Neurosurgery Outlines - Paul E. Kaloostian Surgical Outlines

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      12. Place chest tube if significant pleural tear occurs (can be removed in 2–3 days)

      13. Remove retractor and inspect wound for further bleeding and pleural violations

      14. Place red rubber catheter between endothoracic fascia and parietal pleura

      15. Close fascia with suture

      16. Catheter under water seal; the patient is made to valsalva with help of anesthesia

      17. Remove catheter and tighten last facial suture

      18. Close the muscle, subcutaneous layers, and skin

      Surgical Procedure for Lateral Extracavitary 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 prone on Jackson Table with all pressure points padded

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

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

      6. Make 4 cm incision, 4 cm laterally from midline

      7. Remove proximal rib, costovertebral ligaments, rib head, intercostal vessels, and ipsilateral pedicle

      8. Perform corpectomy, preserving ventral body, anterior longitudinal ligament, and contralateral vertebral margins:

      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

      9. Perform spinal fusion:

      a. Perform reconstruction using titanium mesh, autograft, and/or expandable cages

      i. Supplement with vertebral body screws and rods if deemed necessary

      b. Place posterior percutaneous screws and rods above and below the level of corpectomy

      10. Place chest tube if significant pleural tear occurs (can be removed in 2–3 days)

      11. Remove retractor and inspect wound for further bleeding

      12. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

      Surgical Procedure for Transpedicular 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 prone on Jackson Table with all pressure points padded

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

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

      6. C-arm fluoroscopy equipment set up in operation zone

      7. Make midline incision two levels above and below the level of trauma, preserving the fascia

      8. Perform dissection to lateral edge of transverse processes

      9. Remove posterior elements and bilateral facets, exposing thecal sac and pedicles

      10. Remove pedicles with drill, exposing vertebral body bilaterally

      11. Perform corpectomy:

      a. Using Pituitary rongeurs and 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

      12. Place posterior pedicle screws and rods two levels above and below the level of corpectomy

      13. After appropriate hemostasis is obtained, muscle and skin incisions can then be closed in appropriate fashion

      Pitfalls

      • Reduction in range of motion and mobility of fused spinal segments

      • Intraoperative CSF leak

      • Blood clot (deep vein thrombosis, or more severe pulmonary embolism)

      • Damage to spinal nerves and/or cord

      • Postoperative weakness or numbness or continued pain

      • Postoperative wound infection

      • Continued symptoms postsurgically/unresolved symptoms with no improvement to quality of life

      • Prolonged hospitalization due to invasiveness of surgery and other comorbidities/iatrogenic infection

      • Loss of sensation

      • Progressive kyphosis

      • Residual spinal compression

      • Problems with bowel/bladder control

      • Pulmonary contusion, atelectasis, pleural effusion, chylothorax, hemothorax

      • Lumbar plexus damage, segmental artery damage

      • Muscle dissection-related morbidity

      • Pleural damage

      Prognosis

      • Hospitalization rates depend on the type of procedure performed, preoperative examination status, and patient’s age/comorbidities

      • Pain medications for postsurgical pain

      • Catheter placed in bladder and removed 1 to 2 days after surgery

      • Physical therapy and occupational therapy will be needed postoperatively as outpatient to regain strength

      • External back brace placed after discharge

      2.1.3 Transthoracic Approaches for Decompression and Fusion/Transsternal Approaches for Decompression and Fusion

      Symptoms and Signs

      • Chest tenderness and ecchymoses

      • Paraplegia

      • Diminished control of bowel/bladder function

      • Moderate/severe back pain

      • Respiratory distress

      • Difficulty maintaining balance and walking

      • Loss of sensation in hands

      • Inability to conduct fine motor skills with hands

      • Trachea deviates away from side of tension pneumothorax

      Surgical Pathology

      • Thoracic spine benign/malignant trauma

      Diagnostic Modalities

      • CT

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