Minimally invasive lateral extracavitary corpectomy: cadaveric evaluation model and report of 3 clinical cases

Laboratory investigation

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Object

In this paper, the authors' goal was to demonstrate the clinical and technical nuances of a minimally invasive lateral extracavitary approach (MI-LECA) for thoracic corpectomy and anterior column reconstruction.

Methods

A cadaveric feasibility study and the subsequent application of this approach in 3 clinical cases are reported. Six procedures were completed in 3 human cadavers. Minimally invasive, extrapleural thoracic corpectomies were performed with the aid of a 24-mm tubular retraction system, using a posterolateral incision and an oblique approach angle. Fluoroscopy and postprocedural CT scanning, using 3D volumetric averaging software, was used to evaluate the degree of bone removal and decompression. Three clinical cases, including a T-11 burst fracture, a T-7 plasmacytoma, and a T4–5 vertebral body (VB) tuberculosis lesion, were treated using the approach.

Results

At 6 cadaveric levels, the mean circumferential volumetric decompression was 48% ± 16%, and the mean resection of the VB was 72% ± 13%. The mean change in anterior and posterior vertebral height with expansion of the corpectomy cage was 47 and 61 mm, respectively. There were no violations of the pleura or dura. Pedicle screw reliability was 95.8% (23 of 24 screws) with a single lateral breach. All 3 patients in the clinical cohort had excellent clinical outcomes. There was a single pleural tear requiring chest tube drainage. Operative images and a video clip are provided to illustrate the approach.

Conclusions

A minimally invasive lateral extracavitary thoracic corpectomy has the ability to provided excellent spinal cord decompression and VB resection. The procedure can be completed safely and successfully with minimal blood loss and little associated morbidity. This approach has the potential to improve upon established traditional open corridors for posterolateral thoracic corpectomy.

Abbreviations used in this paper:LECA = lateral extracavitary approach; MI-LECA = minimally invasive LECA; VB = vertebral body.

Article Information

Address correspondence to: Zachary A. Smith, M.D., Good Samaritan Hospital, Department of Neurosurgery, 1245 Wilshire Boulevard, #717, Los Angeles, California 90017. email: zsmithmd@gmail.com.

Please include this information when citing this paper: published online March 9, 2012; DOI: 10.3171/2012.2.SPINE11128.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Fluoroscopic images demonstrating sequential steps in a cadaver model. Initially, percutaneous screws were placed above and below the corpectomy level (A and B). The corpectomy is completed, and the cage is placed and expanded through the minimal access portal (C–F). Arrows in D and E demonstrate the change in cage height before (D) and after (E) opening.

  • View in gallery

    A and B: Intraoperative photographs showing the placement of percutaneous screws and the location of serial dilation at the corpectomy site. C and D: The working portal is shown after it has been expanded at the operative level.

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    Case 1. Preoperative sagittal CT images (A and B) and an axial T2-weighted MR image (C). Postoperative axial CT image (D) showing bone removal after the approach and placement of the cage.

  • View in gallery

    Case 1. A: Intraoperative view after cage placement, showing the cage below the decompressed thecal sac (asterisk). B: Lateral fluoroscopic view showing cage placement. C: Photograph showing the incisions required for the operation. The arrows point to the larger incision used for the corpectomy.

  • View in gallery

    Case 2. A and B: Preoperative sagittal T2-weighted and axial MR images. C: Postoperative radiograph obtained after instrumentation is placed. This demonstrates placement of the cage, as well as the pedicle screw fixation with rod construct that is inclusive of the levels both above and below the corpectomy.

  • View in gallery

    Case 3. A: Axial CT scan demonstrating a destructive VB lesion. A soft-tissue mass associated with this destructive lesion involved the thoracic canal. B and C: Fluoroscopic views showing the sequential steps of percutaneous screw fixation. D–F: Postoperative axial, coronal, and sagittal CT images showing the final fusion construct. The arrow in panel F shows the placement of the cage and associated bone graft within the cage.

  • View in gallery

    The surgeon's view through the microscopic and minimal access portal. A: The initial hemilaminotomy is shown. B: After bone decompression and corpectomy, the thecal sac is decompressed (double arrows). The expandable cage (asterisks) and surrounding bone graft (single arrow) are shown.

  • View in gallery

    Illustrations demonstrating the approach anatomy. A: The preoperative anatomy. B: The approach angle and correlative anatomy of bony removal and cage placement.

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