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Thoracolumbar Metastatic Spinal Disease

  • Charles A. Hogan
  • Robert F. McLain
Chapter

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.

Keywords

Surgical treatment Surgical approaches Minimally invasive Spinal metastases Thoracolumbar Lateral corpectomy Spinal instability Epidural tumor Spinal cord compression 

Notes

Disclosure

The authors have received nothing of value from any entity, industrial agency, or sponsor in relation to any aspect of the work presented here.

References

  1. 1.
    Lazorthes G, Gouaze A, Zadeh J, Jacques Santini J, Lazorthes Y, Burdin P. Arterial vascularization of the spinal cord. J Neurosurg. 1971;35(3):253–62.CrossRefPubMedGoogle Scholar
  2. 2.
    Uribe J, Arredondo N, Dakwar E, Vale F. Defining the safe working zones using the minimally invasive lateral retroperitoneal transpsoas approach: an anatomical study. J Neurosurg Spine. 2010;13(2):260–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Dakwar E, Ahmadian A, Uribe J. The anatomical relationship of the diaphragm to the thoracolumbar junction during the minimally invasive lateral extracoelomic (retropleural/retroperitoneal) approach. J Neurosurg Spine. 2012;16(4):359–64.CrossRefPubMedGoogle Scholar
  4. 4.
    Kawahara N, Tomita K, Baba H, Toribatake Y, Fujita T, Mizuno K, et al. Cadaveric vascular anatomy for total en bloc spondylectomy in malignant vertebral tumors. Spine. 1996;21(12):1401–7.CrossRefPubMedGoogle Scholar
  5. 5.
    Maish M. The diaphragm. Surg Clin N Am. 2010;90(5):955–68.CrossRefPubMedGoogle Scholar
  6. 6.
    Baaj A, Papadimitriou K, Amin A, Kretzer R, Wolinsky J, Gokaslan Z. Surgical anatomy of the diaphragm in the anterolateral approach to the spine. A cadaveric study. J Spin Disord Tech. 2014;27:220–3.CrossRefGoogle Scholar
  7. 7.
    McLain RF. Video assisted spinal cord decompression reduces surgical morbidity and speeds recovery in patients with metastasis. J Surg Oncol. 2005;91:212–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Walsh G, Gokaslan Z, McCutcheon I, Mineo M, Yasko A, Swisher S, et al. Anterior approaches to the thoracic spine in patients with cancer: indications and results. Ann Thorac Surg. 1997;64(6):1611–8.CrossRefPubMedGoogle Scholar
  9. 9.
    Watkins RG. Tenth rib: thoracoabdominal approach. In: Watkins RG, editor. Surgical approaches to the spine. New York: Springer; 1983. p. 83–8.CrossRefGoogle Scholar
  10. 10.
    Moskovich R, Benson D, Zhang Z, Kabins M. Extracoelomic approach to the spine. J Bone Joint Surg. 1993;75(6):886–93.CrossRefGoogle Scholar
  11. 11.
    Kinnear W, Kinnear G, Watson L, Webb J, Johnston I. Pulmonary function after spinal surgery for idiopathic scoliosis. Spine. 1992;17(6):708–13.CrossRefPubMedGoogle Scholar
  12. 12.
    McLain RF. Extracavitary approaches to the thoracolumbar spine. In: Weinstein SL, editor. Pediatric spine surgery. 2nd ed. Philadelphia: Lippincott, Williams and Wilkins; 2000. p. 179–84.Google Scholar
  13. 13.
    Kim M, Nolan P, Finkelstein J. Evaluation of the 11th rib extrapleural-retroperitoneal approach to the thoracolumbar junction. J Neurosurg Spine. 2000;93:168–74.CrossRefGoogle Scholar
  14. 14.
    Zdeblick TA. Anterior thoracolumbar corpectomy and stabilization. In: Bradford DS, Zdeblick TA, editors. The spine: master techniques in orthopaedic surgery. Philadelphia: Lippincott, Williams and Wilkins; 2004. p. 195–207.Google Scholar
  15. 15.
    Molinares D, Davis T, Fung D, Liu J, Clark S, Daily D, et al. Is the lateral jack-knife position responsible for cases of transient neurapraxia? J Neurosurg Spine. 2016;24(1):189–96.CrossRefPubMedGoogle Scholar
  16. 16.
    Scheufler K. Technique and clinical results of minimally invasive reconstruction and stabilization of the thoracic and thoracolumbar spine with expandable cages and ventrolateral plate fixation. Neurosurgery. 2007;61(4):798–809.CrossRefPubMedGoogle Scholar
  17. 17.
    Altaf F, Weber M, Dea N, Boriani S, Ames C, Williams R, et al. Evidence-based review and survey of expert opinion of reconstruction of metastatic spine tumors. Spine. 2016;41:S254–61.CrossRefPubMedGoogle Scholar
  18. 18.
    Park M, Deukmedjian A, Uribe J. Minimally invasive anterolateral corpectomy for spinal tumors. Neurosurg Clin N Am. 2014;25(2):317–25.CrossRefPubMedGoogle Scholar
  19. 19.
    Uribe J, Dakwar E, Le T, Christian G, Serrano S, Smith W. Minimally invasive surgery for thoracic spine tumor removal. Spine. 2010;35(26S):S347–54.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryHouston Methodist HospitalHoustonUSA
  2. 2.Spine and Orthopedic Institute, St Vincent Charity Medical GroupClevelandUSA
  3. 3.Biomedical EngineeringCleveland State UniversitySolonUSA

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