the current as well as the anticipated blood loss allows the anesthesiologist to plan ahead and therefore arrange for the transfusion of blood products as needed and to carry out careful intraoperative hypotensive anesthesia preemptively in an effort to reduce blood loss and minimize the need for transfusion.9 Huang et al.9 reported that intraoperative hypotensive anesthesia helped reduce excessive blood loss. For the surgeon, a sound knowledge of the vascular anatomy, careful handling of instruments, and affording adequate working space can help minimize blood loss. Moreover, limiting the excessive use of suction may also be helpful in reducing bleeding.7,16

In cases in which there is hemodynamic instability with no apparent source of bleeding, a high suspicion for retraction injury to the spleen is merited. Binning et al.2 reported a case of a 60-year-old man who became hemodynamically unstable with no obvious source of bleeding during a thoracoscopic approach for a T-12 corpectomy. His postoperative abdominal CT scan was consistent with a splenic rupture necessitating emergency splenectomy. This was believed to be a result of diaphragm retraction throughout the case in a morbidly obese patient. Another potential source of hemodynamic compromise in the absence of obvious blood loss or ongoing bleeding is tension pneumothorax, either iatrogenically through inadvertent puncturing of the lung or spontaneously. This can compromise venous return and therefore cardiac filling and stroke volume, resulting in a precipitous decrease in blood pressure. Immediate attention is warranted to prevent a cardiac arrest.

Neurosurgical Complications

The dura mater is another structure that may also be inadvertently punctured, resulting in a CSF leak. With a dural rent, immediate repair is warranted to prevent postoperative spinal headaches and meningitis, especially in the presence of a chest tube, which can exacerbate the leakage due to the negative pressure. In such a case, the patient should be kept flat for at least 24 hours, and the chest tube should not be connected to suction.

Complication Avoidance

In light of the aforementioned complications, the surgeon should be highly cognizant of the risks involved with every intervention. Patients with known lung disease should undergo preoperative pulmonary function tests and arterial blood gas evaluation. Continuous positive airway pressure on the nonventilated lung can help prevent atelectasis, as can adequate postoperative respiratory therapy.4,18 The position of the double-lumen endotracheal tube should be rechecked with a bronchoscope prior to proceeding with surgery and any time the arterial oxygen saturation decreases to below 90%.18 Proper padding by placing gel rolls and foam pads over all pressure points can help prevent brachial plexopathy as well as peripheral nerve palsies.15–18 When padding the legs, a special U-shaped gel foam keeps them well cushioned and spaced. This also helps prevent psoas muscle tightening, which could otherwise make retraction more difficult and thus hinder visibility. To avoid injury to the lung parenchyma and postoperative air leaks during initial port placement for the endoscope, digital sweeping movement through the planned port site as well as the use of an endoshear can be helpful.5,18 The first port is placed farthest away from the diaphragm, and we use a “mini-thoracotomy” technique that allows for a direct view to inspect the chest cavity. After the first port has been placed, all other ports are placed under direct endoscopic vision. This avoids any “blind” placement of trocars in the chest cavity. The localization and placement of the portals should be done in a careful and stepwise manner to minimize the chance for injury.1 In the case of a thoracic corpectomy, the target (fractured vertebra) is projected onto the skin level using fluoroscopy, and the inferior and superior vertebral margins of the subjacent superior and inferior levels are marked out, respectively. The working portal is centered over the target vertebra. This access site usually extends 3–4 cm in length and should be large enough to insert the fusion instrumentation during the case. The endoscope channel is placed 2 or 3 intercostal spaces cranial to the target. Trocars for suction/irrigation and retraction are placed 5 and 10 cm anterior to the working and optical channels, respectively (Fig. 5). To avoid injury to the diaphragm, lungs, blood vessels, and nearby organs, the endoscopic or optical portal is inserted first so that the remaining portals may be inserted and removed under direct endoscopic vision.

Fig. 5.
Fig. 5.

Ports of entry for a left-sided thoracoscopic approach. Locations for portals are marked directly on the patient's skin. Cam = camera; R = retractor; S/I = suction/irrigation. Reprinted with permission from Amini et al: Neurosurg Focus 19(6):E4, 2005.

Working within the confines of the thoracic cavity through projected endoscopic vision may be visually deceiving because of the lack of 3D vision. To facilitate orientation at the operative site, K-wires and polyaxial clamps are placed early on in the case through the lateral side of the inferior and superior aspect of the vertebral bodies above and below the fractured level, respectively. The clamps, in essence, act as landmarks for defining the superior and inferior extents of the spine. Furthermore, they help define the entry points for subsequent screw placement and ensure a perpendicular trajectory (Fig. 6). The caudal-segment K-wire is placed first so the visual field is not obstructed, and then the cranial-level K-wire is placed in the same fashion.

Fig. 6.
Fig. 6.

Insertion of the screw and clamps over the K-wire creates a boxlike “safety zone” that helps define the superior and inferior extents of the concerned spinal segment. Reprinted with permission. Copyright Department of Neurosurgery, University of Utah.

Anatomical consideration of the pattern of attachment of the diaphragm to the spine and ribs at the thoracolumbar junction is important. Instead of a radial incision, a lunar or semicircular incision that runs in line with the direction of attachments of the diaphragm helps avoid the late occurrence of a diaphragmatic hernia. An increase in intraabdominal pressure from a semicircular incision parallel to the dome-shaped attachment of the diaphragm causes the resected margins to come together instead of gaping as with the previously mentioned radial incision.

Since soft-tissue pressure of only 5 cm H2O allows air passage between the mediastinum, the abdominal cavity, the thoracic cavity, and the retroperitoneum, surgeons should take ample time during reventilation of the collapsed lung to allow for evacuation of the entrapped air before the trocars are pulled out. Once the trocars are removed, the surgeon should check for bleeding at the port site by using the endoscope. Apparent bleeding can be controlled with bipolar coagulation or clip ligation. With severe bleeding, a Foley catheter can be inserted through the port site and inflated to help tamponade the bleeding.5 Throughout the case, the surgeon should keep in mind that splenic injury and rupture is possible with excessive and forced retraction. If the patient is hemodynamically unstable and the operative field appears to be dry, the likelihood of a splenic injury should be entertained.

Conclusions

The thoracoscopic approach to the anterior thoracic and upper lumbar spine is an innovative technique that avoids many of the risks and complications of open thoracotomy. With the careful handling of endoscopic instruments, limited use of retraction, operative experience, and a multidisciplinary approach involving the surgical staff and the anesthesia team, many of the potential complications can be circumvented.

Disclosure

Dr. Schmidt is a consultant for Aesculap.

Author contributions to the study and manuscript preparation include the following. Conception and design: Schmidt. Acquisition of data: Krisht. Analysis and interpretation of data: Krisht. Drafting the article: Krisht. Critically revising the article: Mumert. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Schmidt.

Acknowledgment

The authors thank Kristin Kraus, M.Sc., for editorial assistance in the preparation of this paper.

References

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Article Information

Contributor Notes

Address correspondence to: Meic Schmidt, M.D., Department of Neurosurgery, University of Utah, 175 North Medical Drive East, Salt Lake City, Utah 84132. email: neuropub@hsc.utah.edu.

© AANS, except where prohibited by US copyright law.

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Figures
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    H. C. Jacobaeus of Stockholm using an early cystoscope to peer through a patient's pleural cavity. Reprinted with permission from Archives of Surgery 139 (1):100–112, 2004. Copyright 2004 American Medical Association. All rights reserved.

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    Ideal operative setup for a thoracoscopic approach to the spine. The anesthesiologist (A) stands at the patient's head. For a left-sided approach, the main surgeon (S1) stands behind the patient. The first assistant (S2) stands to the right of the main surgeon and operates the endoscope while the scrub nurse (SN) stands opposite the surgeons. Video monitors (M1 and M2) display the endoscopic image.

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    Intraoperative photographs showing placement of the plating system. The K-wire is inserted into the level caudal to the fractured vertebra 10 mm anterior to the spinal canal and 10 mm away from superior endplate in the upper third of the vertebral body (A). The polyaxial screw–clamp assembly is then attached to a centralizer tube and inserted over the K-wire (B and C). After placement of the polyaxial screw–clamp assembly in the upper vertebral body superior to the fracture level and after completing the corpectomy and placement of an interbody cage with morcellized bone, the anterolateral interbody plate is placed (D and E). Finally, fixation nuts are placed on the polyaxial heads and tightened with a torque device (F).

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    Anteroposterior upright radiograph of the thoracolumbar junction showing a T-12 interbody cage following a T-12 corpectomy with lateral vertebral body plate and screw fixation. Reprinted with permission. Copyright Department of Neurosurgery, University of Utah.

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    Ports of entry for a left-sided thoracoscopic approach. Locations for portals are marked directly on the patient's skin. Cam = camera; R = retractor; S/I = suction/irrigation. Reprinted with permission from Amini et al: Neurosurg Focus 19(6):E4, 2005.

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    Insertion of the screw and clamps over the K-wire creates a boxlike “safety zone” that helps define the superior and inferior extents of the concerned spinal segment. Reprinted with permission. Copyright Department of Neurosurgery, University of Utah.

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