Although most spinal lesions respond well to radiotherapy, radioresistant tumors and those causing fracture and bony compression of the spinal cord often require direct surgical decompression. In the upper thoracic spine, the surgical approach can be challenging in the best of circumstances. Anterior decompression successfully treats spinal cord compression caused by fracture and tumor mass. Performed for lesions located ventral to the cord, 80% of the vertebrectomy patients retained or regained the ability to walk, compared to only 40% of the laminectomy patients. Posterior stabilization significantly improves pain relief compared to laminectomy alone but requires a second major operation after the anterior tumor surgery.
Posterolateral decompression of the thoracic spine provides both spinal cord decompression and posterior instrumentation, reducing operative time, morbidity, and hospital stay. Drawbacks to the traditional posterolateral decompressions have included poor access to tumor immediately anterior to the spinal cord—the cause of neural compression and most local recurrence—and the need to manipulate the spinal cord to completely remove both adjacent tumor and tumor adherent to the dura.
Using standard endoscopic instruments, subtotal and total vertebrectomy, cord decompression, and anterior reconstruction can be accomplished through the same incision used for the posterior instrumentation. This approach has proven useful for a variety of metastatic tumors and permits sound anterior and posterior column reconstruction using any of a variety of construct strategies.
Laminectomy may be distinctly detrimental to neurologic outcome in patients with anterior cord compression. If the cord is manipulated in an effort to reach anterior tumor tissue, the risk of neurological injury is high, particularly in the thoracic region. Experience has shown that patients with vertebral collapse fail to improve after laminectomy because adequate decompression of the cord is not possible. Retropulsed vertebral fragments and tumor must be removed from the canal, and this cannot be accomplished without traumatizing the cord. Even if adequate decompression could be obtained, the resulting instability results in a high risk of postoperative kyphosis, cord compression, and paraplegia.
Traditional costotransversectomy has been used to debulk and stabilize metastatic tumors, but the results have not been as good as the anterior approach, even when combined with posterior, segmental instrumentation. Surgeons have reported good short-term results in small series of metastatic lesions but felt that an anterior approach was indicated in patients with a life expectancy greater than 1 year, in order to achieve local control. Herein, we discuss options for gaining a satisfactory decompression and surgical stability in patients with thoracic level metastatic disease.
Spinal tumors Thoracic spine Metastatic tumors Endoscopic surgery Cancer Spine surgery Decompression Instrumentation Reconstruction Corpectomy
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The author has received nothing of value from any entity, industrial agency, or sponsor in relation to any aspect of the study presented here.
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