LITMIR.BIZ

Скачать книгу

      • Blunt trauma (complete and incomplete SCI)

      – Pneumohemothorax, pulmonary contusion, cardiac contusion

      • Penetrating trauma (complete and incomplete SCI)

      • Wedge/Compression fracture

      • Burst fracture

      • Chance fracture

      • Fracture-dislocation

      Treatment Options

      • Acute pain control with medications and pain management

      • Physical therapy and rehabilitation

      • If symptomatic with cord compression:

      – Urgent surgical decompression and fusion over implicated segments if deemed suitable candidate for surgery

      • If poor surgical candidate with poor life expectancy, medical management recommended

      – Surgery may be done anteriorly, posteriorly, or combined two-stage approach for added stabilization

      – May include a combination of the following techniques: Laminectomy (entire lamina, thickened ligaments, and part of enlarged facet joints removed to relieve pressure), Laminotomy (section of lamina and ligament removed), Foraminotomy (expanding space of neural foramen by removing soft tissues, small disk fragments, and bony spurs in the locus), Laminoplasty (expanding space within spinal canal by repositioning lamina), Diskectomy (removal of section of herniated disk), Corpectomy (removal of vertebral body and disks), Bony Spur Removal

      • Corpectomy approaches:

      – Anterior (Thoracoscopic): Pleural entry to access anterior thoracic; broadest canal decompression, satisfactory visualization of thecal sac; easy graft insertion; anterolateral screw-plate fixation (see ▶Fig. 2.4 and ▶Fig. 2.5)

      – Anterolateral (Retropleural): Most direct anterior approach requiring retropleural dissection; canal decompression; anterolateral screw-plate fixation

      – Posterolateral (Lateral Extracavitary): Satisfactory visualization of thecal sac; anterior stabilization; posterior tension band preservation; unilateral decompression (see ▶Fig. 2.6)

      – Posterior (Transpedicular): Circumferential decompression; difficult graft insertion; unideal thecal sac positioning (see ▶Fig. 2.7)

      Fig. 2.4 (a–c) Posterolateral approach to performing a cervicothoracic corpectomy. Illustration demonstrates operative view. Intraoperative image demonstrates exposure for multilevel thoracic corpectomy, and postoperative CT scan demonstrates successful corpectomy from a unilateral approach. (Source: Cervicothoracic corpectomy. In: Fessler R, Sekhar L, eds. Atlas of Neurosurgical Techniques: Spine and Peripheral Nerves. 2nd ed. Thieme; 2016).

      Fig. 2.5 (a, b) Illustration demonstrates trajectory of thoracic corpectomy, from a posterior approach, as well as the area of bone removal (colored). Postoperative CT scan demonstrates successful thoracic corpectomy. (Source: Procedure. In: Kim D, Choi G, Lee S, et al, eds. Endoscopic Spine Surgery. 2nd ed. Thieme; 2018).

      Fig. 2.6 (a–d) Preoperative MRI reveal thoracic disk herniation (T7–T8) in a patient who received lateral, retropleural partial corpectomy. Postoperative MRI reveal residual intradural disk (free-floating calcified portion) and cord decompression. (Source: Surgical management. In: Baaj A, Kakaria U, Kim H, eds. Surgery of the Thoracic Spine: Principles and Techniques. 1st ed. Thieme; 2019).

      Indications for Surgical Intervention

      • Spinal stenosis

      • No improvement after nonoperative therapy (physical therapy, pain management)

      • Partial paraplegia

      • Progressive cord compression

      • Progressive kyphosis/deformity

      • Existence of blunt chest trauma or potential hemorrhagic lesions

      • Unstable patterns of fracture

      • Sufficient disruption of supporting ligaments

      • Compression places thoracic spine at risk of permanent damage

      Fig. 2.7 Surgical trajectories to addressing a thoracic disk herniation (image demonstrates giant calcified herniation in central canal). Line A is a costotransversectomy approach, Line B is a lateral transthoracic/retropleural approach, and Line C is an anterior transthoracic approach. Both transthoracic approaches do not require cord retraction. (Source: Surgical management. In: Baaj A, Kakaria U, Kim H, eds. Surgery of the Thoracic Spine: Principles and Techniques. 1st ed. Thieme; 2019).

      Surgical Procedure for Retropleural Thoracic Corpectomy

      1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Advil/Celebrex/Ibuprofen/Motrin/Naprosyn/Aleve/other anticoagulants and anti-inflammatory drugs for at least 2 weeks

      2. Appropriate intubation and sedation and lines (if necessary) as per the anesthetist

      3. Patient placed in left/right lateral decubitus position with padding of upper and lower extremities, held in place with tape over upper and lower extremities

      4. Fluoroscopy is used to confirm that no vertebral movement has occurred

      5. Neuromonitoring may be required to monitor nerves (if necessary and indicated)

      6. Time out is performed with agreement from everyone in the room for correct patient and correct surgery with consent signed

      7. Make 6 cm incision from posterior axillary line to 4 cm lateral of midline

      8. Dissect toward the rib head:

      a. Perform rib resection

      b. Incise endothoracic fascia, dissecting off the parietal pleura

      c. Dissect areolar tissue until endothoracic fascia is opened over rib head

      9. Take down costovertebral ligaments and proximal rib head, exposing vertebral body

      10. Perform corpectomy in a pedicle-to-pedicle fashion, preserving anterior shell of bone and anterior longitudinal ligament:

      a. Using hand-held curved high-speed drill, remove the posterior wall of vertebral bodies

      b. Remove the vertebral bodies and disks associated with the trauma

      c. Introduce hemostatic agents, if necessary, to control bleeding

      d. Achieve hemostasis

      11. Perform spinal fusion

      a. Perform reconstruction with expandable cage and autograft

      b. Perform ventrolateral screw-plate fixation

      c. Perform

Скачать книгу