The technique was less frequently used mainly due to its associated morbidity risk; but the development of videoscopy tools now allows less invasive surgery, compared to conventional thoracophrenolombotomy. Given also the mechanical drawbacks of posterior assembly in certain types of fracture, a video-assisted anterior approach is becoming more common. A conjunction of a staged anterior followed by a posterior approach has progressively developed, to address the needs of spinal trauma: this encompasses posterior surgical reduction-internal fixation, sometimes performed in emergency, with or without laminectomy followed by corporectomy, then anterior spinal reconstruction by graft with or without osteosynthesis to improve medullary decompression and avoid secondary correction loss and non-union.
Adapting vertebroplasty techniques to spinal traumatology should gradually limit indications for an anterior approach for purely mechanical purposes; this later will, however, logically remain indicated when anterior spinal cord compression is present with associated neurological deficit, whether or not persisting after posterior reduction-osteosynthesis.
Surgical management of thoracolumbar fracture has three objectives: to reduce the traumatic spine deformity, to restore spinal canal anatomy in case of medullary decompression, and to achieve consolidation by stabilizing the spine by osteosynthesis, sometimes associated to bone graft. To these ends, the approach may be posterior, anterior or combined, in whichever order. Presence of neurologic disorder and anatomopathologic fracture type determine the role of surgery in most reports, but indications for an anterior approach remain poorly defined.
Primary posterior osteosynthesis will determine the requirements of a subsequent anterior approach according to the resulting decompression and stability. Surgery is classically performed under selective intubation to collapse the operated lung. Projection of the fractured vertebra onto the wall of the thorax under image intensification determines the level of the incision, which should be exactly perpendicular to the vertebral body, as the distance between wall and spine entails a long instrumental trajectory. Anterolateral decompression for neural involvement in thoracolumbar fractures J.
Click here to see the Library ] Figure 1. T12 fracture. Conventional thoracophrenolombotomy for corporectomy and arthrodesis by MACS plate.
Minimally invasive thoracotomy associated to 2 working introducers. Photo: J. Corporectomy should initially respect the anterior and posterior body walls. This has two advantages: it avoids beginning with the most hemorrhagic stage, which is intracanal bone fragment exeresis and also, by conserving the anterior wall, protects the prespinal vessels from any forward slip of a curette.
The final stage of posterior corporectomy should not be anteroposterior but on the contrary should push the intracanal bone fragments forward, using a curved curette. Posterior longitudinal ligament PLL exeresis enables visualization of the dura mater. Entry should be through the foramen, located in the inferior thorax levels by following the intercostal nerve, to resect the left pedicle, so as to visualize the dura mater, and then remove intracanal fragments Figure 3. This stage should be executed rapidly, as it is always hemorrhagic due to epidural veins torn during the fracture and mobilized during decompression.
Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. L2 burst fracture Magerl type A3 with Frankel B paraplegia. Pre- and post-op CT, sagittal reconstruction. Reduction-laminectomy and osteosynthesis by initial posterior approach followed by partial posterosuperior corporectomy with anterior arthrodesis by tricortical graft and screwed plate.
Posterior Approach to Lumbar Spine
Incomplete neurologic recovery Frankel D paraplegia. Peroperative view of anterior decompression by partial T11 corporectomy. The full width of the dural sheath should be visualized. Madi et al. There may be an indication for isolated body graft following very stable posterior assembly. II : Click here to see the Library ].
Impacting tricortical iliac graft. Many types of synthesis material are used, some of which were developed specifically for endoscopy. Results are given for 19 series, comprising cases of surgery on an anterior approach; all or almost all cases are of dorsolumbar hinge involvement Table 2. Deep sepsis is a very rare complication.
- Anterior Approach to Spine Surgery.
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In the 12 reports that detail complications, only five deep infections occurred out of cases: i. Anterior plating in thoracolumbar spine injuries. Surgical treatment of traumatic fractures of the thoracic and lumbar spine Spine. Without primary posterior stabilization surgery, mean surgery time ranges from 2. Mean peroperative bleeding ranges from 0. Material should be lateral, without contact with arterial vessels, as some cases of late aortic erosion by projecting plates or screws have been reported [ 21 Djian P. Aortic erosions and lacerations associated with the Dunn anterior spinal instrumentation.
Click here to see the Library ]. The material should therefore be such as to minimize projection maximum plate thickness, 10 mm , without projecting relief. For some authors, this risk argues for a straight approach, to position the material at a distance from the aorta. Click here to see the Library ], with systematic and effective pulmonary drainage in case of a transpleural approach or of leakage during re-expansion, while minimizing surgery time.
No English-language teams, however, so much as mention an indication for this examination in traumatology. The risk thus seems to be slight or non-existent? As its interest appears to be very hypothetical, we do not recommend undertaking preoperative medullary arteriography.
Conditions Treated Using MIS Procedures
There were no cases of neurologic aggravation in the 16 published series, and it is thus completely exceptional. T12 fracture, Magerl type C, with Frankel B paraplegia. Pre-op myelogram. Horizontal slice No dural sheath opacity due to medullary compression. Post-op control myelogram at D Horizontal slice. Medullary decompression. Instrumental arthrodesis using an isolated anterior approach thus seems to be effective against secondary recurrence of kyphosis. An anterior approach is to be recommended on mechanical grounds, to repair anterior bone loss, and neurologically, to release medullary compression by removing intracanal bone fragments.
It provides a one-shot solution: decompression by corporectomy, reduction by anterior spinal reopening, inter- or intrabody bone graft and, finally, plate osteosynthesis. Neurologic recovery rates are slightly better than in posterior surgery, with better spinal profile correction [ 29 Guigui P, Lassale B, Deburge A.
Surgical Approaches to the Spine | Robert G. Watkins | Springer
It also involves a smaller number of instrumentally fixed levels: following corporectomy, arthrodesis usually concerns three vertebrae two disks. It tends to be more hemorrhagic than posterior surgery, even with minimally invasive techniques. Certain contra-indications, however, are to be borne in mind: morbid obesity, certain chest pathologies inducing respiratory insufficiency thoracic involvement with pulmonary contusion in multiple trauma , pleural synechia purulent pleurisy or coagulation disorder DIVC.
Certain traumatic lesions irreducible dislocation are more obviously and easily reduced using a posterior approach. For many authors, they also follow from the limits of the posterior approach in terms of the degree anterior spinal destruction, post-traumatic kyphosis and canal stenosis. Decompression is then based on corporectomy with associated graft and osteosynthesis.
Lateral Access Spine Surgery
Symposium de la SoCOT In terms of post-traumatic kyphosis, multiple trauma rate and neurological complications, patients operated on with an anterior approach would seem to have been the more severe cases. There is too much uncertainty as to prognostic factors for functional result, and particularly for neurological evolution, for a formal decision tree to be drawn up. We shall therefore try give some answers to the main questions raised by the management of thoracolumbar fracture.
Goutallier et al. L1 fracture, Magerl type C, with Frankel C paraplegia. Pre-op lateral X-ray. Pre-op CT. Sagittal reconstruction.
RCSEd – Surgical Approaches to the Spine
Pre-op MRI. Post-op control X-ray. Post-op control scanner at D D12L2 graft aspect. Posterior corporectomy with medullary decompression. Post-op CT at 3 yrs FU. D12L2 arthrodesis consolidation. Full neurologic recovery.
Horizontal slices. Lateral X-ray at 8 yrs FU. Results with laminectomy vary greatly between reports. Surgery time and hemorrhage are increased, and there is a risk of dural breech and of neurologic sequelae [ 29 Guigui P, Lassale B, Deburge A. I : Click here to see the Library ], recovery was equivalent between the 25 patients with deficit treated on a posterior approach without laminoarthrectomy or any anterior stage and the laminectomy group. Laminectomy is no doubt pointless in certain types of fracture, and should not be systematic, even in case of neurologic involvement [ 29 Guigui P, Lassale B, Deburge A.
Intracanal bone fragments adhering to the disks are partially repositioned by the ligamentotactic effect of the PLL during restoration of vertebral body height and kyphosis correction, exerting indirect partial decompression.