Thoracolumbar Metastatic Spinal Disease

Abstract

Anterolateral or lateral approach to the thoracolumbar junction is a powerful method to perform corpectomy in the setting of tumor. The presence of the diaphragm and the transition between the chest and abdominal cavities are the main obstacle to this case. The open thoracoabdominal approach has stood the test of time as the dependable workhorse. It provides a safe and reliable exposure to perform corpectomy for tumors in this T12–L2 region where blood loss and distorted regional anatomy from tumor invasion are not uncommon. Above T11, a lateral transthoracic approach gives excellent visualization and is straightforward. Similarly at this level, retropleural thoracotomy provides excellent access without the need for a chest tube. Below L2 the lateral retroperitoneal approach usually provides access, but variability of the crural attachments occasionally prompts proximal extension into a thoracoabdominal approach. The mini-open lateral thoracotomy minimal access technique detailed here is another safe and effective means to perform corpectomy for tumor. We suggest this is best suited for anterior tumor burden and possibly unilateral pedicular involvement. The limited view this affords is sufficient to accomplish the surgery and may be less morbid, but working in a long narrow corridor may prove challenging for those less familiar with minimally invasive techniques. Additionally, pleural adhesions may make an extracoelomic approach difficult in a tumor setting. Particularly, tumors with bilateral posterior element involvement would best be served with a more traditional bilateral transpedicular corpectomy. The literature is less populated with outcomes for tumor surgery via this approach, but those available demonstrate reasonable outcomes. Finally, some lesions, in selected patients, may prove accessible and most easily treated through a true MISS (minimally invasive spine surgery) approach, made feasible through advances in intraoperative image guidance and improved retractor and instrument design. An understanding of the regional anatomy and familiarity with more conventional thoracoabdominal approach as well as lateral lumbar interbody fusion help transition to the mini-open lateral approach to the thoracolumbar junction.

Here, we review anterolateral and minimal access lateral approaches to corpectomy for metastatic tumors of the thoracolumbar junction and discuss strategies for resection and reconstruction at this challenging spinal segment.