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a and 1b. a) Left-sided twin tube airway: standard position in thoracic surgery. b) Right-sided twin tube.
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The use of endoscopic, minimally invasive surgical techniques in the reconstruction of the anterior column of the spine results
in a significant decrease of approach-related complications. Depending on the level of injury, every stage of the surgical
procedure is associated with a specific risk of complications requiring a detailed preparation of t...
Citations
... 7,22,23,40,47 Unfortunately, restoration of lordosis with anterior-only approaches has been reported to be difficult, less predictable than posterior or combined instrumentation, and often incomplete. 43,53,55,60,61 The matter is reflected by only a few technical reports on how to achieve lordosis. No standard method to create lordosis by an anterior-only approach exists. ...
In thoracolumbar deformity surgery, anterior-only approaches are used for reconstruction of anterior column failures. It is generally advised that vertebral body replacements (VBRs) should be preloaded by compression. However, little is known regarding the impact of different techniques for generation of preloads and which surgical principle is best for restoration of lordosis. Therefore, the authors analyzed the effect of different surgical techniques to restore spinal alignment and lordosis as well as the ability to generate axial preloads on VBRs in anterior column reconstructions.
The authors performed a laboratory study using 7 fresh-frozen specimens (from T-3 to S-1) to assess the ability for lordosis reconstruction of 5 techniques and their potential for increasing preloads on a modified distractable VBR in a 1-level thoracolumbar corpectomy. The testing protocol was as follows: 1) Radiographs of specimens were obtained. 2) A 1-level corpectomy was performed. 3) In alternating order, lordosis was applied using 1 of the 5 techniques. Then, preloads during insertion and after relaxation using the modified distractable VBR were assessed using a miniature load-cell incorporated in the modified distractable VBR. The modified distractable VBR was inserted into the corpectomy defect after lordosis was applied using 1) a lamina spreader; 2) the modified distractable VBR only; 3) the ArcoFix System (an angular stable plate system enabling in situ reduction); 4) a lordosizer (a customized instrument enabling reduction while replicating the intervertebral center of rotation [COR] according to the COR method); and 5) a lordosizer and top-loading screws ([LZ+TLS], distraction with the lordosizer applied on a 5.5-mm rod linked to 2 top-loading pedicle screws inserted laterally into the vertebra). Changes in the regional kyphosis angle were assessed radiographically using the Cobb method.
The bone mineral density of specimens was 0.72 ± 22.6 g/cm(2). The maximum regional kyphosis angle reconstructed among the 5 techniques averaged 9.7°-16.1°, and maximum axial preloads averaged 123.7-179.7 N. Concerning correction, in decreasing order the LZ+TLS, lordosizer, and ArcoFix System outperformed the lamina spreader and modified distractable VBR. The order of median values for insertion peak load, from highest to lowest, were lordosizer, LZ+TLS, and ArcoFix, which outperformed the lamina spreader and modified distractable VBR. In decreasing order, the axial preload was highest with the lordosizer and LZ+TLS, which both outperformed the lamina spreader and the modified distractable VBR. The technique enabling the greatest lordosis achieved the highest preloads. With the ArcoFix System and LZ+TLS, compression loads could be applied and were 247.8 and 190.6 N, respectively, which is significantly higher than the insertion peak load and axial preload (p < 0.05).
Including the ability for replication of the COR in instruments designed for anterior column reconstructions, the ability for lordosis restoration of the anterior column and axial preloads can increase, which in turn might foster fusion.
... K rekonstrukci obratlového těla je možné použít autologní trikortikální štěp z lopaty (2,19,20,41), alograft (31,38) nebo titanovou náhradu (24,26). Titanová klec se může dislokovat nebo probořit do těla obratle, proto řada autorů doporučuje doplnit stabilizaci předního sloupce implantátem (13,35). Důvody dislokace a proboření do těla jsou: primárně špatné uložení klece, nedostatečné rozvinutí klece, nedostatečný kontakt mezi rovnou plochou klece a konkavitou krycí desky obratle, porušení krycí desky při diskektomii a přípravě kontaktní plochy krycí desky, osteoporóza těla obratle. ...
A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column.
Between 2002 and 2006, a total of 127 patients were treated by this technique. The age of the group, including 75 men and 52 women, ranged from 18 to 75 years (average, 45.9 years). L1 and Th12 fractures were treated in 71 and 66 patients, respectively. Based on CT scans and operative findings, the fractures were assessed as type A in 81, type B in 42 and type C in four patients. The causes of injury were a fall from height in 72, a pedestrian's fall in 29, a traffic accident in 23 and other in three patients. On admission 19 patients had a neurological deficit of varying degree: Frankel grade A, eight patients; grade B, four; grade C, five; and grade D, two patients.
The patients were treated by either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone. Transpedicular posterior stabilization was performed in 52 patients. All of them had an anterior procedure completed with screw-rod-screw stabilization, and the vertebral body was replaced with an allograft or an expandable titanium cage in 50 and two patients, respectively. The anterior approach alone was used in 75 patients, who received a bisegmental angle-stable implant in 43 and a monosegmental plate in 32 cases. To replace the vertebral body, allografts were used in 71 and an expandable titanium cage in four patients.
The average follow-up period was 3.9 years (range, 1 to 6 years). In the anterior procedure, the average operative time was 90 min (range, 50 to 130 min) and blood loss ranged from 200 ml to 2300 ml. A complication due to deep infection occurred in one patient and required removal of both the anterior and posterior implants. Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at 1-year follow-up. No conversion of the minimally invasive technique to a conventional approach due to visceral or vascular injury was necessary; nor was revision surgery for fluidothorax needed. No loosening of an anterior implant or cage dislocation was recorded. Hypesthesia in the operative wound area was found in four patients (3.1%). Improvement in neurological status by at least one Frankel grade was found in 10 of the 19 affected patients.
The anterior approach is recommended for reconstruction of the anterior spinal column in burst fractures of the thoracolumbar junction in particular. An isolated posterior approach may result in implant failure during bony union or in the loss of correction after implant removal that can lead to the recurrence of kyphosis. Conventional thoracotomy is often associated with significant morbidity and hence there is a need for a minimally invasive approach to treat thoracolumbar junction injury.
The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.
The anterior support in thoracolumbar spine fractures is the most important step for reconstructing the shape of the vertebral column to preserve satisfying long-term results. A lot of biomechanical and clinical investigations confirm the necessity of anterior reconstruction in bisegmental posterior stabilizations to avoid posterior implant failure. Potential of healing of a bisegmental corticocancellous graft is limited. With vertebral body replacements (VBR) the loss of correction after removal of the posterior stabilization device is small. VBRs with expandable components allow an adapted anterior defect bridging and open the possibility of anterior reduction.
Aims:
A retrospective analysis of patients with thoracolumbar junction fractures who underwent video-assisted thoracoscopic surgery via a minimally invasive approach (minithoracotomy) for reconstruction of the anterior spinal column.
Methods:
Between 2002 and 2014, a total of 176 patients were treated by this technique. The patients received either posterior stabilization and, at the second stage, the minimally invasive technique via an anterior approach, or the minimally invasive anterior procedure alone.
Results:
In the anterior procedure, the average operative time was 90 min. (50 to 130 min). Bony fusion without complications was achieved in all patients within a year of surgery. The loss of correction after the anterior procedure with an allograft or titanium cage was up to 2 degrees at two years follow-up.
Conclusion:
The minimally invasive approach (minithoracotomy up to 6-7 cm) combined with thoracoscopy is an alternative to an exclusively endoscopic technique enabling us to provide safe surgical treatment of the anterior spinal column.
The anterior support in thoracolumbar spine fractures and in some special cases of tumour diseases is one of the most important steps for reconstructing the shape of the vertebral column to preserve satisfying long-term results. A lot of biomechanical and clinical investigations confirm the necessity of anterior reconstruction in bisegmental posterior stabilizations to avoid posterior implant failure. Potential of healing of a bisegmental corticocancellous graft is limited. With vertebral body replacements (VBR), the loss of correction after removal of the posterior stabilization device is small. VBRs with expandable components (see Fig. 33.1) allow an adapted anterior defect bridging and open the possibility of anterior reduction.
Clinical study of endoscopic surgery for calcification of the ligamentum flavum (CLF) in the cervical spine.
The current study evaluates the technical feasibility and clinical outcomes of endoscopic decompression in 3 patients with cervical myelopathy due to CLF.
CLF is a disease which results in calcium pyrophosphate dihydrate crystal deposition in the ligamentum flavum and which sometimes causes radiculomyelopathy and spinal stenosis. Cervical myelopathy associated with CLF is a rare entity. Most patients with myeloradiculopathy due to CLF were treated by laminectomy.
Three patients with cervical myelopathy due to CLF underwent endoscopic partial laminectomy using the METRx system. The operative procedure is presented. Clinical results were evaluated using a scoring system for the treatment of cervical myelopathy adopted by the Japanese Orthopedic Association (JOA score, highest score: 17 points).
There were no dural tears or other intraoperative complications. There were no postoperative complications. All of the patients recognized the improvement of the symptoms caused by spinal cord compression. Postoperative JOA scores in the 3 cases were 17, 17, and 16.5, respectively. Visual analog scale of neck pain was 0/10 in all 3 patients at follow-up. No patients showed evidence of spinal instability after surgery.
Endoscopic surgery can be used to treat cervical myelopathy due to CLF with minimal soft tissue invasion.
