Simultaneous anterior—posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization

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Object. Thoracic or lumbar spine malignant tumors involving both the anterior and posterior columns represent a complex surgical problem. The authors review the results of treating patients with these lesions in whom surgery was performed via a simultaneous anterior—posterior approach.

Methods. The hospital records of 26 patients who underwent surgery via simultaneous combined approach for thoracic and lumbar spinal tumors at our institution from July 1994 to March 2000 were reviewed. Surgery was performed with the patients in the lateral decubitus position for the procedure. The technical details are reported.

The mean survival determined by Kaplan—Meier analysis was 43.4 months for the 15 patients with primary malignant tumors and 22.5 months for the 11 patients with metastatic spinal disease. At 1 month after surgery, 23 (96%) of 24 patients who complained of pain preoperatively reported improvements (p < 0.001, Wilcoxon signed-rank test), and eight (62%) of 13 patients with preoperative neurological deficits were functionally improved (p = 0.01). There were nine major complications, five minor complications, and no deaths within 30 days of surgery. Two patients (8%) later underwent surgery for recurrent tumor.

Conclusions. The simultaneous anterior—posterior approach is a safe and feasible alternative for the exposure tumors of the thoracic and lumbar spine that involve both the anterior and posterior columns. Advantages of the approach include direct visualization of adjacent neurovascular structures, the ability to achieve complete resection of lesions involving all three columns simultaneously (optimizing hemostasis), and the ability to perform excellent dorsal and ventral stabilization in one operative session.

Article Information

Address reprint requests to: Ziya L. Gokaslan, M.D., Department of Neurosurgery, Box 442, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030. email: zgokasla@notes.mdacc.tmc.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    The patient is placed in the lateral decubitus position. First, a posterolateral thoracotomy incision is fashioned depending on the location and extent of the tumor. This is followed by a posterior midline incision. As illustrated, when these two incisions connect, a triangular skin flap is formed, which needs to be fashioned so that its base is as wide as possible to avoid any vascular compromise or healing problems. The trapezius muscle is then detached from the midline fascia, mobilizing it rostrally. The latissimus dorsi muscle (m) is incised along the course of the rib.

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    Upper: The skin flaps are retracted along with the muscles in cephalad and caudal directions. The chest cavity is then entered, and the ribs are transected laterally. Along the midline incision, thoracodorsal fascia is incised, and spinous processes, laminae, and the transverse processes are all exposed in a subperiosteal fasion. Paraspinal muscles are then completely mobilized, and a Penrose drain is looped around them to retract these away from the laminae. Lower: Depicted in green are the laminae that are removed to expose the underlying thecal sac.

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    Upper: Nerve roots ipsilateral to the tumor are transected, and epidural tumor is dissected free from the dura by using Penfield dissectors. Lower: At this point, at least a unilateral posterior segmental fixation is performed several levels above and below the lesion—by placing a hook/pedicle screw and rod construct depending on the region of the spinal column affected by the tumor—so that the spinal alignment can be maintained during anterior resection.

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    Upper: Artist's illustration showing the cuts (broken line) that are needed to achieve a complete spondylectomy. Shaded in green are the dorsal elements that need to be removed prior to en bloc resection of the tumor along with the chest wall. Lower: Artist's depiction of the variation in en bloc resection in cases in which the tumor does not involve the contralateral pedicle. In this situation, it is usually possible to drill a trough by using a diamond burr in rostral—caudal direction to the periosteum ventrally. Removal of the discs above and below then allows for the tumor to be mobilized while the remaining periosteal attachment can be incised with electrocautery.

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    Artist's illustration depicting all the critical structures found during a thoracic total spondylectomy involving both T-7 and T-8 VBs. Shown are the dorsal elements that have already been removed, except for ipsilateral T-7 and T-8 transverse processes that are left attached to the tumor. Also depicted are the transected ipsilateral nerve roots, which are being retracted with sutures. After the incision of the parietal pleura and ligation of segmental vessels, the ventral structures, namely aorta, azygos and esophagus, are mobilized away from the spinal column. At this point, a Gigli saw is then passed ventral to the thecal sac and dorsal to the disc spaces; the spinal column is then disarticulated by sectioning through the discs above and below the site of neoplasm, while protecting the vital ventral structures with a malleable retractor. V = vein.

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    Artist's illustration showing the final construct. The posterior segmental fixation device, which had been partially placed contralateral to the tumor, is now completely in place. Ventral reconstruction of the spinal column is performed using the chest tube technique with polymethylmethacrylate. After the solidification of cement, hardware is added to prevent distraction failure by placing either thoracolumbar or cervical locking plate/screw system depending on the levels that need to be instrumented. Finally, posterior fusion is performed using allograft and Grafton, a fusion promoter.

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    Upper Left: The patient is positioned in the right lateral decutibus position. The thoracotomy line, posterior midline incision, and the tip of the scapula are marked on the skin. Upper Right: The skin flaps are fashioned and retracted rostrally and caudally, allowing exposure of the chest wall, midline, and ipsilateral paraspinal musculature. Center Left: The chest cavity is entered between the fifth and sixth rib, and the dorsal spinal column is exposed in a sunperiosteal fashion. Center Right: The paraspinal muscles are dissected free from the posterior chest wall and mobilized so that a Penrose drain can be placed around them for retraction to expose the underlying tumor involving the chest wall. Lower Left: Laminectomies of T6–7 are completed and the sixth and seventh ribs are transected lateral to the tumor. The nerve roots of T-6 and T-7 are ligated and transected. After dissection of the tumor from the dural sac, the tumor is mobilized and removed en bloc as described in Fig. 4 lower. Also seen are the dorsal segmental fixation with hooks and rods, laminectomy defect, and the resected chest wall. Lower Right: View of the thecal sac through the chest cavity. Visualized dorsally are the rods and posterior instrumentation. Ventrally, the anterior spinal column is reconstructed with polymethlmethacrylate by using the chest tube technique. Additional fixation was obtained using a cervical locking plate and screws because the T-5 body was too small to accept a standard thoracolumbar plate and screws.

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    Imaging studies obtained in the same patient. Upper Left and Right: Preoperative and postoperative sagittal magnetic resonance images revealing tumor involvement laterally and ventrally at T9–10 (upper left), and decompression of the thecal sac as well as reconstruction and instrumentation following resection (upper right). Lower Left and Right: Anteroposterior (lower left) and lateral (lower right) plain radiographs demonstrating anterior reconstruction in which acrylic and posterior segmental fixation with hooks and pedicle screws was performed. Also noted is the augmentation of methylmethacylate with a 4-mm titanium rod coaxially placed to prevent any flexion failure.

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    Bar graph showing preoperative and postoperative median VAS pain scores of 24 patients in whom pain was a significant preoperative complaint. A score of 10 indicates severe pain and a score of 0 indicates no pain.

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    Kaplan—Meier survival curves for all 26 patients in whom surgery was performed via a simultaneous anterior—posterior approach for the resection of primary malignant (unbroken line) and metastatic (short-dashed line) thoracic and lumbar tumors.

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