PPT Ilmiah Spine

Anterior Thoracic Decompression and

fusion : open and minimally invasive
Present By : Vito Masagus, dr.

Departemen Ilmu Bedah Saraf

Faculty of Medicine – Universitas Padjajaran
Bandung - 2022
 Anterior Thoracic Decompression and fusion : open and minimally invasive

Background
Minimally invasive surgery
(MIS) Increasingly popular recently

surgeon experience
Goals of MIS

Decrease tissue
Preference
damage and
therefore to provide The decision to perform an
open versus minimally
invasive approach therefore
depends on :
system availability

improved functional
improved morbidity faster recovery
outcomes
patient preference

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Background
Benefits and limitations of the anterior approach to thoracic spine

This approach provides excellent

access to the anterior aspects of avoiding the use of rib resection
the thoracic spine and limits or retractors
manipulation of the spinal cord
Benefits :

Benefit of MIS specifically : reduced blood loss

required increased anesthetic

monitoring due to single lung
Limitation : diminished postoperative pain
ventilation  demanding
procedure

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Indications
Anterior thoracic spine
fractures classified as AO
classification type A1.2, a1.3,
Discoligamentous segmental
A2, A3, B, and C with Thoracic disc herniation
instability
significant curvature
displacement of 20° or more
in the sagittal or AP plane

Degenerative stenosis or
Osteomyelitis/tuberculosis Tumor
deformity

The anterior approach enables direct decompression and restoration of stability as

laminectomy alone is not adequate for anteriorly located pathology

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Contraindication
Previous chest trauma or surgery

Adhesions

Infection

Comorbidity that would make single-lung ventilation dangerous

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Multiple approaches have been described to perform anterior thoracolumbar decompression and fusion :

open transthoracic
approach

thoracoscopic
Surgical Options : approach for
discectomy
posterolateral
extracavitary technique
multiple minimally
invasive approaches
lateral minimally
invasive approach

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Open Transthoracic Approach

Fluoroscopy is used to identify

Placing the patient in the
lateral decubitus position, hips
and knees flexed to relax the
ipsilateral psoas
the targeted vertebral level. An
After incision through Selfretaining retractors are
oblique incision 4–6 inches in
subcutaneous tissue, a placed and the lung is
length is centered over the rib
thoracotomy is performed retracted carefully.
two at the desired surgical
level.

• Right-sided approach :
performed between the 3rd
and 10th thoracic levels to
The parietal pleura is then split
avoid the great vessels,
• Left-sided approach : the
11th thoracic through the 1st
lumbar level.
The caudad rib is traced and
The corresponding intercostal
the base excised
longitudinally and segmental
nerve is identified and traced
subperiosteally taking care to
to confirm the correct level for
vessels ligated and divided. divide the costovertebral
disc excision
ligaments

The Resident’s Guide to Spine Surgery. Springer Publishing

Exposure of the thoracic spine after entry
into the thoracic cavity and placement of a
self-retaining chest retractor. The parietal
pleura has been separated from the ribs and
spinal column with the segmental vessels
along the side of the vertebrae identified

Reference : BENZEL Spine Surgery

 After tumor resection, the end plates and cancellous After the Silastic tubing is inserted into the spinal
bone of adjacent vertebral bodies can be removed to defect, a syringe is used to fill the tube with slow-
the degree shown (dotted line) using an angled high- curing, low-viscosity polymethylmethacrylate.
speed drill or angled curettes

Reference : BENZEL Spine Surgery

 Anterior Thoracic Decompression and fusion : open and minimally invasive
Approaches/Techniques
Open Transthoracic Approach
Subperiosteal dissection
is performed to
delineate the adjacent
vertebral bodies, as well
as the pedicle of the
caudad vertebral body.
After discectomy, a cage
or bone graft can be
placed if fusion is
desired.
The Resident’s Guide to Spine Surgery. Springer Publishing
The inferior pedicle is annulotomy is
The isolated intercostal
removed, exposing the performed and the mid-
nerve is again traced to
underlying dura and lateral portion of the disc
identify the appropriate
revealing the herniated is removed with a
foramen.
disc. pituitary rongeur
After the disc has been Extruded or herniated
The posterior annulus is
addressed, the PLL is disc material is then
addressed last and is
then bluntly dissected pulled into the cavity
bluntly freed from the
off the cord and created by already
dura using a penfield.
removed. removed disc material.
 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Minimally Invasive : Posterolateral Extracavitary Technique

K-wire is placed
Pre-op preparation : the patient is positioned percutaneously down the
identify the desired level A 2-cm vertical incision is
Neuromonitoring with prone on a Jackson frame rib angle to the transverse
with fluoroscopy made through fascia
SSEPs and MEPs with the abdomen free process of the caudad
vertebral body

target disc should be Progressive dilators are A finger is then used to

parallel to and in the center Biplanar fluoroscopy is placed to form port, bluntly dissect and dilate
of the working access of the again used to identify typically up to 22 mm, and muscle fibers to the
portal on the lateral correct level secured to the surgical able transverse process and
radiograph using a mounted arm. facet of the target level

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Minimally Invasive : Posterolateral Extracavitary Technique

The lateral aspect of the lamina

Using an operating microscope,
a combination of cautery and
rongeurs are used to free the
remaining soft tissue from the
inferior transverse process-facet
complex.
A drill is used to remove the
transverse process and expose
the intertranverse ligament,
which is opened sharply to
access the underlying disc
space.
better access to the disc space.
and the pars overlying the
Decompression of the flavum
neural foramen are
The ligamentum flavum is allows a near-lateral view of the
decompressed from lateral to
dissected off the underlying spinal cord and disc space is
medial, and the cephalad
nerve root and lateral cord. obtained, highlighting any disc
portion of the inferior pedicle is
fragments.
flattened with a drill to allow

slowly remove your retractors Discectomy then performed,

with cautery available as
bleeding can be encountered
during closure
Position of the cage is
confirmed on fluoroscopy.
An annulotomy is performed
and endplates are curetted with
allowing access to the disc
placement of interbody cage if
space.
fusion is desired.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Minimally Invasive : Lateral Technique via transthoracic window

The cavity is
The junction A 3–5 cm The entered over the
Position : lateral between the incision is subcutaneous superior edge of
decubitus posterior and centered over tissue and the rib is that
position with the middle thirds of the mark which intercostal overlying the
bed broken at the disc space is perpendicular muscle is affected disc
the affected is marked on to the direct divided, allowing space in order
level the skin under posterior access to the to avoid the
fluoroscopy. approach. thoracic cavity. neurovascular
bundle.

• For a single level : dissection between the adjacent ribs and intercostal muscle is performed and pleural access
is provided through blunt dissection.
• For a multi-level case : a small portion of the rib must be resected to allow adequate access

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Minimally Invasive : Lateral Technique via transthoracic window

A dilator is used in the Decompression of the

plane of the disc space to
access posterior to the
thoracic cavity, stopping
at the junction of the rib
head and vertebral body.
disc space is then
performed in similar Parietal pleura is divided
fashion  This approach longitudinally
can also allow a
transpleural window.

Standard closure is The rib head overlying

performed and a chest the posterolateral corner
tube is placed if a of the disc is identified
transpleural window is and removed, allowing
employed access to the disc space.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Approaches/Techniques
Thoracoscopic approach for discectomy

The first port placed blindly

General anesthesia is
performed using a double lumen
ET tube to allow for collapse of
the ipsilateral lung.
The patient is also placed in a
lateral decubitus position.
Three or four ports are typically
above the superior aspect of the
needed: one on the posterior
AP and lateral fluoroscopy used rib above, and the remaining
axillary line, and an additional
to localize endoscopic ports. two ports triangulated 8–10 cm
two ports on the anterior axillary
apart, centered over the
line.
affected level.

The parietal pleura over the

The pedicle is removed using a
The target disc fragments are
drill, as well as small portions of
removed endoscopically and the
the vertebral bodies adjacent to
spinal canal is decompressed
the affected disc.
proximal 2 cm of the rib head
adjacent to the desired level is Lung retraction performed by
resected, and the proximal 2 cm rotating the surgical table A Steinman pin is placed for
of the rib is resected using a anteriorly by 30°, with resection spinal level localization.
burr, exposing the lateral of pleural adhesions as needed.
pedicle, neural foramen, and
disc.

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Postoperative Care
Patient
Patient Incentive ambulation
DVT
Extubation transfer into Monitoring spirometry with
prophylaxis
ICU utilization physical
therapist

Avoid :

Bending
for 4–6 weeks while Additional Info:
Twisting
the fusion forms • Bracing is not generally required
Lifting

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Outcomes
• Pulmonary effusion Therefore, incentive spirometry is critical to
• decrease atelectasis and subsequent pneumonia
Hemo/pneumothorax

Hematoma, dural injury, hardware malpositioning, or graft dislodgment

Should be suspicion when there is :

Evidence of Changes in the Postoperative
horner’s neuromonitoring neurologic
syndrome during the case deficits

Radiography including MRI, CT, and X-ray should be obtained

quickly to evaluate these possible etiologies

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Outcomes
Wait et al. :
The thoracoscopic
group was reported
to have :

less risk of intercostal

shorter chest tube less estimated blood neuralgia compared
shorter hospital stays fewer transfusions
duration loss to an unmatched
thoracotomy cohort

initial complication rate of 28.3% in the first 6 years

Reintubation
Reoperation
These complications included : Pleural
Durotomy
for Delayed
for residual
effusion respiratory fusion
disc
distress

The Resident’s Guide to Spine Surgery. Springer Publishing

 Anterior Thoracic Decompression and fusion : open and minimally invasive

Outcomes

Khoo et al. demonstrated that a MIS approach to the thoracic spine for discectomy
and interbody fusion produced similar radiographic and clinical outcomes to an open
approach at 1-year follow-up in 13 MIS patients compared to a matched cohort.

The MIS group had statistically significant improvements in estimated blood loss,
operative time, duration of ICU stay, transfusion incidence, and overall length of stay

The Resident’s Guide to Spine Surgery. Springer Publishing

Anterior Thoracic Decompression and fusion : open and minimally invasive

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