1:48 Comparing anterolateral, extracavitary and transpedicular approaches to thoracolumbar spine reconstruction

Abstract

Purpose of study: Multiple approaches are used to access the anterior thoracolumbar spine. Although variations of posterior approaches were developed, improvements in anesthesia and internal fixation fostered anterolateral (AL) approaches to the thoracolumbar spine. Advocates suggest improved visualization reduces the risk of neurological injury. However, some have raised concerns about increased perioperative morbidity after thoracotomy. Although the lateral extracavitary (LEC) approach offers better anterior visualization than the transpedicular (TP) approach, both offer more limited visualization than the AL approach. This study examines operative parameters and complications of these approaches in anterior spinal reconstruction to identify a preferred approach.Methods used: A prospective analysis of a consecutive series of 87 patients requiring thoracolumbar spinal reconstructions by one surgeon over 68 months was performed. Patients were grouped by approach including AL (n=21), TP (n=37) and LEC (n=29). The office, hospital and anesthesia records and radiographs were examined. Demographic parameters examined included age, gender and pathological indication. Operative parameters recorded included number of levels fused, estimated blood loss and operative time. Perioperative and postoperative complications were identified. Parameters were compared with analysis of variance and t tests using a p=.05 level of significance.of findings: The common reasons for reconstruction were trauma (AL=13, TP=12, LEC=12), neoplasm (AL=6, TP=10, LEC=8), and infection (AL=0, TP=14, LEC=9). Two thirds fewer segments were fused in AL patients when compared with LEC or TP patients. The estimated blood loss was significantly higher in patients treated with LEC compared with TP (p<.022). Moreover, the operative duration was significantly longer in LEC in comparison to TP and AL (p<.00024). Twenty-two complications were observed. No postoperative wound infections occurred after AL, whereas seven occurred in TP and three in LEC. Seven instrumentation or graft complications occurred (AL=1, TP=3, LEC=3). Three patients had transient neurological worsening (AL=1, LEC=2). Finally, both perioperative deaths were observed in elderly patients undergoing TP for pyogenic osteomyelitis. One died of respiratory failure, and the other died from a myocardial infarction. Median follow-up exceeds 2 years.Relationship between findings and existing knowledge: Less frequent infectious complications and shorter segment fixation are achieved with AL. However, TP allows safe circumferential reconstruction with less time and blood loss, providing a viable alternative. The LEC requires more time and has more frequent blood loss without improving neurological outcome over TP.Overall significance of findings: Several approaches allow access to the anterior thoracolumbar spine. Conclusions drawn from this study are limited by the retrospective analysis. However, AL approaches, even in older patients, do not appear to be associated with increased perioperative morbidity and allow successful reconstruction with shorter segment fixation. In contrast, TP approaches allow more rapid reconstruction with less blood loss than AL. The LEC approach does not seem to offer an advantage over the other approaches. Consequently, AL approaches may be preferred in most patients requiring thoracolumbar spine reconstructions. However, TP approaches may reduce operative duration and blood loss but are accompanied by more frequent infectious complications.Disclosures: No disclosures.Conflict of interest: No conflicts.