Posterolateral Transpedicular Approach Research Articles

Posterolateral transpedicular approach for ventrally seated cervicothoracic spinal cord lesions: how I do it

BackgroundSurgical exposure of lower cervical and upper thoracic intradural extramedullary lesions located along the ventral medulla are among the most complexes to address in spinal surgery, and their surgical removal carries a high risk.MethodsWe describe the surgical steps of a posterolateral transpedicular approach for resection of an intradural extramedullary lesion located anterolaterally at C7-T1 level.ConclusionsA posterolateral transpedicular approach is a safe and efficient surgical corridor to explore the ventral spinal cord and to have a direct access to lower cervical-upper thoracic lesions without the extensive manipulation of the spinal cord and the spine instability.

Combined Percutaneous Kyphoplasty/Pediculoplasty by Posterolateral Transpedicular Approach for Painful Cervical Spine Metastases: A Single-Center Prospective Study.

PurposeIn patients requiring percutaneous kyphoplasty (PKP) for painful cervical spine metastases (PCSMs), the surgical approach is of utmost importance. Anterolateral and transoral routes are generally used at present, whereas PKP as well as percutaneous pediculoplasty (PPP) via posterolateral transpedicular approach (PTPA) has yet to be pursued in the treatment of PCSMs. The study was designed to evaluate safety and efficacy of PKP procedures combined with PPP via PTPA as treatment of PCSMs.Patients and MethodsThe patients with PCSMs were enrolled and housed in a database. The pain intensity of enrolled patients was gauged by Visual Analog Scale (VAS), ranging from 0 (none) to 10 (extreme). After preprocedural imaging assessment, combined PKP/PPP via PTPA was performed under the guidance of CT and fluoroscopic monitoring. Postprocedural VAS scores, complications, cement dosage, and hospitalization were recorded in the database for analysis. All cases were followed up for 6 months.ResultsAdult enrollees (7 women, 4 men) with PCSMs successfully underwent PKP/PPP via PTPA between February 2019 and January 2020, injected with 3.7±0.7 mL (range, 2.5–4.8 mL) of cement on average. Other than a single instance of asymptomatic cement leakage into paravertebral soft tissues, no complications ensued. Significant analgesic effects observed 24 hours after procedures were sustained for up to 6 months in follow-up surveys. Postprocedural hospitalizations were as brief as 2.2±0.8 days.ConclusionCombined PKP/PPP via PTPA is safe and effective as treatment of PCSMs, enabling quick pain relief and patient recovery.

A transpedicular approach to complex ventrally situated thoracic intradural extramedullary tumors: technique, indications, and multiinstitutional case series.

Ventrally situated thoracic intradural extramedullary tumors are surgically challenging and difficult to access, and they may be complicated by extensive adhesions and calcifications. Selecting an approach for adequate ventral access is key to complete resection and optimization of outcomes. The authors present a case series of patients who underwent resection of ventral thoracic intradural extramedullary tumors and discuss indications and considerations for this technique. Additionally, they describe the use of a posterolateral transpedicular approach for resection of ventral thoracic intradural extramedullary tumors compared with other techniques, and they summarize the literature supporting its application. From May 2017 to August 2020, 5 patients with ventral thoracic intradural extramedullary tumors underwent resection at one of the two academic institutions. Patient ages ranged from 47 to 75 (mean 63.4) years. All tumors were diagnosed as meningiomas or schwannomas by histological examination. Three of the 5 patients had evidence of partial or extensive tumor calcification. Four of the 5 patients underwent an initial posterolateral transpedicular approach for resection, with positive radiographic and clinical outcomes from surgery. One patient initially underwent an unsuccessful traditional direct posterior approach and required additional resection 2 years later after interval disease progression. There were no postoperative wound infections, CSF leaks, or other complications related to the transpedicular approach. Posterolateral transpedicular tumor resection is a safe technique for the treatment of complex ventrally situated thoracic intradural extramedullary tumors compared with the direct posterior approach. Anecdotally, this approach appears to be particularly beneficial in patients with calcified tumors.

Single-Stage Posterolateral Transpedicular Approach With 360-Degree Stabilization and Vertebrectomy in Primary and Metastatic Tumors of the Spine

Currently, anterior, posterior, or combined approaches are used in various spinal disorders; however, a single-stage posterolateral transpedicular approach with 360° stabilization and vertebrectomy provides better results for spinal tumors. We evaluated the age, sex distribution, presenting symptoms, neurologic examination findings according to the pre- and postoperative Frankel classification, pre- and postoperative VAS pain scores, preoperatively administered medical therapies, pre- and postoperative corset use, level of the lesion, levels of previous surgical interventions, root ligation (if performed), results of the primary disease, hospitalization duration (after the operation), postoperative complications (if any), postoperative follow-up duration, and postoperative survival duration of 22 patients. We observed that primary bone tumors were localized in the lumbar (75%) and thoracic regions (25%) and that metastatic tumors were localized in the thoracic (77.78%) and lumbar regions (22.22%). The VAS and Frankel scores of the 22 patients who were included in the study revealed that this surgical treatment modality was associated with statistically significant improvements in test scores (P < 0.001). No ribcage dislocation was observed. In 1 patient (4.54%), a neurologic deficit developed. Two patients (9.09%) required revision because of screw malposition. In spinal tumors, 360° fusion performed via a posterolateral approach is a less risky, relatively safe, and less invasive method. This method, which reduces the risks of anesthesia and internal problems and decreases cost, is an essential technique for decreasing hospitalization duration, improving pain levels, and achieving faster mobilization and faster initiation of radiotherapy and chemotherapy.

Minimally Invasive Corpectomy in Metastatic Thoracolumbar Spine Disease:The Posterolateral Transpedicular Approach

Study design: Retrospective review of prospectively collected data. Background: There is no consensus regarding the ideal approach for corpectomy in destructive metastatic thoracolumbar spine disease. Many surgical techniques have been described but none has proved its definite superiority. The main drawback of these procedures is directly related to the morbidity of the approach. As one-stage minimally invasive pedicle screw fixation combined with mini-open posterolateral transpedicular corpectomy for treatment of thoracolumbar metastatic lesions is gaining popularity, its efficacy has yet to be established. Purpose: The purpose of this study is to report operative data, clinical and radiological outcomes of patients undergoing minimally invasive stabilization, decompression, transpedicular corpectomy and anterior column reconstruction of thoracolumbar metastatic disease at our institutions. Methods: Forty patients underwent minimally invasive pedicle screws stabilization, mini open decompression and transpedicular corpectomy for treatment of single-level metastatic destruction of the thoracic or lumbar spine. All patients were neurologically intact. There were 19 males and 21 females with an average age of 58 years. Results: The mean follow-up was 17 months (7—2 1 months). The mean operative time was 256 min (230-390 min) and the mean blood loss was 1350 mL. VAS was significantly improved from 6.7 to 0.7 at last follow-up. Vertebral kyphosis decreased by 16◦ to 7.8◦ postoperatively (P < 0.001). Local kyphosis and percentage of collapse were also significantly improved from 8◦ to 5.6◦ and from 35% to 16% at last follow-up. No patient worsened his or her neurological condition postoperatively. Conclusion: Minimally invasive transpedicular corpectomy seems to be a safe and effective technique to manage thoracolumbar fractures without neurological impairment.

Surgery for ventral intradural thoracic spinal tumors with a posterolateral transpedicular approach.

Surgery for ventrally seated thoracic tumors requires an anatomically specific approach that is distinct from cervical or lumbar spinal cord surgery as the narrower spinal canal of the thoracic spinal cord makes it sensitive to surgical procedures. However, reports describing this operative technique are few. To obtain a wide operative field and minimize thoracic spinal cord retraction, we employed a posterolateral transpedicular approach in ventral-located tumors and investigated the efficacy and limitations of this technique. Eighteen patients with lesions (meningioma or neurinoma) located in the ventral intradural thoracic region were surgically treated between 2009 and 2014. The relationship among the clinical outcome, tumor location, and postoperative spinal alignment was analyzed. Postoperative neurological function improved in all patients, namely those with meningioma (p = 0.012) and schwannoma (p = 0.018). One patient who underwent removal of two facet joints suffered a postoperative compression fracture. Removal of two facet joints and pedicles resulted in a worsening of spinal alignment (p = 0.03), while this was not the case for the removal of one facet joint and pedicle (p = 0.72). This case series clarified the benefits of the posterolateral transpedicular approach for resection of ventral intradural extramedullary tumors. Removal of one pedicle and facet joint seems to be more beneficial.

A modified posterolateral transpedicular approach to thoracolumbar corpectomy with nerve preservation and bilateral cage reconstruction

This retrospective study investigated the early results of a single-stage posterolateral transpedicular corpectomy and fusion in the thoracolumbar spine. A modified technique with nerve preservation and bilateral expandable cage implantation is described. Four patients with vertebral metastasis and one patient with vertebral osteomyelitis were included in this series. Two patients underwent two level corpectomies, whereas three patients underwent single level corpectomy. The mean follow-up was 3.3months. No perioperative complication was encountered. Improvement in neurological status was observed in patients with preoperative neurological deficits. Vertebral height and sagittal and coronal deformity were corrected using the current technique. Bilateral cage implantation offers an additional advantage of asymmetrical reconstruction of the ventral column in cases of hemicorpectomy. Single-stage posterolateral transpedicular corpectomy and fusion is a useful approach to treat ventral thoracolumbar pathologies.

360-degree osteosynthesis via a posterolateral transpedicular approach in high-risk patients

Patients requiring anterior-posterior thoracic spine stabilization and suffering from concomitant cardiopulmonary disease are at increased risk to develop procedure-related complications. In order to reduce cardiopulmonary complications, the efficacy of a posterolateral transpedicular approach for 360-degree fusion was investigated. Fourteen consecutive patients presenting with spinal cord compression from osteoporotic, metastatic and tuberculotic fractures were treated. Spinal cord decompression was achieved by laminectomy, facetectomy and corpectomy with subsequent posterior instrumented fusion using a screw-rod system. The procedure was successfully performed in 14 high-risk patients. Preoperatively, all patients presented with thoracic and lower back pain and nine patients with a paraparesis (Frankel grade C). The implants were introduced monoportally or biportally. In all cases, neurological symptoms moderately improved. The posterolateral transpedicular approach might be a safe, less-invasive and efficient alternative to anterior-posterior fusion. However, biomechanic efficacy and long-term outcome as compared to the transthoracic technique remains to be studied in a larger patient cohort.

Anterior construct location following vertebral body metastasis reconstruction through a posterolateral transpedicular approach: does it matter?

The posterolateral transpedicular approach (PTA) is a widely used method for the surgical treatment of vertebral body metastases. It is crucial to understand the optimal location of the anterior graft in terms of sound and durable reconstruction following PTA. The purpose of this study was to investigate whether postoperative construct stability is related to the location of anterior grafts. The authors conducted a retrospective review of 45 cases of metastatic spine disease with epidural tumor extension in which patients underwent circumferential decompression and fusion by means of PTA. Mechanical (anterior construct stability), pain (visual analog scale score), and neurological (American Spinal Injury Association scale) outcomes were evaluated and correlated with the anterior graft location (lateral or central) and surgical approach (unilateral or bilateral), number of decompressed levels, types of anterior graft, screw density of posterior fixation (number of screws used divided by the number of pedicles spanned), and kyphotic angle change from the immediate postoperative period to the most recent follow-up. Seven of 45 constructs were judged unstable--5 with a lateral location of the anterior graft and 2 with a central location. The anterior graft was located laterally in 31 cases (69%), centrally in 11 (24%), and bilaterally in 3 (7%). A unilateral approach was used in 33 cases and a bilateral approach in 12. Neither the location of the anterior graft nor the approach had a significant effect on the stability of the reconstructed spine (p > 0.05). There was a significant difference in construct stability between the single-level decompression group (33 patients) and the multiple-level decompression group (12 patients) (p = 0.0001). The types of anterior graft, screw density, and kyphotic angle change were not correlated to the mechanical outcome. The anterior graft location showed no significant relationship to the final mechanical, pain, and neurological outcomes.

Juvenile Xanthogranuloma in an Adult Lumbar Spine

Case report. To report a very rare case of juvenile xanthogranuloma (JXG) of the spine in an adult. JXG is very rare in the spine, with only five prior reports in infants and children. To the best of our knowledge, this tumor has never been reported in an adult spine. The patient is a 47-year-old woman who presented with bowel and bladder incontinence. Magnetic resonance imaging showed a very large lesion arising from the L2 vertebral body, with massive extension into the retroperitoneum with extensive intradural involvement. She had decreased rectal tone, had 4/5 strength in the right hip flexor, and had diminished sensation in her anterior right thigh and perineal region. She was otherwise neurologically intact. After preoperative embolization, a decompressive laminectomy was performed and the tumor was resected through a posterolateral transpedicular approach, followed by stabilization. Because of extensive involvement of retroperitoneum, complete resection was not possible. After pathologic evaluation of the specimen, a diagnosis of JXG was made. Patient underwent postoperative radiation therapy, and her neurologic examination improved significantly over the next several months. To the best of our knowledge, this is the first reported case of JXG in an adult spine. Although complete resection of the tumor was not possible, decompression of the dural sac followed by postoperative radiation led to an excellent clinical outcome.

C2/C3 pathologic fractures from polyostotic fibrous dysplasia of the cervical spine treated with percutaneous vertebroplasty

We will discuss a potential role of percutaneous vertebroplasty (PVP) in the management of patients with severe fibrous dysplasia of the spine with multiple cervical lesions and C2-C3 pathologic fractures that may not be a good surgical candidate. Polyostotic fibrous dysplasia involvement of the cervical spine is rare. Review of literature indicates only few reported cases of surgical management with one case of mortality indicating increased risks associated with surgical intervention. While PVP is commonly used for the treatment of osteoporotic thoracolumbar vertebral compression fractures, its role in vertebral stabilization for fibrous dysplasia has not been reported. A 35-year-old man with McCune-Albright syndrome and severe polyostotic fibrous dysplasia of C2 and C3 vertebrae presented with severe neck pain, radiculopathy, quadriparesis and myelopathy. The lesion had pathologic fractures, and there was an os odontoideum with cervical cord atrophy at the C1 level. After discussing need for aggressive surgical management and potential complications, we offered PVP due to surgical risks involved. PVP was performed with a posterolateral transpedicular approach without complication. The patient had remarkable improvement in clinical relief of neck pain and improvement of myelopathic symptoms at 1-year follow-up. We present a case that illustrates a potential use of PVP in the management of a patient with symptomatic spinal fibrous dysplasia with associated pathologic fractures who was poor surgical candidate.

Surgical Results of Metastatic Spinal Cord Compression Secondary to Non-Small Cell Lung Cancer

The results for 37 surgical interventions in 31 consecutive patients with non-small cell lung cancer (NSCLC) with symptomatic spinal cord compression were reviewed retrospectively. To evaluate postoperative outcomes and survival rates of NSCLC patients surgically treated for symptomatic spinal metastasis. For patients with spinal cord compression secondary to lung cancer, the prognosis is usually poor. However, with the development of new chemotherapeutic drugs and targeted therapeutic agents, the survival rate may be better. From November 2000 to March 2005, 31 patients with symptomatic metastatic spinal cord compression secondary to NSCLC underwent palliative surgery using a posterolateral transpedicular approach (PTA) or combined posterior and anterior procedures. The indication for surgery was neurologic progression due to spinal cord compression. The patients ranged in age from 20 to 81 years (mean, 61.4 years). Twenty-eight patients (90%) underwent PTA, and 3 patients had combined posterior and anterior procedures. Neurologic improvement by at least one Frankel grade was noted in 25 of 31 cases (80%). Overall, 74% of patients (23 of 31) were able to walk after surgery. There was no case of intraoperative mortality, but two deaths occurred in the postoperative period. Median survival time was 8.8 months. Even though lung cancer is considered an aggressive tumor, it is justifiable to aggressively treat patients with symptomatic spinal cord compression. Surgery by PTA can lead to good results in these patients.

Pathological Fractures from Craniocervical Polyostotic Fibrous Dysplasia Treated with Percutaneous Vertebroplasty: Case Report

We will discuss a potential role of percutaneous vertebroplasty (PVP) in the management of patients with severe fibrous dysplasia of the spine with multiple cervical lesions and C2-C3 pathologic fractures who may not be good surgical candidates. Polyostotic fibrous dysplasia involvement of the cervical spine is rare. Review of the literature indicates only few reported cases of surgical management with one case of mortality indicating increased risks associated with surgical intervention. While PVP is commonly used for the treatment of osteoporotic thoracolumbar vertebral compression fractures, its role in vertebral stabilization for fibrous dysplasia has not been reported. A 35-year-old man with McCune-Albright syndrome and severe polyostotic fibrous dysplasia of C2 and C3 vertebrae presented with severe neck pain, radiculopathy, quadriparesis, and myelopathy. The lesion had pathologic fractures, and there was an osodontoideum with cervical cord atrophy at the C1 level. After discussing need for aggressive surgical management and potential complications, we offered PVP because of the surgical risks involved. PVP was performed with a posterolateral transpedicular approach without complication. The patient had remarkable improvement in clinical relief of neck pain and improvement of myelopathic symptoms at the 1-year follow-up. We present a case that illustrates a potential use of PVP in the management of a patient with symptomatic spinal fibrous dysplasia with associated pathologic fractures who was a poor surgical candidate.

Single-stage posterolateral transpedicular approach for resection of epidural metastatic spine tumors involving the vertebral body with circumferential reconstruction: results in 140 patients. Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004.

Patients with metastatic spine tumors often have multicolumn involvement and high-grade epidural compression, requiring circumferential decompression and instrumentation. Secondary medical and oncological issues add morbidity to combined approaches. The authors present their experience in using the single-stage posterolateral transpedicular approach (PTA) to decompress the spine circumferentially and to place instrumentation. From September 1997 to February 2004, 140 patients with spine metastases underwent the PTA. Magnetic resonance imaging revealed high-grade spinal cord compression in 120 patients (86%) and lytic vertebral body destruction in all patients. Preoperatively 84 patients (60%) received radiotherapy directed to the involved level and 42 (30%) underwent tumor embolization. Following circumferential decompression, all patients underwent anterior reconstruction with polymethylmethacrylate and Steinmann pins, and posterior segmental fixation. The median operative time was 5.1 hours, the median blood loss was 1500 ml, and the median hospital stay was 9 days. Ninety-six percent of the patients experienced postoperative pain improvement and improvement in or stabilization of neurological status. In 51 nonambulatory patients with poor Eastern Cooperative Oncology Group grades, 75% regained the ability to walk. One month postoperatively 90% of patients achieved good-to-excellent performance scores. The overall median patient survival time was 7.7 months. Patients with colon and lung carcinomas had significantly shorter survival times. Major operative complications occurred in 20 patients (14.3%). Wound complications occurred in 16 patients (11.4%), but this was not correlated with preoperative radiation treatment. The PTA allows circumferential epidural tumor decompression and the placement of anterior and posterior spinal column instrumention. Immediate spinal stability is achieved without the use of brace therapy. This technique achieved a high success rate for pain palliation, neurological preservation, and functional improvement, while avoiding the morbidity associated with combined approaches.

Single-stage posterolateral transpedicle approach for spondylectomy, epidural decompression, and circumferential fusion of spinal metastases.

Retrospective review of prospectively maintained institutional spine database. To assess the pain, neurologic, and functional outcome of patients with metastatic spinal cord compression using a posterolateral transpedicular approach with circumferential fusion. Patients with spinal metastases often have patterns of disease requiring both an anterior and posterior surgical decompression and spinal fusion. For patients whose concurrent illness or previous surgery makes an anterior approach difficult, a posterior transpedicular approach was used to resect the involved vertebral bodies, posterior elements, and epidural tumor. This approach provides exposure sufficient to decompress and instrument the anterior and posterior columns. During the past 15 months, 25 patients were operated on using a posterolateral transpedicular approach. The primary indications for surgery were back pain (15 patients) and neurologic progression (10 patients). All patients had vertebral body disease, and 21 patients had high-grade spinal cord compression from epidural disease as assessed by magnetic resonance imaging. Seven patients underwent preoperative embolization for vascular tumors. In each patient, the anterior column was reconstructed with polymethyl methacrylate and Steinmann pins and the posterior column with long segmental fixation. All patients achieved immediate stability. Pain relief was significant in all 23 patients who had had moderate or severe pain. Neurologic symptoms were stable or improved in 23 patients. One patient with an acutely evolving myelopathy was immediately worse after surgery, and one patient had a delayed neurologic worsening, progressing to paraplegia. The posterolateral transpedicular approach provides a wide surgical exposure to decompress and instrument the anterior and posterior spine. This technique avoids the morbidity associated with anterior approaches and provides immediate stability. Vascular tumors may be removed safely after embolization. Patients can be mobilized early after surgery.

Complications of bone metastases: surgical management.

Patients with metastatic disease to the bone present a management challenge. Of the complications encountered in these patients, the predominant types that require surgical intervention are pathologic or impending fractures and neurologic compromise secondary to cord compression from spinal metastases. A multimodality approach is helpful in caring for these patients, and addressing complications related to bony metastatic disease with timely and appropriate intervention is an important step in optimizing care and quality of life. This article incorporates information from multiple sources and presents recent reviews of the experience at the Memorial Sloan-Kettering Cancer Center with acetabular reconstruction for metastatic lesions, and with the use of the posterolateral transpedicular approach to address metastatic disease in the spine. Of 55 patients who underwent reconstruction of the acetabulum for metastatic disease, although there was a 25% incidence of local disease progression, there was only a 9% incidence of late fixation failure. Of the 41 who were evaluable at 3 months, 83% continued to experience significant pain relief, and 50% of nonambulatory patients regained walking ability secondary to the procedure. Of the patients with more than 2 years of follow-up, 86% maintained pain relief and 71% maintained their ability to ambulate and function in their community. The preliminary series of 25 patients managed with a posterolateral transpedicular approach to address metastatic disease in the spine showed excellent tumor control, pain relief, and neurologic preservation with the technique. Particular benefit was obtained for patients with extensive epidural disease in which an anterior approach was contraindicated. Although a multimodality approach to the treatment of patients with metastatic disease to bone combining appropriate surgical intervention with systemic therapy and radiation can entail a major operative procedure, the overall benefits to a patient's quality of life outweigh the risks in most cases. Clinician awareness of the various therapeutic options and their indications, and aggressive advocacy of quality of life for these patients, can improve the care delivered to people with metastatic disease.