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Surgery

Minimally Invasive Surgery for Traumatic Spinal Pathologies

A Mini-Open, Lateral Approach in the Thoracic and Lumbar Spine

Smith, William D. MD*†; Dakwar, Elias MD; Le, Tien V. MD; Christian, Ginger BS; Serrano, Sherrie BS; Uribe, Juan S. MD

Author Information
doi: 10.1097/BRS.0b013e3182023113
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The decision-making process in treating cases of acute spinal trauma is difficult. Considerations include the fracture morphology (extent of instability of the fracture, the current or potential injury to the spinal cord, and the status of the posterior ligamentous complex), the likelihood of success with conservative care, the presence of polytrauma, access surgeon and hospital resource availability, and patient demographics.1,2 In cases where surgical intervention is indicated, the type of procedure used is largely decided by surgeon preference and comfort, but can include anterior, lateral, posterolateral, or posterior approaches through endoscopic, mini-open, or open exposures. Historically, open, long-segment posterior fixation alone has been the standard for thoracolumbar fracture reconstruction.3–5 This technique provides for some indirect decompression of the anterior column and reestablishment of sagittal alignment, although the long-term viability of posterior-only approaches has been challenged biomechanically and clinically.6–9 Anterior techniques allow for direct decompression of the spinal cord and for anterior column reconstruction through the use of vertebral body replacement devices,9 although open thoracotomy and thoracoabdominal approaches carry significant risks of excessive blood loss, permanent diaphragm disfiguration, damage to the abdominal wall, pulmonary complications, and prolonged incisional pain.10,11

There are certainly advantages and disadvantages to different techniques, though the literature is less than ideal as a guide. Few examples exist of level I and II data, mostly with exceedingly small sample sizes by conventional standards and indications which are limited primarily to stable fractures without neurologic injury.2,4,5,12,13

Recent advancements in percutaneous and short-segment posterior fixation and minimally disruptive techniques for thoracolumbar corpectomy suggest that similar or improved benefit can be obtained without the complications and morbidities commonly associated with open techniques.14 Although the adoption of endoscopic techniques for trauma has been slow due to extensive and expensive instrumentation, significant learning curves,10 emergent conversions to open approaches,10,15–17 and difficulty in placing anterior instrumentation,16 mini-open approaches have shown promise in using conventional surgical techniques and direct visualization with minimal collateral damage to healthy soft tissue.18–22 The objective of this study was to examine the treatment and outcome characteristics of patients treated for acute traumatic thoracolumbar fractures with a mini-open, 90° lateral approach for corpectomy.

Materials and Methods

Between 2006 and 2009, all consecutive patients treated with a mini-open, lateral approach for unstable traumatic fracture with or without neurologic deficit by 2 neurosurgeons working at level I trauma centers (University Medical Center, Las Vegas, NV, and University of South Florida, Tampa, FL) were included in this evaluation. This series included unstable traumatic pathologies, mostly with neurologic deficit, which are more universally accepted as clear surgical candidates, rather than to have included patients with stable and non-neurologically impaired pathologies, where surgical intervention is more controversial.4,12 Patient and outcome data were collected through a prospective registry, whereas operative and hospitalization data were collected via retrospective chart review. Neurologic status was assessed using the classification system set forth by the American Spinal Injury Association's (ASIA) standard neurologic classification of spinal cord injury worksheet. The ASIA classification ranks neurologic status from A (complete neurologic injury) to E (completely neurologically intact).

Technique

The patients presenting to the trauma center with thoracolumbar burst fracture with spinal cord injury were treated with high-dose steroids according to the second national acute spinal cord injury study-II guidelines.23 When stabilized for surgery, patients were placed in the lateral decubitus position, with the skin incision (5–7 cm length) along the corresponding rib guided by fluoroscopy. Neuromonitoring was performed using free-run and discrete-threshold, directionally stimulated electromyography with somatosensory and motor-evoked potentials used for thoracic levels (NeuroVision® M5®, NuVasive®, Inc, San Diego, CA). Real-time neuromonitoring was used throughout each case, with stimulated monitoring used during passage through the psoas muscle (where relevant), retractor expansion, and instrument implantation. Accessing the anterior column in the lumbar spine (L2–L5) for corpectomy uses the same retroperitoneal, transpsoas approach as extreme lateral interbody fusion (XLIF®, NuVasive, Inc), which has been previously described.24 Modifications to the approach used in this series include the omission of a second fascial incision, the use of a slightly larger incision to allow for adequate working space for the corpectomy, and minimized table break so as not to disrupt unstable fractures. In the thoracic spine (T5–T11), a lateral transpleural approach was used, typically with a small segment of rib resected. For all thoracic cases, the ipsilateral lung remained inflated: dual lumen, single-lung intubation was not used in this series. For T12 and L1 cases, a retropleural approach was used where a plane between the parietal pleura and the inner surface of the rib inferior to the access incision was created with the diaphragm and pleura retracted and dissected anteriorly (Figures 1A–D).

Figure 1
Figure 1:
Illustrations of the retropleural exposure including initial exposure (A), deflection of the diaphragm (B, C), and anterior column access using sequential tube dilators (D).

Sequential tube dilation preceded docking of an expandable retractor (MaXcess®, NuVasive, Inc) on the anterior spinal column. The retractor was positioned to perform the corpectomy, allowing for a 90° safe working zone ventral to the spinal canal, beginning with inferior and superior discectomies (Figure 2). After coagulation of segmental vessels, the corpectomy was performed working within the space defined by the retractor on lateral projection until the retropulsed fragments were mobilized and the spinal canal was decompressed (Figure 3).

Figure 2
Figure 2:
Anterior illustration (left) and fluoroscopic view (right) of disc preparation inferior to the vertebral fracture.
Figure 3
Figure 3:
Lateral fluoroscopy (left) and intraoperative photograph (right) of fracture exposure using a mini-open, lateral approach.

Vertebral body replacement was performed using either an expandable titanium (Ti) cylindrical cage (Obelisc®, Ulrich Medical, Inc, Ulm, Germany) or a wide-footprint expandable Ti cage (XCore®, NuVasive, Inc). Autograft was used in each case either alone, with a β-tricalcium phosphate and hydroxyapatite synthetic graft extender (Formagraft®, NuVasive, Inc) or with rh-BMP2 (Infuse®, Medtronic, Sofamor Danek, Inc, Memphis, TN). Supplemental internal fixation included either an anterolateral plate (Traverse®, NuVasive, Inc), anterolateral rod and screw construct (SpheRx® Anterior, NuVasive, Inc), posterior pedicle screw fixation (SpheRx, NuVasive, Inc), or both anterolateral and posterior pedicle screw fixation. Red rubber catheters and an underwater (tube) Valsalva maneuver were used on final incision closure. After the retropleural space was void of air, the catheter ceased creating bubbles during Valsalva and the tube was removed, thus avoiding the use of chest tubes.

Results

Fifty-two patients were treated for acute traumatic unstable spine fractures with a mini-open, lateral approach for corpectomy from T7 to L4. The mean age of the patients was 43 years (range, 14–67), with an average BMI of 27.7 (range, 18.2–40.7); 63.5% (33 patients) were male. There were 52 baseline morbidities present, distributed over 27 patients. The most common comorbidity was hypertension (32.7%), followed by tobacco use (28.8%). Most patients (94.2%) were diagnosed with rotation or distraction fractures (AO types B and C25), with 50% exhibiting kyphotic deformities greater than 20°, and 92.3% presenting with neurologic deficit (ASIA A through D). Complete demographic information is included in Table 1. The majority of patients (69.2%) were treated at the thoracolumbar junction, T12 or L1. A right-sided approach was used from T7 to T10; a left-sided approach was used from T11 to L4. Transpleural approaches were used in a total of 9 cases, including all levels from T7 through T11 and in 1 case at T12. Using the red rubber catheter underwater Valsalva maneuver, chest tube placement was avoided in all but 2 (3.8%) of cases. A retropleural approach was used in cases at the thoracolumbar junction; a retroperitoneal transpsoas approach was used in the lumbar region. Expandable cylindrical Ti cages were used in 34 (65.4%) cases, and an expandable wide-footprint Ti cage was used in the remaining 18 (34.6%) cases. Autograft was used in all cases, with synthetic biologic extenders the most common supplement in 75% of cases. Supplemental internal fixation was used in all cases, with 75% anterolateral fixation and 46% pedicle screw fixation (28.8% combined anterolateral and pedicle screws fixation). Short segment fixation (1 level above and below the corpectomy) was used in 75% of pedicle screw cases, with long-segment fixation used in the remainder. Six cases were staged (11.5%), all for placement of long-segment pedicle screw fixation, all in cases of extreme kyphotic and/or rotatory or distraction deformities. Complete treatment information is included in Table 2.

Table 1
Table 1:
Patient Demographics
Table 2
Table 2:
Treatment Summary

Median operative time (OR time) from cut to close was 127.5 minutes (range, 36–686), median estimated blood loss (EBL) was 300 (range, 50–4200), and median postoperative hospitalization (length of stay [LOS]) was 4 days (2–19 days). EBL and OR times were reported as the combined times for anterior and posterior procedures (when used), and LOS included the staging intervals for staged patients.

Seven (13.5%) patients experienced 8 (15.4%) complications, with 2 instances each of dural tear, intercostal neuralgia, and deep vein thrombosis; 1 pleural effusion; and 1 superficial posterior infection. Mild radiographic subsidence of the anterior cage occurred in 7 patients (13.5%), all with expandable cylindrical Ti cages. No instances of subsidence were observed in patients treated with expandable wide-footprint Ti cages. Subsidence progression was marked by early postoperative subsidence and subsequent stabilization. Of the patients with radiographic subsidence, 1 (14.3%) developed resultant symptoms (pain) and is pending revision (Figure 4). Follow-up compliance for the 2 groups (cylindrical vs. wide-footprint cage patients) was similar at each time point, suggesting that subsidence rates were not artifacts of follow-up mismatch. Retention was 94%, 73.5%, and 55.9% of patients at the postoperative, 12-month, and 24-month time points, respectively, in the cylindrical cage group and 94.4%, 100%, and 55.6%, respectively, in the wide foot-print cage group.

Figure 4
Figure 4:
Lateral radiograph showing subsidence with an expandable cylindrical titanium cage.

ASIA scores were significantly improved at all postoperative time points (all, P < 0.001). No patient experienced neurologic deterioration at any intermediate or final follow-up interval. All patients were available for at least 1 follow-up visit, with 94.2%, 82.7%, and 55.8% returning at postoperative, 12 month, and 24 months, respectively. This suggests that incidence of subsidence was not an effect of greater or longer retention in the cylindrical cage group, but rather it was because of the type of implant used. Individual ASIA status scores are included in Figure 5. Complete outcome information is included in Table 3.

Figure 5
Figure 5:
Individual ASIA scores from preoperative (left) to postoperative at last follow-up (right). The change in ASIA status is indicated by arrows, with the number of patients progressing from pre- to postoperative classifications listed immediately above the line. Number of patients in each category and pre- and postoperative timepoints are included outside the letters. No neurologic deterioration was observed at any time point.
Table 3
Table 3:
Outcome Characteristics

A representative case is included in Figures 6, 7A–C.

Figure 6
Figure 6:
Sagittal magnetic resonance imaging (A) and computed tomography (CT) (B) and axial CT (C) and magnetic resonance imaging (D) of an L2 burst fracture after fall with gross instability and neurologic impairment.
Figure 7
Figure 7:
A, Lateral fluoroscopy (left) and intraoperative photograph (right) of the placement of the expandable wide-footprint titanium cage. B, Anterior fluoroscopy (left) and intraoperative photograph (right) of the placement of anterolateral plating. C, Anterior (left) and lateral (right) immediate postoperative fluoroscopy showing wide-footprint expandable titanium cage and anterolateral plating.

Discussion

From the beginning through the middle of the 20th century, methods of treatment for spinal trauma were limited to conservative care, specifically casting or bracing and extended bed rest, mainly because of an absence of known surgical techniques and instrumentation to treat this difficult patient population.4,26 As surgery became more common in treating traumatic spinal fractures, the morbidities associated with extensive posterior, and later, anterior approaches led to several studies comparing surgery and conservative care, with mixed results.12,13,27–29 Those in support of conservative over surgical care argued against the high initial cost, complication rates, extensive damage to posterior musculature,30,31 and similar clinical outcomes of surgical intervention compared with conservative care.4,26,32 Proponents of surgical intervention touted decreased late medical and pulmonary complications with early fracture stabilization and patient mobilization (conservative regimens can include as much as 3 to 5 months of bed rest, casting, and bracing4), the inability of conservative care to treat unstable fractures or patients with neurologic or pending neurologic deficits, and the strict long-term follow-up and patient compliance required in a population that is often transient.29

Early surgical techniques were mainly posterior-only approaches, first using Luque and Harrington rods, then pedicle screws with plates or rods.3 Luque and Harrington rod instrumentation are generally insufficient in stabilizing and maintaining thoracolumbar burst fractures,7,9 with complication rates as high as 104.3% and 94.4%,3,5 respectively, and reoperation rates in Harrington rod instrumentation as high as 55.5%.3,5 Subsequent kyphotic settling with posterior instrumentation alone (albeit almost always asymptomatic4,9), particularly with Harrington rod instrumentation,3 led to questions of long-term sustainability of techniques that only indirectly decompress the anterior column.

Subsequent biomechanical testing of anterior column reconstruction showed that the direct decompression of the anterior column and restoration of sagittal alignment gained with a corpectomy and vertebral body replacement with lateral plating or supplemental pedicle screw fixation was a superior construct to posterior fixation alone.6–8,33,34 However, with the majority of traumatic fractures occurring at the thoracolumbar junction and in the thoracic spine, thoracotomies and thoracoabdominal approaches, with their significant associated morbidities, were the primary approaches used for anterior column exposure.35 With incision lengths commonly exceeding 20 cm,15 significant pulmonary complications because of dual lumen, single-lung intubation,36,37 high blood loss,9,19,38 the risk of permanent diaphragmatic disfiguration, high infection rates,4,19 and post-thoracotomy pain syndrome present in as many as 50% of patients during the postoperative period, 30% with continuing symptoms at 5 years postoperative,39 the thoracotomy and transabdominal approach are 2 of the most invasive and consequential approaches to the anterior column.40

The resultant trend toward less invasive techniques in acute thoracolumbar trauma to, theoretically, minimize the morbidities associated with these open anterior and posterior approaches was driven by the introduction of endoscopic techniques for spinal fusion procedures and percutaneous pedicle screw instrumentation.10,14,15,17,41–44 In reality, however, endoscopic techniques have not been broadly adopted in spinal fusions or fracture reconstruction because of a steep learning curve, expensive instrumentation, 2-dimensional visualization, the need for experienced assistants and staff, pulmonary complications (single-lung intubation), difficult management of intraoperative complications (the most important instruments during an endoscopic procedure are the rescue instruments), extended operative times, and in the case of anterior corpectomies, struggles with introducing and properly placing vertebral body replacement devices and anterolateral plating.10,16,17,41,43

This has culminated in the development of mini-open techniques that maximize the theoretical benefits of endoscopic techniques—minimal blood loss and soft tissue dissection, decreased LOS, high cosmesis, fewer complications compared with open techniques, and faster return to normal daily life and productivity—while using direct visualization and standard surgical techniques.18,19,21,22 Recent developments in mini-open approaches for thoracolumbar corpectomy have focused on posterior and posterolateral approaches. The minimally invasive surgery (MIS) posterior-based approaches for corpectomies use, basically, transforaminal interbody fusion access portals through the facets to perform a partial corpectomy,21 or a large transforaminal interbody fusion exposure for full corpectomy.15,16,19 In these posterior-based approaches, the risk of neurologic injury is high (in addition to the sacrifice of the exiting nerve root required to negotiate the placement of expandable cages15, 16,19), and the technical reports do not have sufficient samples to know the full risk profile.

The current series represents the results of a technique for a mini-open, lateral corpectomy for thoracic or lumbar burst fractures. In our series, delays in decompression of spinal cord injuries were minimized by the technique not requiring an approach surgeon and scheduling around multiple surgeons' availability. This suggests the opportunity for very early decompression—within a matter of hours, a reported benefit in the most complex cases (“early intervention” defined as decompression between 8 and 24 hours from the time of injury).29,45 Median operative variables, OR time, and EBL, were 128 minutes for combined anterior and posterior approaches with 300 mL of blood loss. This compares favorably with reports of both minimally invasive (MIS) and open techniques for operative time (MIS, 101–450 minutes18,19; open, 210–617 minutes19,38) and blood loss (MIS, 543–1857 mL19,46; open, 2100–3136 mL38,47). Eight (15.4%) complications in 7 (13.5%) patients were observed in this series, none of which required revision. Reported complication rates in MIS and open literature for thoracolumbar corpectomy have ranged from 9.6%16 to 29%19 and 15%5 to 104.3%,3 respectively. LOS had also reduced compared with historical examples, despite the fact that most patients treated in this series had polytrauma and represented severe cases (neurologically incomplete, unstable fractures) compared with those reported in the literature.4,5,13,19,26,28,32 Patients in the current series were discharged a median of 4 days postoperatively, where other MIS and open techniques have reported hospital stay ranges of 4.720 to 6.546 days and 10.75 to 35.53 days, respectively. Table 4 shows the results of representative studies of MIS and open techniques for surgical treatment of traumatic spine fractures, alongside the results from the current study.

Table 4
Table 4:
Treatment and Outcome Data for Different Techniques for the Surgical Management of Thoracolumbar Trauma
Table 4
Table 4:
Continued

Subsidence and radiographic settling after surgical correction for spinal fractures are commonly reported events, sometimes with neurologic or painful consequence,16 though typically asymptomatic.4,5,9 Endplate anatomy may contribute to kyphotic settling, particularly with the use of cylindrical cages for vertebral body replacement, which rest inside the border of the apophyseal ring.48 Radiographic subsidence in the current study was observed only in patients in whom a cylindrical cage was used and was avoided in those treated with the wide-footprint cage. The use of the wide-footprint cage, in this series, eliminated subsidence after corpectomy by loading the apophyseal ring rather than the center of the endplate.

Most patients (82.7%) were available for follow-up at 12 months, showing maintained or improved neurologic status, without any instances of neurologic deterioration. This trend and significant improvement over baseline neurologic status was maintained in the patients available for follow-up at 24 months. These improvements are substantially equivalent to historical reports of neurologic status after corpectomy for traumatic injuries of the spine.28,33 Despite the advantages of the mini-open lateral approach for acute trauma, an advanced understanding of the relevant anatomy and the minimally invasive exposure in a lateral approach are essential before utilization.

Conclusion

There is little consensus in the literature as to the best method of treatment for a particular type of spine fracture, mainly because of the difficulty in generating well-controlled trials of different approaches. The thoracotomies and extensive posterior procedures introduce significant approach-related morbidities that decrease the value of the intervention while increasing the time and decreasing the quality of patients' recovery.14 Endoscopic techniques that have largely eliminated these morbidities have subsequently introduced new challenges that hinder broad adoption of the technology. A mini-open approach, such as the one described here, may serve as a middle ground between open and endoscopic approaches, exploiting the benefits while minimizing the disadvantages of each.

Key Points

  • The management and study of acute traumatic thoracolumbar spine fractures is complex because of highly varied pathologies and morphology, neurologic status, the presence of polytrauma, and a myriad of surgical options with distinct advantages and disadvantages.
  • Corpectomies carried out by traditional thoracotomy and open posterior exposures result in significant morbidity and long-term adverse consequences that decrease the value of surgical intervention.
  • Endoscopic techniques minimize the morbidities of traditional open approaches but bring their own challenges, namely, a steep learning curve, expensive instrumentation, and difficulty in placing anterior vertebral body replacement devices in corpectomies.
  • The mini-open, extreme lateral approach for corpectomy in the thoracolumbar spine represents a middle-ground between open and endoscopic approaches, allowing for a minimally disruptive approach through a small incision with direct visualization of the pathology and utilization of conventional corpectomy techniques.
  • Despite the advantages of the mini-open lateral approach described here, an advanced understanding of the relevant anatomy and the minimally invasive exposure in a lateral approach are required before utilization.

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Keywords:

lateral; mini-open; corpectomy; trauma; thoracic; lumbar; fracture; spine; burst

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