Feasibility of thoracic nerve root preservation in posterior transpedicular vertebrectomy with anterior column cage insertion: a cadaveric study

Laboratory investigation

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Object

Transpedicular thoracic vertebrectomy (TTV) is a safe alternative to the more standard transthoracic approach. A TTV is most commonly used to address vertebral body fractures due to tumor or trauma.

Transpedicular reconstruction of the anterior column with cage/bone traditionally requires unilateral thoracic nerve root sacrifice. In a cadaveric model, the authors evaluated the feasibility of transpedicular anterior column reconstruction without nerve root sacrifice. If feasible, this may be a reasonable approach that could be extended to the lumbar spine where nerve root sacrifice is not an option.

Methods

A TTV was performed in 8 fixed cadaveric specimens. In each specimen, an alternate vertebra (either odd or even) was removed so that single-level reconstruction could be evaluated. The vertebrectomy included facetectomy, adjacent discectomies, and laminectomy; however, the nerve roots were preserved. The authors then evaluated the feasibility of inserting a titanium mesh cage (Medtronic Sofamor Danek) without neural sacrifice.

Results

Transpedicular anterior cage reconstruction could be safely performed at all levels of the thoracic spine without nerve root sacrifice. The internerve root space varied from 18 mm at T2–3 to 27 mm at T11–12; thus, the size of the cage that was used also varied with level.

Conclusions

Cage reconstruction of the anterior column could be safely performed via the transpedicular approach without nerve root sacrifice in this cadaveric study. Removal of the proximal part of the rib in addition to a standard laminectomy with transpedicular vertebrectomy provided an excellent corridor for anterior cage reconstruction at all levels of the thoracic spine without nerve root sacrifice.

Abbreviations used in this paper: PMMA = polymethylmethacrylate; PPI = pedicle-to-pedicle inlet; PTA = posterior transpedicular approach; TTV = transpedicular thoracic vertebrectomy; VB = vertebral body.

Article Information

Address correspondence to: Bharat Guthikonda, M.D., Department of Neurosurgery, LSUHSC–Shreveport, 1501 Kings Highway, Shreveport, Louisiana 71130. email: bguthi@lsuhsc.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Digital images of the cadaveric thoracic spine at T-12. A TTV was performed on the left side and the T-12 nerve root was identified (upper). Insertion of the titanium mesh cage was done without resection of the nerve root (lower).

  • View in gallery

    Photographs of the different sizes of thoracic and thoracolumbar titanium mesh cages (Medtronic Sofamor Danek).

  • View in gallery

    Diagrams. Posterior (upper) and posterolateral (lower) views of the transpedicular vertebrectomy and insertion of the titanium mesh cage without resection of the nerve root.

  • View in gallery

    Diagram (posterolateral view). After insertion of the caudal end of the titanium mesh cage into the vertebrectomy space, the rostral end was tamped in to ensure good contact and a tight fit against the inferior endplate of the upper vertebra.

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