Neurosurgery Outlines - Paul E. Kaloostian Surgical Outlines

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Thoracic Decompression/Thoracic Fusion

      Symptoms and Signs

      • Moderate back pain

      • Muscle weakness and reduction of mobility from pain (as opposed to from nerve impairment, which typically requires emergent treatment, particularly if it relates to bladder function)

      • Pain and discomfort derived from consistent nerve irritation

      • Difficulty maintaining balance and walking

      • Tingling numbness in arms/legs/hands

      • Abnormal spinal curvature

      • Spinal instability

      Surgical Pathology

      • Thoracic spine benign/malignant trauma

      • Thoracic spine benign/malignant tumor

      • Thoracic vascular benign/malignant lesion

      Diagnostic Modalities

      • Clinical examination

      • CT of thoracic spine with and without contrast

      • MRI of thoracic spine with and without contrast

      • CT or X-ray chest

      • Ultrasonography

      • Angiography

      • PET scan (search for tumor foci)

      • Biopsy (determine severity of tumor and possible type of cancer)

      Differential Diagnosis

      • Thoracic disk herniation

      • Spinal stenosis (narrowing of the spine)

      • Scoliosis

      • Bulging thoracic disk

      • Presence of bony spurs

      • Tumor:

      – Metastatic (malignant, requiring emergent treatment)

      – Primary (benign or malignant)

      • Vascular lesion (typically requiring supplemental embolization):

      – Fibromuscular dysplasia (FMD)

      – Spinal arteriovenous malformation (AVM)

      – Spinal dural arteriovenous fistula (AVF)

      – Thoracic outlet syndrome (TOS)

      • Vertebral fracture:

      – Blunt trauma (incomplete SCI)

      – Penetrating trauma (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 asymptomatic or mildly symptomatic with pain/radiculopathy with small focus of tumor:

      – Radiation treatment (radiation oncology consultation)

      – Some metastatic tumors are radioresistant

      – Chemotherapy (medical oncology consultation)

      – Some metastatic tumors are radioresistant

      – Kyphoplasty (to treat pain)

      – Surgical instrumentation and fusion (if there is concern for deformity, instability, or cord compression)

      • If asymptomatic or mildly symptomatic with thoracic cord compression:

      – 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

      – Approaches: Posterior, anterior transthoracic, anterior transsternal

      Indications for Surgical Intervention

      • Spinal stenosis

      • No sufficient improvement of pain and other symptoms after nonoperative measures (physical therapy, medications/injections, pain management)

      • Thoracic compression

      • Spinal condition isolated to specific locus of the body

      • Significant reduction in everyday activities due to symptoms

      • Expected postsurgical favorable outcome

      Surgical Procedure for Posterior Thoracic Spine

      1. Informed consent signed, preoperative labs normal, no Aspirin/Plavix/Coumadin/NSAIDs/Celebrex/Naprosyn/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

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

      6. Make an incision down the midline of back

      7. Perform subperiosteal dissection of muscles bilaterally exposing the spinous process and paraspinal muscles

      8. Dissect tissue planes along spinous process and laminae using rongeurs

      9. Move paraspinal muscles laterally to expose the laminae

      10. Once the locus of interest is exposed, it is best to localize and verify the correct vertebra via X-ray or fluoroscopic imaging and confirming with at least two people in the room

      11. Perform the decompression procedure over the desired segments based on preoperative imaging of levels that are compressed due to trauma (see ▶Fig. 2.11 to Fig. 2.14):

      a. Using Leksell rongeurs and hand-held high-speed drill, remove the bony spinous process and bilateral lamina as indicated for specific procedure (laminectomy)

      b. Or, remove bone of lamina above and below spinal nerves to create a small opening of lamina, relieving compression (laminotomy)

      Fig. 2.11 A middle-aged woman with a dorsal epidural lesion in T3–T8 and cord compression (a) received left T3–T5 hemilaminotomies and

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