With the introduction of new techniques and hardware, surgical approaches to the anterior thoracic spine have evolved over the past decades to lower morbidity, improve fusion, and balance quality of life outcomes. With advances in adjuvant therapies, the surgical treatment of spinal metastases remains palliative where the goals are decompression, stabilization, diagnosis, and local tumor control. The primary indications for surgery are to decompress severe canal stenosis for radioresistant tumors and to address mechanical instability.
While the laminectomy provides access to posterior pathology, it does not provide sufficient access to anterior pathology without significant neurological morbidity. Extending the dissection from a laminectomy, the transpedicular (TP), costotransversectomy (CT), and lateral extracavitary (LECA) approaches each offer progressively larger extent of resection and access to the anterior ventral thoracic spinal column.
This chapter presents an account of how we perform the lateral extracavitary approach. We detail preoperative planning, angiography, positioning, neuromonitoring, dissection, fusion, and cage placement. At each step we discuss technical nuances and strategies to avoid or manage complications. Through the description of the exposure and resection, it should become apparent that the LECA approach is within a continuum of posterior approaches to the anterior spine, with laminectomy, transpedicular, and costotransversectomy serving as limited versions of the LECA. By learning this approach, the techniques needed to complete the LECA exposure will enable the surgeon to also perform the exposure and resections for TP and CT.
Larson SJ, Holst RA, Hemmy DC, Sances A. Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J Neurosurg. 1976;45(6):628–37.CrossRefGoogle Scholar
Ohgiya Y, Oka M, Hiwatashi A, Liu X, Kakimoto N, Westesson PL, et al. Diffusion tensor MR imaging of the cervical spinal cord in patients with multiple sclerosis. Eur Radiol. 2007;17(10):2499–504.CrossRefGoogle Scholar
Patchell RA, Tibbs PA, Regine WF, Payne R, Saris S, Kryscio RJ, et al. Direct decompressive surgical resection in the treatment of spinal cord compression caused by metastatic cancer: a randomised trial. Lancet (London, England). 2005;366(9486):643–8.CrossRefGoogle Scholar
Bilsky M, Smith M. Surgical approach to epidural spinal cord compression. Hematol Oncol Clin North Am. 2006;20(6):1307–17.CrossRefGoogle Scholar
Laufer I, Rubin DG, Lis E, Cox BW, Stubblefield MD, Yamada Y, et al. The NOMS framework: approach to the treatment of spinal metastatic tumors. Oncologist. 18. Durham, NC, USA, 2013. p. 744–51.Google Scholar
Bilsky MH, Laufer I, Fourney DR, Groff M, Schmidt MH, Varga PP, et al. Reliability analysis of the epidural spinal cord compression scale. J Neurosurg Spine. 2010;13(3):324–8.CrossRefGoogle Scholar
Gerszten PC, Mendel E, Yamada Y. Radiotherapy and radiosurgery for metastatic spine disease: what are the options, indications, and outcomes? Spine (Phila Pa 1976). 2009;34(22 Suppl):S78–92.CrossRefGoogle Scholar
Moussazadeh N, Laufer I, Yamada Y, Bilsky MH. Separation surgery for spinal metastases: effect of spinal radiosurgery on surgical treatment goals. Cancer Control: J Moffitt Cancer Center. 2014;21(2):168–74.CrossRefGoogle Scholar
Lubelski D, Abdullah KG, Steinmetz MP, Masters F, Benzel EC, Mroz TE, et al. Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications. J Spinal Disord Tech. 2013;26(4):222–32.CrossRefGoogle Scholar
Champlin AM, Rael J, Benzel EC, Kesterson L, King JN, Orrison WW, et al. Preoperative spinal angiography for lateral extracavitary approach to thoracic and lumbar spine. Am J Neuroradiol. 1994;15(1):73.PubMedGoogle Scholar
Dvorak M, MacDonald S, Gurr KR, Bailey SI, Haddad RG. An anatomic, radiographic, and biomechanical assessment of extrapedicular screw fixation in the thoracic spine. Spine (Phila Pa 1976). 1993;18(12):1689–94.CrossRefGoogle Scholar
Cruz LC Jr, Domingues RC, Gasparetto EL. Diffusion tensor imaging of the cervical spinal cord of patients with relapsing-remising multiple sclerosis: a study of 41 cases. Arq Neuropsiquiatr. 2009;67(2B):391–5.CrossRefGoogle Scholar
Miller MD, Chhabra AB, Hurwitz HR, et al. Posterior extracavitary/costotransversectomy/posterolateral approach to the thoracic spine. In: Orthopaedic surgical approaches. Philadelphia: Saunders/Elsevier; 2008. p. 296–303.Google Scholar
Lau D, Chou D. Posterior thoracic corpectomy with cage reconstruction for metastatic spinal tumors: comparing the mini-open approach to the open approach. J Neurosurg Spine. 2015;23(2):217–27.CrossRefGoogle Scholar