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Minimally Invasive Lateral Thoracic Decompression


Summary of Key Points

  • Patient selection is paramount when choosing a lateral approach for a thoracic decompression.

  • Fluoroscopy or stereotactic navigation is critical to define the anteroposterior and lateral axes before incision.

  • Mastery of the lateral anatomic constraints of the thoracic spine is critical to avoid complications and limit morbidity.

  • Stand-alone single- and multilevel lateral interbody fusions are still under investigation, and many surgeons still advocate for supplemental instrumentation by way of percutaneous or open pedicle screw placement.

  • Dissecting in a retropleural plane may limit pulmonary complications and obviate the need for lung deflation and chest tube insertion.

Minimally invasive or minimal access surgery was developed to address the approach-related morbidity associated with open spine surgery. Beginning with the introduction of the microscope by Yasargil, minimal access technology is now used to treat spinal deformity, trauma, degenerative disease, and tumors. Lateral approaches to the thoracolumbar spine represent an emerging frontier allowing decompression and ventral reconstruction of the thoracolumbar spine, while theoretically decreasing morbidity and mortality. This chapter describes minimal access lateral approaches used for decompression of the thoracic spinal canal.

Indications for Operative Intervention

As with surgeries of the cervical and lumbar spine, thoracic spine surgery is warranted in pathologies that destabilize and/or cause compression of the neural elements.

Neoplasm

Bony metastatic disease represents a large proportion of pathology encountered in the ventral thoracic spine. Spinal neoplasms can present with pain, progressive deformity, or neurological compromise. Operative goals are often to determine histopathological diagnosis, debulk the tumor, decompress the neural elements, and provide spinal stabilization. Important considerations for operative intervention include patient age, preoperative functional status, systemic extent of metastatic disease, life expectancy, and medical comorbidities. Nonemergent surgical intervention should be reserved for patients with a life expectancy of greater than 6 months. Urgent or emergent intervention must be considered in the setting of acute or progressive neurological decline, regardless of life expectancy, if surgical intervention may significantly improve quality of life. , Adjuvant therapy with radiation, chemotherapy, or hormone modulation is often required after surgery; however, in the setting of spinal cord compression, they are often unable to be initiated safely. The surgeon must take all of these factors into consideration when evaluating patients with neoplastic disorders, and minimally invasive approaches can be used to treat these patients while minimizing morbidity and mortality. The workhorse approach for tumor debulking and resection in the subaxial spine is transpedicular decompression. However, as surgeons become increasingly comfortable with minimally invasive surgery (MIS) lateral thoracic approaches, these likely will be used with increasing frequency. Initially, the extreme lateral approach was reported in eight patients operated on at the University of Miami, wherein corpectomy and cage reconstruction were performed with good decompression. Of note, pedicle screw placement was used in all eight cases (in some cases, percutaneous; in others, open placement). Furthermore, in a 2020 systematic review and pooled analysis by Spiessberger, various approaches to the thoracic spine in the setting of metastatic disease were compared. Specifically included were the lateral extracavitary, transthoracic, and thoracoscopic approaches, which will be discussed in detail later. The pooled analysis demonstrated improved outcomes in MIS approaches with regard to blood loss, operative time, and postoperative complications, demonstrating the importance of these MIS lateral approaches specifically in the setting of metastatic disease.

Trauma

Thoracolumbar trauma typically occurs at the junction in over 50% of cases involving levels T10 to L2. , Flexion-distraction and compressive loading forces transmit directly through this transition zone and oftentimes result in vertebral body fractures, such as compression or burst fractures with or without traumatic disc extrusions. All traumatic fractures with or without significant loss of height involving the vertebral body in the setting of neurological injury or when canal compromise is present should be evaluated emergently for surgical consideration. The surgical approach remains controversial, and many spine surgeons elect for a dorsal decompression and instrumentation, but minimally invasive reconstruction of the vertebral body through a lateral approach is an emerging option with low morbidity and mortality. Of note in complex fracture patterns where both ventral and dorsal elements are unstable, a ventral construct may be inadequate to resist flexion and distraction forces, and supplemental dorsal stabilization must be considered on a case-by-case basis. There are some data to suggest that MIS lateral approaches for decompression and/or fusion should not be performed without supplemental percutaneous pedicle screw placement in patients with a high Thoracolumbar Injury Classification System score (i.e., >4). Furthermore, there are limited data to support the use of a transpleural approach to the retroperitoneum for corpectomy and subsequent cage placement and lateral instrumentation for burst fractures in the thoracolumbar spine, although this needs further exploration.

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