SLIDE 1 Mini-Open Transpedicular Corpectomy for the Treatment of Painful Spine Tumors
UCSF Spine Symposium June 1, 2013
Dean Chou, M.D. Associate Professor of Neurosurgery Associate Director, The UCSF Spine Center University of California San Francisco
Disclosure
Consultant: Globus Honorarium: Medtronic Honorarium: Depuy Honorarium: Stryker
Why use an osteotomy?
Need to move the spine (correct kyphosis,
scoliosis)
Spine is rigid from either previous fusion or
degenerative aging changes
Introduction
Selecting osteotomies
Smith-Petersen/Ponte (10 degrees) Pedicle subtraction osteotomy (30 degrees) Vertebral column resection (VCR) (60 degrees)
SLIDE 2
- F. SCHWAB – SPINE MOBILIZATION
ANATOMICAL CONSIDERATIONS
6 Grades of Destabilization:
- 1. Partial facet joint
- 2. Complete facet joints
- 3. Partial body*
- 4. Partial body and disc*
- 5. Complete body + discs*
- 6. >1 body, adjacent*
*posterior vs. anteroposterior
Why Ponte osteotomy?
Straightforward Effective Fast Can do a multiple levels Smooth, gradual
correction of kyphosis
Reasons not to do a Ponte osteotomy
Sharp, angular kyphosis Significant kyphosis
needing more than 10 degrees of correction/level
Rigid, circumferential or
anterior solid fusion masses
Pedicle subtraction osteotomy
Anterior column intact Hinge dorsally Cut wedge, not square Consider removal of the
disc also
Average 30 degrees
correction
SLIDE 3 Indications
Sharp, angular kyphosis Flatback syndrome after iatrogenic fusion Needing approximately 30 degrees of correction Average 11cm of sagittal correction per PSO
PSO
VCR
Essentially a posterior based corpectomy Use the skills and techniques from posterior
corpectomies
Extremely unstable, be careful of both
translation and spinal cord lengthening during
Mini-open vertebrectomy
Technically challenging Must be familiar with open VCR Must be comfortable with percutaneous pedicle
screws
Easiest to start with thoracic kyphosis. Consider kyphotic tumor case to start
SLIDE 4
Evolution of mini-open vertebrectomy
T6 Metastatic hepatocelluar carcinoma Cord compression Gait disturbance Neurologic deficit
Skin incision—make single midline incision or multiple stab incisions? (Fessler)
Single skin incision Place Jamshidi needles
SLIDE 5
Jamshidi’s in Place k-wires in Open fascia or skin Tap goes in
SLIDE 6
Tap under fluoro Place screw—control k-wire Start laminectomy
Place temporary rod to prevent translation
SLIDE 7
Remove towers after rod in Place expandable cage Skin closure
Same skin incision—but is it the same surgery?
Open Mini open
SLIDE 8 Evolution to mini-open VCR
Similar steps to corpectomy Similar principles Consider not using the biggest possible cage.
- F. SCHWAB – SPINE MOBILIZATION
ANATOMICAL CONSIDERATIONS
6 Grades of Destabilization:
- 1. Partial facet joint
- 2. Complete facet joints
- 3. Partial body*
- 4. Partial body and disc*
- 5. Complete body + discs*
- 6. >1 body, adjacent*
*posterior vs. anteroposterior
THE TRADITIONAL POSTERIOR APPROACH
Kyphosis correction during posterior based vertebrectomy using cantilever technique
Open transpedicular corpectomy
SLIDE 9
Implants placed. Laminectomy done Contour rods into the shape you want spine to look
Cantilever to correct kyphosis Post correction
SLIDE 10
Can we do the same thing less invasively?
Mini-open corpectomy with kyphosis correction
Breast cancer—kyphosis correction via Mini-Open approach
Kyphosis intraop picture Cage insertion
SLIDE 11 Kyphosis correction Kyphosis correction VCR for severe thoracic kyphosis
80 yo female with 90 degree thoracic kyphosis Failed non-surgical care Wished to proceed with surgery Understood significant risk of surgery Planned mini-open VCR given age Cement augmentation given osteoporosis
Preop
Severely limited in
ambulation
Chronic narcotic use Sits in chair all day 90 degrees kyphosis 2 compression fractures
above & below
SLIDE 12
Standard skin incision Preserve fascia Jamshidi needles placed Place proximal screws
SLIDE 13
Place distal screws Multiple Jamshidis save on fluoro Open fascia over VCR site only Begin laminectomy
SLIDE 14
Complete VCR—temporary rod Place cage for pivot
Thread rod through fascia—cut the fascia distal end Correct kyphosis—rod in shape of how you want spine to be
SLIDE 15 Fascial opening Drains placed, skin closed
500cc EBL No intraop
transfusion
Back pain much
better
Caveat:s: cement
PE, new adjacent fracture at L4
Conclusions
Use the same principles as in open surgery—
correct kyphosis
After a vertebrectomy, you’ve essentially done a
VCR—take advantage of it
Be careful in osteoporotic patients—
instrumentation is very powerful and bone- screw interface may not be.
SLIDE 16
Thank you!
