Safety of fluoroscopy guided percutaneous access to the thoracic spine

Abstract

Fluoroscopy-guided percutaneous access to thoracic vertebrae is technically demanding due to the complex radiological anatomy and close proximity of the spinal cord, major vessels and pleural cavity. There is a trend towards computed tomography (CT) guidance due to a perceived reduction in the risk of spinal canal intrusion by instrumentation causing neurological injury. Due to limited access to CT guidance, there is a need for safe fluoroscopy-guided percutaneous access to the thoracic spine. To evaluate the safety of a strict radio-anatomical protocol in avoiding access-related neurological complications due to tool misplacement in fluoroscopy-guided percutaneous procedures on the thoracic spine. A combined two-surgeon prospective case series of 444 procedures (biopsy, vertebroplasty or kyphoplasty) covering all thoracic vertebral levels T1-T12. Clinical examination and routine observations were used to identify access-related complications including neurological, vascular and visceral injury using physiological parameters. No patient in our series was identified to have sustained a neurological deficit or deterioration of preoperative neurological status. Percutaneous access to the thoracic spine using fluoroscopic guidance is safe. The crucial step of the protocol is not to advance the tool beyond the medial pedicle wall on the anterior-posterior projection until the tip of the instrument has reached the posterior vertebral cortex on the lateral projection.