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SN Comprehensive Clinical Medicine

, Volume 1, Issue 12, pp 1094–1097 | Cite as

Transaxillary left-sided minimally invasive approach for upper thoracic vertebral resection and reconstruction at T2–T3 levels: a case report

  • Bassam RedwanEmail author
  • Volkan Kösek
  • Martin Matip
  • Maximilian Puchner
  • Burkhard Thiel
Surgery
  • 69 Downloads
Part of the following topical collections:
  1. Topical Collection on Surgery

Abstract

Surgical procedures of the upper thoracic spine are often challenging due to the anatomical topography of the thoracic spine. The most common approaches include the anterior supramanubrial, transmanubrial, and transsternal as well as the posterior approach with costotransversectomy. Recently, an infraaxillary right-sided thoracotomy was described for upper thoracic vertebral decompression and fusion at T2–T6 levels. In the current case, we report a transaxillary left-sided mini-thoracotomy for thoracic vertebral resection and reconstruction at T2–T3 levels. The incision enabled safe and uncomplicated surgery of the upper thoracic spine providing excellent exposure of the surgical site. Compared with the common incisions applied for surgery of the upper thoracic spine, surgical trauma is minimized without the need of sternotomy, division of the back muscles or resecting a rib. Moreover, anatomical critical structures such as the common carotid trunk, the jugular vein, or trachea are not encountered, hence increasing the safety of the procedure.

Keywords

Thoracotomy Upper thoracic spine Corporectomy Minimally invasive 

Introduction

Surgical procedures of the upper thoracic spine are often challenging due to the anatomical topography of the thoracic spine. The most common approaches include the anterior supramanubrial (Smith Robinson), transmanubrial, and transsternal as well as the posterior approach with costotransversectomy [2]. Recently, an infraaxillary right-sided thoracotomy was described for upper thoracic vertebral decompression and fusion at T2–T6 levels [1]. In the current case, we report a transaxillary left-sided mini-thoracotomy for thoracic vertebral resection and reconstruction at T2–T3 levels.

Case Presentation

A 51-year-old male patient with known history of intravenous drug abuse was admitted to our hospital with progressive bilateral leg weakness. On clinical examination, leg paresis with a muscle strength grade of (2–3/5) was observed. Moreover, urinary and rectal incontinence were present. Magnetic resonance imaging (MRI) and computed tomography (CT) revealed an extensive spondylodiscitis with intraspinal and epidural abscess and almost complete destruction of the vertebral bodies T2–T3 (Figs. 1 and 2). Spinal tuberculosis was suspected. Due to the clinical manifestation and the spinal compression, emergency surgery was indicated. Navigation-assisted placement of an internal fixation T1–T4 using the Occipito-Cervico-Thoracic Spinal System (OASYS®, Stryker, Duisburg, Germany) and laminectomy at T2–T3 for the spinal cord decompression were performed. After recovery, elective corporectomy of the vertebral bodies T2 and T3 was planned. Due to the anticipated intrapleural inflammatory reaction with possible lung adhesions, multidisciplinary surgery including neuro- and thoracic surgeons was planned.
Fig. 1

Magnetic resonance imaging (MRI) showing extensive spondylodiscitis with intraspinal and epidural abscess with spinal compression

Fig. 2

Computed tomography (CT) after laminectomy and internal fixation showing severe destruction of the vertebral bodies T2 and T3

Under general anesthesia, single-lung ventilation was initiated by a left-sided Robertshaw double-lumen endobronchial tube. The patient was placed in a right-sided lateral decubitus position using a vacuum mattress. The left upper arm was abducted anteriorly and the elbow flexed to 90°. A transaxillary mini-thoracotomy (4 cm) was performed and the chest cavity was opened in the second intercostal space. Massive adhesions and a local pleural empyema were present at the site of spondylodiscitis. After pleurolysis and decortication of the lateral left upper lobe, the vertebral bodies T2 and T3 were exposed. Subsequently corporectomy was performed. Vertebral body replacement was carried out using the X-Core 2 system (NuVasive®, Bremen, Germany) (Figs. 3 and 4). Due to the accompanying pleural empyema, two chest drains were inserted.
Fig. 3

Corporectomy of the vertebral bodies T2 and T3 via transaxillary left-sided mini-thoracotomy

Fig. 4

Vertebral body replacement using the X-Core 2 system (NuVasive®, Bremen, Germany)

The postoperative course was uneventful. Chest tubes were removed on postoperative day (POD) 5. Postoperative CT scan showed the correct position of the vertebral body replacement (Fig. 5). The initial leg paraparesis improved markedly with a muscle strength grade of 4/5 and the patient was able to mobilize himself independently in the wheel chair. The microbiological examination revealed an infection with staphylococcus epidermidis ruling out the initially suspected spinal tuberculosis. On POD 18, the patient was discharged for further neurological rehabilitation (Fig. 6).
Fig. 5

Postoperative CT scan showing correct position of the vertebral body replacement

Fig. 6

Transaxillary left-sided minimally invasive incision (4 cm) at discharge

Discussion

In the present case, a novel left-sided transaxillary minimally invasive approach for corporectomy and subsequent vertebral body replacement was described. The incision enabled safe and uncomplicated surgery of the upper thoracic spine providing excellent exposure of the surgical site. Compared with the common incisions applied for surgery of the upper thoracic spine, surgical trauma is minimized without the need of sternotomy, division of the back muscles or resecting a rib. Moreover, anatomical critical structures such as the common carotid trunk, the jugular vein or trachea are not encountered, hence increasing the safety of the procedure. In the latest work of Liu et al., a similar approach was reported [1]. However, in this work, an 8–12-cm right-sided infraaxillary incision was applied. In our case, only a 4-cm incision was needed.

Another important factor to facilitate safe surgery is the multidisciplinary approach. In our case, massive pleural adhesions and an empyema were present, including thoracic surgeons helped in gaining the best exposure to the vertebral bodies after pleurolysis without compromising the lung tissue. We therefore routinely perform such surgeries in a multidisciplinary team at our institution and strongly recommend this concept.

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

Not applicable.

Informed Consent

The patient has consented to the submission of the case report for submission to the journal (SN Comprehensive Clinical Medicine).

References

  1. 1.
    Liu J, Li S, Huang K, Lu X, Shi Y, Xie K, et al. Right infraaxillary thoracotomy approach for upper thoracic vertebral decompression and fusion at T2-T6 levels: a technical note. Eur Spine J. 2019;28(3):470–6.CrossRefGoogle Scholar
  2. 2.
    Singhatanadgige W, Zebala LP, Luksanapruksa P, Daniel Riew K. Can standard anterior Smith-Robinson supramanubrial approach be utilized for approach down to T2 or T3? Eur Spine J. 2017;26(9):2357–62.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Thoracic Surgery, Klinik am ParkKlinikum WestfalenLünenGermany
  2. 2.Department of Neurosurgery Knappschaftskrankenhaus RecklinghausenKlinikum VestRecklinghausenGermany

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