Ebook Spinal tumor surgery: Part 2
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Ebook Spinal tumor surgery: Part 2
^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2xtracavitary Approaches: Standard Intralesional Resection14James G. Malcolm, Michael K. Moore, and Daniel RefaiIntroductionSurgical approaches to the anterior thoracic spine have evolved over the last century. As early as 1894, Menard developed the costo-transverseclomy (CT) for the treatment of Pou Ebook Spinal tumor surgery: Part 2’s disease 11|. Until 1976. when Larson popularized the lateral extracavitary approach (LECA). the most commonly performed procedure for ventral lesioEbook Spinal tumor surgery: Part 2
ns remained a laminectomy. With the advent of the LECA, greater access to ventral lesions led to less morbidity and improved outcomes in ventral thora^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2through dorsal approaches.In consideration of dorsal versus ventral approaches to the anterior thoracic spine, the goal of surgery is paramount. Most tumors of the spine are metastases: therefore, debulk-J. G. Malcolm (E3) • M. K. MooreEmory University. Department of Neurosurgery.Atlanta. GA. USAe-m Ebook Spinal tumor surgery: Part 2ail: james.malcolm@emory.eduD. RefaiEmory University. Department of Neurosurgery and Orthopaedics, Atlanta. GA. USAing through intralesional (piecemeaEbook Spinal tumor surgery: Part 2
l) resection of the tumor, not en bloc resection, is the primary goal with gross total resection when possible. Resection of the tumor mass enables us^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2 body weight at Tl to 47% of body weight at TI2 |3J. Removal and replacement of a weakened anterior column restores biomechanical stability. This at minimum prevents progressive collapse in patients with pathologic fractures and can be used to correct kyphotic deformity. Cages or allograft struts ar Ebook Spinal tumor surgery: Part 2e often used to achieve anterior column support. Second, the removal of the lesion reduces tumor burden creating a corridor between the neural structuEbook Spinal tumor surgery: Part 2
res and tumor. Third, to halt or reverse neurologic deterioration from compression of neural structures. In selecting a corridor, the surgeon must wei^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2ion |4|. the decision to operate can be guided by the NOMS framework [5. 6|. Neurologic (N) considerations include the degree of myelopathy, functional radiculopathy, and epidural spinal cord compression |7|. When© Springer Nature Switzerland AG 2019D. M. Sciubba (cd.). Spinal Tumor Surgery. https:/ Ebook Spinal tumor surgery: Part 2/doi.org/l0.l0077978-3-319-98422-3_l4141142J.G. Malcolm et al.possible, pail) should be separated into biological and mechanical sources. Oncologic (OEbook Spinal tumor surgery: Part 2
) considerations center primarily on the radiologic sensitivity of the tumor. For example, myeloma and lymphoma are considered radiosensitive: breast ^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2essment of mechanical (M) instability includes movement-related pain and involved levels. Systemic (S) disease burden encompasses the extent of disease throughout the body as well as associated co-morbidities. With this framework in mind, resection is often recommended when there is high-grade epidu Ebook Spinal tumor surgery: Part 2ral compression, radioresistance, mechanical radiculopathy or back pain, and instability and when the patient is able to tolerate surgery [5 J. In casEbook Spinal tumor surgery: Part 2
es with significant canal involvement for a tumor otherwise suitable for radiotherapy, surgery may be performed to separate the spinal cord from the t^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2on therapy. In most institutions, the radiation oncologists request between 1 and 3 mm of cerebrospinal fluid (CSF) signal between the spinal cord and tumor margin IO enable them to deliver complete lesional coverage with radiotherapy [7|.Access to the ventral thoracic spine has been historically ac Ebook Spinal tumor surgery: Part 2complished through a variety of approaches with the main approaches being transthoracic or some combination of laminectomy (L) plus transpedicular (TPEbook Spinal tumor surgery: Part 2
), costotransver-sectomy (CT), or lateral extracavitary (LECA). Of these four approaches, the last three are posterior and can be thought of as in con^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2progresses from removal of the lamina (L). to pars and pedicle (TP), to removal of the transverse process and proximal rib (less than 4-6 cm) (CT), to a LECA in which extensive rib (beyond 6 cm) dissection is employed to enable contralateral access to ventral pathology from a unilateralFig. 14.1 Axi Ebook Spinal tumor surgery: Part 2al illustration of thoracic vertebral body and rib with various posterior approaches overlaid: lateral extracavitary approach (LECA). transpedicular (Ebook Spinal tumor surgery: Part 2
TP>. and costotransversectoiny (CT). Each of these extends the standard laminectomy (L). LECA provides greater access to the ventral aspect of the ver^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2in a traditional open or mini-open manner (Fig. 14.5).Case DescriptionFor illustration, we present a 30-year-old female with a history of breast cancer who presented to clinic with progressive thoracic back pain radiating down her left flank through the T7 dermatome. Imaging revealed a lesion at T6- Ebook Spinal tumor surgery: Part 2T7 with spinal cord effacement but without cord signal change (Fig. 14.6). Since the lesion was eccentric to the left and involved the ribs with signiEbook Spinal tumor surgery: Part 2
ficant invasion of the vertebral body, the decision was made to perform a lateral extracavitary approach from the left taking the T6-T7 ribs and over ^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2 two levels, instrumentation was planned from T3 to T9 (three above, two below). On the day of surgery', her neurologic exam had further declined to a T6 sensory level with motor movements of 1-2 out of 5 in her bilateral lower extremities.14 Anterior/Anterolateral Thoracic Access and Stabilization Ebook Spinal tumor surgery: Part 2from Posterior Approach: Transpedicular... 143Fig. 14.2 Skin incision and rib exposure for lateral extracavitary approach to the thoracic spine (a-d).Ebook Spinal tumor surgery: Part 2
(Reprinted withpermission from Miller Ct al. 114).)Fig. 14.3 Lateral cxtracavitary approach. A. Rib disarticulation.B. Extracavitary retraction. (Rep^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral Ex Ebook Spinal tumor surgery: Part 2 (a. b). (Reprinted with permission from Miller Ct al. 114|.)^3/Check for LC-xtoiAnterior/Anterolateral Thoracic Access and stabilization from Posterior Approach: Transpedicular, Costotransversectomy, Lateral ExGọi ngay
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