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Endoscopically Assisted Decompression for Metastatic Thoracic Neoplasms

McLain, Robert F., MD


Study Design. The author describes a technique for complete vertebrectomy and anterior decompression followed by a formal anterior column reconstruction, using readily available endoscopic instruments. This procedure is indicated in patients with radioresistant metastasis of the thoracic spine, particularly those involving the upper thoracic segments where a thoracotomy is difficult and causes a high rate of morbidity. This is also a suitable technique for patients with pulmonary disease who cannot tolerate a standard thoracotomy.

Objectives. To demonstrate the feasibility and potential benefits of endoscopically controlled decompression through an extrapleural, posterolateral approach.

Summary of Background Data. Posterolateral decompression of the thoracic spine offers potential advantages in comparison with traditional anterior-posterior procedures combining thoracotomy and posterior instrumentation, including decreased operative time, decreased morbidity, and reduced hospital stay. Results of previous studies have not demonstrated the same benefit for posterolateral decompression as for anterior vertebrectomy and decompression. Drawbacks to the traditional posterolateral decompressions have included poor visualization of the spinal cord and anterior tumor, poor access to tumor on the side contralateral to the approach, and the need to manipulate the spinal cord to completely remove adjacent tumor and tumor adherent to the dura.

Methods. Surgical indications, rationale, and technique are provided, and initial clinical results are described.

Results. Transpedicular decompression using endoscopy is described in five patients. The mean operative time for the combined procedure was 7.25 hours, with a mean blood loss of 1800 mL. Neurologic recovery and maintenance were excellent. Inpatient days averaged 7.5, and intensive care days averaged 2. One patient died of disease 8 months after surgery, and four were living, with disease, 3-24 months after surgery.

Conclusions. Endoscopically assisted decompression can reduce morbidity, hospital stay, and treatment costs while matching the efficacy of traditional combined procedures. Endoscopy provides a readily available and easily applied tool that dramatically improves the surgeon's vision, providing light, magnification, and a direct view of remote structures.

From the Department of Orthopaedic Surgery, The Cleveland Clinic Foundation, Cleveland Ohio.

Acknowledgment date: March 27, 1997.

Acceptance date: October 27, 1997.

Device status category: 10.

Address reprint requests to: Robert F. McLain, MD; Department of Orthopaedic Surgery/A41; The Cleveland Clinic Foundation; 9500 Euclid Avenue; Cleveland, OH 44195.

© Lippincott-Raven Publishers.