Thoracic vertebrectomy and spinal reconstruction via anterior, posterior, or combined approaches: clinical outcomes in 91 consecutive patients with metastatic spinal tumors

Clinical article

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Object

Adequate decompression of the thoracic spinal cord often requires a complete vertebrectomy. Such procedures can be performed from an anterior/transthoracic, posterior, or combined approach. In this study, the authors sought to compare the clinical outcomes of patients with spinal metastatic tumors undergoing anterior, posterior, and combined thoracic vertebrectomies to determine the efficacy and operative morbidity of such approaches.

Methods

A retrospective review was conducted of all patients undergoing thoracic vertebrectomies at a single institution over the past 7 years. Characteristics of patients and operative procedures were documented. Neurological status, perioperative variables, and complications were assessed and associations with each approach were analyzed.

Results

Ninety-one patients (mean age 55.5 ± 13.7 years) underwent vertebrectomies via an anterior (22 patients, 24.2%), posterior (45 patients, 49.4%), or combined anterior-posterior approach (24 patients, 26.4%) for metastatic spinal tumors. The patients did not differ significantly preoperatively in terms of neurological assessments on the Nurick and American Spinal Injury Association Impairment scales, ambulatory ability, or other comorbidities. Anterior approaches were associated with less blood loss than posterior approaches (1172 ± 1984 vs 2486 ± 1645 ml, respectively; p = 0.03) or combined approaches (1172 ± 1984 vs 2826 ± 2703 ml, respectively; p = 0.05) but were associated with a similar length of stay compared with the other treatment cohorts (11.5 ± 9.3 [anterior] vs 11.3 ± 8.6 [posterior] vs 14.3 ± 6.7 [combined] days; p = 0.35). The posterior approach was associated with a higher incidence of wound infection compared with the anterior approach cohort (26.7 vs 4.5%, respectively; p = 0.03), and patients in the posterior approach group experienced the highest rates of deep vein thrombosis (15.6% [posterior] vs 0% [other 2 groups]; p = 0.02). However, the posterior approach demonstrated the lowest incidence of pneumothorax (4.4%; p < 0.0001) compared with the other 2 cohorts. Duration of chest tube use was greater in the combined patient group compared with the anterior approach cohort (8.8 ± 6.2 vs 4.7 ± 2.3 days, respectively; p = 0.01), and the combined group also experienced the highest rates of radiographic pleural effusion (83.3%; p = 0.01). Postoperatively, all groups improved neurologically, although functional outcome in patients undergoing the combined approach improved the most compared with the other 2 groups on both the Nurick (p = 0.04) and American Spinal Injury Association Impairment scales (p = 0.03).

Conclusions

Decisions regarding the approach to thoracic vertebrectomy may be complex. This study found that although anterior approaches to the thoracic vertebrae have been historically associated with significant pulmonary complications, in our experience these rates are nevertheless quite comparable to that encountered via a posterior or combined approach. In fact, the posterior approach was found to be associated with a higher risk for some perioperative complications such as wound infection and deep vein thromboses. Finally, the combined anteriorposterior approach may provide greater ambulatory and neurological improvements in properly selected patients.

Abbreviations used in this paper: ASIA = American Spinal Injury Association; DVT = deep vein thrombosis; HR = hazard ratio; LOS = length of stay.

Article Information

Address correspondence to: Daniel M. Sciubba, M.D., 600 North Wolfe Street, Meyer 8-161, Baltimore, Maryland 21287. email: dsciubb1@jhmi.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Images obtained in a 65-year-old male with a history of prostate cancer who presented with ambulation difficulty and numbness in his lower extremities. a and b: Sagittal (a) and axial (b) MR images show a T-6 compression fracture with posterior extension of bone into the spinal canal. A right posterolateral thoracotomy (fifth-rib approach) was used to gain exposure to the thoracic spine. A T-6 vertebrectomy and decompression of the thecal sac was then performed, and anterior thoracic reconstruction was performed using a distractible titanium cage. The patient was discharged home on postsurgery Day 9. c and d: The patient did not experience any surgically related complications during his follow-up, and at his most recent visit (1-year postoperatively) anteroposterior (c) and lateral (d) plain radiographs showed no hardware failure and no presence of kyphotic deformity.

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    Images obtained in a 55-year-old female with a history of breast cancer and osteoporosis who presented with acute onset of severe lower-back pain, urinary incontinence, and lower-extremity weakness. a: A sagittal MR image demonstrated a T-11 pathological fracture. b and c: An axial MR image (b) and CT scan (c) showed retropulsion of the bone into the spinal canal and subsequent conus compression. The patient underwent bilateral T10–12 laminectomies, right costal transversectomy, right T-11 rhizotomy, and transpedicular removal of the T-11 vertebral body via a posterior approach. Anterior thoracic correction of kyphotic deformity and reconstruction was achieved using a distractible titanium cage, and intraoperative vertebroplasties of T7–10, T-12, and L-1 were performed bilaterally. Posterior fixation was achieved via pedicle screws bilaterally in T7–L1. Postoperatively, the patient developed a systemic methicillin-resistant Staphylococcus aureus infection and an empyema of the pleural cavity, for which a chest tube was placed for 14 days. Two months from her initial operation, the patient developed another compression fracture at L-1. For this fracture, the patient underwent another posterior approach to the thoracolumbar spine, wherein the hardware from T8–L1 was removed, bilateral T-12, L-1, and L-2 laminectomies were performed, and an L-1 pedicle subtraction osteotomy was used to correct the kyphosis. Pedicle screw fixation was added from T-4 through L-4, although some pedicle screws were not used due to the patient's severe osteoporosis. Postoperatively, the patient developed pleural effusions, hyponatremia, DVT, hypotensive shock, and pneumonia. After aggressive resuscitative efforts, the patient stabilized and was discharged on postoperative Day 42 to a rehabilitation facility. d and e: At her latest follow-up at 10 months, lateral (d) and anteroposterior (e) radiographs demonstrated adequate positioning of hardware with no kyphotic deformity. The patient continues to improve in her strength and stamina.

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    Images obtained in a 65-year-old female who presented with a diagnosis of a right-sided non–small cell lung cancer. Sagittal (a) and axial (b) MR images, as well as an axial CT scan (c), demonstrated a right-sided middle-lobe tumor involving the T-4 and T-5 vertebral bodies with almost complete replacement of the entire T-5 vertebral body, at least half of the T-4 vertebral body, and also part of the right rib head. Given the patient's lack of any significant response to adjuvant treatment, and that this was the only disease site, the decision was made to proceed with radical resection of this tumor. Stage I of the operation involved a posterior approach to the thoracic spine, wherein T3–6 laminectomies, complete facetectomies, and pediculectomies of T3–4 and T4–5 were performed bilaterally. Posterior segmental fixation was achieved using thoracic pedicle screws at T1–8. Stage II of the operation involved an anterior approach, with a right posterolateral thoracotomy, a partial T-3 vertebrectomy, complete T-4 and T-5 vertebrectomies, and segmental resection of the right-sided superior lobe tumor. Anterior thoracic reconstruction was accomplished using distractible titanium cages. A plastic surgery team performed complex closure of the surgical defect, and 3 chest tubes were placed. Each postoperative drain was removed gradually without complication. The patient was discharged in a coherent state to inpatient rehabilitation on Day 26, with 4/5 to 5/5 strength in all extremities. At her most recent follow-up at 7 months, the patient was doing well functionally. She is ambulating without assistance and has 5/5 motor strength in all extremities. The patient's lateral (d) and anteroposterior (e) plain radiographs demonstrated no loosening and good position of the hardware.

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