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Ann Thorac Surg 2008;86:1762-1768. doi:10.1016/j.athoracsur.2008.07.087
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Technical Challenges and Utility of Anterior Exposure for Thoracic Spine Pathology

Brian L. Pettiford, MD*, Matthew J. Schuchert, MD, Geetha Jeyabalan, MD, James R. Landreneau, Arman Kilic, BS, Joshua P. Landreneau, Omar Awais, MD, Michael S. Kent, MD, Peter F. Ferson, MD, James D. Luketich, MD, Andrew B. Peitzman, MD, Rodney J. Landreneau, MD

Heart, Lung, and Esophageal Surgery Institute, and Department of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania

Accepted for publication July 23, 2008.

* Address correspondence to Dr Pettiford, Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Shadyside Medical Office Building, Suite 715, 5200 Centre Avenue, Pittsburgh, PA 15232 (Email: pettifordb{at}upmc.edu).

Presented at the Poster Session of the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008.


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Thoracic surgeons are frequently called upon to provide exposure to the anterior cervicothoracic, thoracic, and proximal lumbar spine. We reviewed our surgical experience and the perioperative outcomes of these spinal approaches. Relevant technical and anatomic considerations of each procedure are highlighted.

Methods: A total of 213 patients (116 female, 97 male) undergoing anterior thoracic spinal exposures over an 11-year period at a single institution were analyzed. Primary endpoints include morbidity, mortality, and perioperative outcomes.

Results: Mean age was 53.7 years. Surgical approaches were determined based on the location and length of spinal involvement, and included cervicothoracic (5), thoracotomy (117), and thoracoabdominal (91) techniques. Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08). Procedures for infection were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001) and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy.

Conclusions: The increased use of anterior approaches to spinal pathology necessitates greater involvement by thoracic surgeons. Familiarity with the anatomic and technical features of the anterior spinal exposure is required by thoracic surgeons to optimize surgical outcomes.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Neurosurgeons and orthopedic surgeons often enlist the assistance of thoracic and general surgeons to provide spinal access during the anterior approach. Anterior thoracic spine exposure may be used alone or in combination with a posterior midline procedure. This requires a thorough knowledge of cervical, thoracic, and lumbar anatomy and the relationship between the target spine lesion and the proposed incision site along the thoracic cage.

Anterior spine exposure by thoracotomy was initially used to treat Pott's disease in the early twentieth century. Although this approach was initially employed for lumbosacral disease, it became widely accepted for treating thoracic spine infections [1–3]. With advances in spinal instrumentation, including cages, autografts, and heterografts, vertebral abnormalities such as spondylolisthesis and compression fractures were treated by an anterior approach. Anterior and posterior approaches are now performed in a staged or sequential fashion based upon the lesion location, spine surgeon's preference, and overall patient condition.

Most cases of disc herniation are treated by discectomy and autograft placement. The autograft may include a portion of rib harvested at the time of thoracotomy or a portion of the ipsilateral crest. Corpectomy alone or in combination with discectomy may be used in cases of fracture or vertebral body metastasis. A plate or cage reconstruction is frequently used in cases of corpectomy. Drainage and debridement with corpectomy and discectomy are performed in cases of osteomyelitis. Scoliosis often involves multilevel corpectomy and strut or plate insertion and fusion. An anterior and posterior approach may be frequently required in the latter case.

In this study, we report our 11-year experience of anterior cervical and thoracic spine exposure at a single institution. We highlight key technical considerations associated with the different approaches, and analyze the associated perioperative outcomes and related morbidity and mortality trends.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
A waiver for the need of patient consent and approval for record evaluation was granted by the Investigative Review Board at our institution. We performed a retrospective review of the records of 213 patients who underwent anterior thoracic, lumbar, and cervicothoracic spine exposure over an 11-year period between March 1996 and March 2007. Primary endpoints were morbidity, mortality, and perioperative outcomes.

Surgical Technique
The most common procedure was muscle-sparing lateral or posterolateral thoracotomy. Single lung ventilation was accomplished most frequently using a double lumen tube. Bronchial blocker was used in cases where double lumen tube placement was not technically feasible. Arterial line monitoring was used routinely. All thoracic and thoracolumbar exposure patients were positioned in a lateral decubitus position after somatosensory evoked potentials (SSEP) lead placement. In cases of preoperative sensory deficits, monitoring was instituted prior to positioning. The thoracic and spine surgeons were both present at the time of positioning.

Incision placement was approximately two interspaces above the target vertebral body or disc space. The authors preferred a right-sided approach for most thoracic spine exposures in patients with disc herniation and osteomyelitis. In patients with scoliosis, the incision laterality was made on the convex side of the spine. During partial rib resection, the specimen was retained on the operative field for possible use as an autograft. A BOOKWALTER retraction system (Codman, Raynham, MA) was commonly used and provided adequate retraction of the chest wall, lung and diaphragm (Fig 1). A moist laparotomy pad and "wide malleable" BOOKWALTER blades provided excellent lung and peritoneal retraction. Two shallow bladder blades maintained adequate chest wall separation. The deep, straight blades were effective in maintaining downward traction on the ipsilateral diaphragm.


Figure 1
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  		Fig 1. Thoracolumbar spine exposure. Note the BOOKWALTER retraction system in place. This allows retraction at several points and angles in comparison to a standard "ribspreader" system.

 
Somatosensory-evoked potentials monitoring was frequently used to guide ligation of segmental vessels when needed to optimize exposure. Every attempt was made to avoid segmental artery ligation, particularly when performing an anterior thoracic spine approach in the left chest. The parietal pleural envelope was opened at least one interspace above and below the target lesion to maximize exposure. A spinal needle was placed into the target disc space and intraoperative plain film X-ray was used to confirm the proper level.

A thoracolumbar approach was used for patients with T11-L2 lesions. The approach usually required resection of the tenth rib and limited posterolateral division of the ipsilateral hemidiaphragm about its paravertebral interface with the upper psoas musculature. Special care was taken to preserve at least a 1-cm-diaphragmatic margin along the chest wall to allow for reattachment during closure. Elevation of the psoas musculature over the lower thoracic and upper lumbar vertebra was then performed to expose the T11-L2 vertebral levels. Segmental vessels were then carefully exposed and occluded with an atraumatic clamp. If necessary, the segmentals were divided if the SSEP monitoring revealed no change from baseline after clamping.

After completion of the spinal portion of the operation, the pleural edges were loosely reapproximated over the repair site. Often this was not feasible secondary to an inflammatory response and the presence of friable and noncompliant tissue. In cases of diaphragm division, the muscle edges were reapproximated using a running 0 nonabsorbable suture such as prolene. Chest closure was performed in the standard fashion after assuring adequate hemostasis. A single chest tube was inserted at the conclusion of operation.

A thoracoscopic approach was used in a small subset (n = 3) of the patients in this group. Two patients had single level disc herniation. The third had multiple level scoliosis and underwent an anterior release. A right-sided approach was used in all 3 patients.

A small number (n = 5) of patients underwent cervicothoracic spine exposure. These patients were intubated with a single lumen endotracheal tube and positioned supine with a transverse shoulder roll. The upper body was elevated with the head turned away from the operative side and an oblique incision was made anterior to the sternocleidomastoid muscle. The sternocleidomastoid muscle and carotid sheath were retracted laterally while the laryngeal mechanism was reflected medially (Fig 2). A nasogastric tube was inserted to facilitate identification of the cervical esophagus. The manubrium was then split with a standard sternotomy saw. A pediatric Finochietto retractor was then insinuated between the edges of the split manubrium to gain further access to the thoracic inlet. The oblique path of the right recurrent laryngeal nerve toward the laryngeal mechanism at the thoracic inlet increases the risk of traction injury to this structure when a right sided approach is used. Accordingly, whenever technically feasible we chose to utilize a left cervical approach to this spinal level exposure, as the left recurrent nerve is anatomically more closely associated with the tracheoesophageal groove at the thoracic inlet. This anatomic relationship tends to reduce the risk of traction injury to the nerve with upper sternal split and thoracic inlet exposure. The prevertebral space is then entered and the lower cervical and upper thoracic spine then identified after elevation of the longus coli muscle.


Figure 2
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  		Fig 2. Cervical spine exposure through left neck. Special care is taken to avoid injury to the recurrent laryngeal nerve during self-retaining retractor positioning. The sternocleidomastoid and carotid sheath are retracted laterally to provide exposure to the cervical spine with extension into an upper sternal split.

 
Postoperative Management
All patients were followed closely by the spine service and thoracic surgeon. Daily chest X-rays were obtained. Early mobilization to chair and ambulation were performed unless restricted by the spine service. Incentive spirometry was provided to all patients. Most chest tubes were placed to water seal on postoperative day 1. Chest tubes were removed when the 24-hour drainage did not exceed 200 mL.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
A total of 213 patients underwent anterior cervical, thoracic, or thoracolumbar spine exposure. The location and extent of spinal involvement determined the approach, as did the underlying pathology in cases of scoliosis. Approaches included cervicosternal (n = 5), thoracic (n = 117), and thoracolumbar (n = 91). Although not frequently performed in this series, the cervicosternal approach provided excellent exposure of C4-T2. Mean age was 53.7 years with a range between 14 and 86 years. One-hundred sixteen patients were female, whereas 97 were male. Indications for operation included malignancy (n = 60), trauma-fracture (n = 43), kyphoscoliosis (n = 34), degenerative disease (n = 51), and infectious etiology (n = 25). Table 1 lists the indications and respective perioperative data including 30-day mortality.


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  		Table 1 Indications for Surgery and Perioperative Data
 
Malignant and degenerative processes were the most common indications for operation (Table 1). Malignant etiologies were associated with the highest perioperative mortality (6.7%, p = 0.08), whereas procedures for infectious processes were associated with a significantly higher complication rate (p = 0.041) and length of stay (p = 0.033). Correction of scoliosis required longer operative times (p < 0.001), and resulted in a trend toward higher blood loss (p = 0.16). Thoracoabdominal approaches were associated with increased operative times (386 vs 316 minutes) and length of stay (8 vs 6 days) compared with thoracotomy. Table 2 lists the perioperative data based upon approach.


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  		Table 2 Anterior Approach and Perioperative Data
 
Only 3 patients underwent thoracoscopic spine exposure. The length of stay was 5.6 days versus 9.6 days in the open exposure group. The estimated blood loss of 450 cc was slightly less than one-half of the mean estimated blood loss for open spine exposure procedures.

Complications occurred in 42.7% of patients in this cohort. Pulmonary complications occurred in 57 patients, including respiratory failure (n = 17) and pneumonia (n = 12). Respiratory failure was defined as the need for reintubation secondary to hypoxemia and (or) progressive dyspnea or a mechanical ventilation need for greater than 3 days postoperatively. Tracheostomy was required in 3 patients who developed respiratory failure and reintubation. Cardiac complications including atrial arrhythmias occurred in ten patients. Only one patient suffered a perioperative myocardial infarction. Ileus was the most frequent gastrointestinal complication occurring in 8 patients. A total of 10 patients developed wound infection. Indications for reoperation included bleeding (n = 2), spinal root pedicle screw impingement (n = 1), anterior spinal cord syndrome (n = 1), hardware migration (n = 1), and evisceration (n = 1). The evisceration occurred in one patient who underwent a thoracolumbar spine exposure. Miscellaneous complications including failed fusion, cerebrospinal fluid leak, chylothorax, and pseudoaneurysm development occurred in a total of 11 patients. Table 3 lists the number of complications by major approach level.


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  		Table 3 Complication by Anatomic Site
 
There were 11 deaths for an overall mortality rate of 5.1% in this patient group including a 30-day mortality rate of 2.8%. Respiratory failure was listed as a cause of death in 6 of these patients. Four of the 6 perioperative deaths occurred in patients with progression of metastatic malignancy including lung cancer (n = 2), breast cancer (n = 1), and plasmacytoma (n = 1). Sepsis and multiple system organ failure accounted for the causes of death for 3 of the 5 patients within the 90-day mortality group. Pulmonary hemorrhage and progression of metastatic lung cancer were the causes of death in the remaining 2 patients within the 90-day mortality group.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Innovations in spine surgery coupled with an aging and more active population have resulted in a progressive increase in spine instrumentation. This has created the need for anterior spine exposure techniques by the thoracic surgeon. Initial reports of anterior thoracotomy for spine exposure were related to Pott's disease. However, with the advent of effective antitubercular medical therapy and public health programs, a decline in the number of cases of tuberculosis led to a decreased need for the surgical management of Pott's disease [4]. The widespread use of computed tomography and magnetic resonance imaging has increased the accuracy of diagnosis of spondylolisthesis and paravertebral abscess.

Anterior thoracic spine exposure has therefore been frequently employed to provide suitable access to the target area along the vertebral column. This approach is further supported by a reduction in operative time, transfusion requirements, and increased early ambulation in comparison with the posterior approach. Furthermore, the anterior approach minimizes damage to the posterior ligamentous structures, spinal cord, and segmental nerve roots. The classic midline posterior approach with laminectomy for anterior spinal pathology carries a significant morbidity and mortality with poor outcomes. This approach is associated with long operative times, significant blood loss, and a high incidence of back pain [5–8]. In our series pathology was limited to the anterior aspect of the vertebral column, which is more effectively addressed by an anterior approach. In addition, the few studies that have evaluated the role of extracavitary posterior decompression are limited to malignant vertebral body involvement and contain a small number of patients [9, 10]. Patients with malignant vertebral involvement constituted 28% of the patients within our study group.

The anterior approach to cervical disc disease was initially recommended in 1955 during which an anterior discectomy with interbody fusion was performed [11]. A combined neck-sternal split was recommended for access between C7 and T2. Upper sternal sternotomy to the fourth interspace also provided optimal exposure of T4 [12]. Judicious retractor placement is essential as aggressive or careless retraction medially could result in recurrent nerve injury. Some feel that a right-sided cervical dissection places the recurrent nerve at greater risk of injury because its course is less consistent than the left [13, 14].

The cervical and combined cervical-upper sternal approaches may be inadequate for accessing larger cervicothoracic tumors with spinal involvement. Korst and Burt [15] demonstrated a "hemi-clamshell" approach in 42 patients, which provided excellent access from C4–T3 levels. Despite limitations in accessing the posterior chest and neural foramina, this method had acceptable morbidity and no mortality [15]. More recently a modified transmanubrial approach has been described, which can provide exposure from C7 to T5 [16]. The low number of patients who underwent cervicothoracic spine exposure is likely due to the inherently low number of patients with benign disease affecting this area. Radiation therapy is frequently applied for metastases affecting the cervical spine. While spine surgeons may independently approach the proximal to mid cervical spine, exposure to the upper thoracic spine for stabilization often requires dissection into the thoracic inlet and the assistance of a thoracic surgeon. The cervicothoracic cases in our cohort represent the latter instance.

Thoracic spine lesions from T2 to T6 are approached through a right thoracotomy. In general, lesions from T6 to T12 are approached through a left posterolateral thoracotomy. A left thoracoabdominal incision with diaphragmatic takedown has been recommended for lower thoracic spine and lumbar lesions extending to L3 [17]. This approach has been recommended to avoid exposure limitations created by the need to retract the liver. An alternative anterior thoracolumbar approach is the 11th rib extrapleural-retroperitoneal incision. This technique involves minimal diaphragmatic division with resultant diaphragmatic dysfunction and is facilitated with the use of an abdominal self-retaining retractor. This approach is also associated with low postoperative pain, fewer pulmonary complications, and improved wound healing [18, 19].

In our series, posterolateral thoracotomy with a high paravertebral skin incision was used to provide access to T3 and T4 lesions. The paravertebral skin incision was extended to the base of the posterior neck. We also found that right lateral and posterolateral thoracotomy also provided access from T5 to the superior border of L3 (Table 4). We feel that when applicable the right-sided approach provides adequate thoracolumbar spine exposure, and when used with SSEP monitoring can minimize the risk of spinal cord ischemia. We do not routinely obtain angiographic identification of the artery of Adamkiewicz unless multiple spinal levels along the mid to lower thoracic spine are involved. Even in those circumstances, we have relied heavily upon somatosensory-evoked potentials monitoring to guide segmental artery sacrifice. Intraoperative SSEP changes at the time of segmental test clamping were not consistently recorded and therefore could not be commented upon in this patient group.


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  		Table 4 Approach by Lesion Location
 
Although seemingly straightforward, anterior thoracotomy with spine exposure does carry considerable morbidity and mortality. Naunheim and colleagues [20] reported an operative mortality rate of 3.2% and demonstrated that patients with osteomyelitis were at an increased risk for perioperative mortality. Complication rates as high as 40% have been reported. The most feared complication rate is spinal cord ischemia secondary to division of the anterior artery of Adamkiewicz, which is located on the left side in approximately 80% of patients. This artery accounts for blood supply to the lower one-half of the spinal cord and has a widely variable origin, arising anywhere from T5–L2. However, it most commonly arises from T9–T12 [21, 22]. During left thoracotomy, unilateral ligation close to the aorta is recommended to preserve collateral spinal cord perfusion [23]. Anderson and colleagues [12] have advocated a spinal angiogram if multiple segments inferior to T6 are involved. Magnetic resonance imaging may provide a relatively safe means of identifying the artery of Adamkiewicz preoperatively [24, 25]. Despite these concerns, there are numerous reports of its uneventful sacrifice [26–28].

Respiratory complications including atelectasis, pneumonia, and pneumothorax are quite common in this group and may be present in up to 50% of patients. Prevention is paramount and should include preoperative pulmonary function testing in patients with a history of heavy tobacco abuse, chronic obstructive pulmonary disease, and interstitial lung disease. We advocate perioperative incentive spirometry and early patient mobilization if not precluded by postoperative activity restrictions.

Adequate pain control is also essential in this group of patients. In the immediate postoperative period, severe chest wall pain may result in inadequate respiratory mechanics leading to atelectasis and (or) pneumonia. We have found that the judicious use of paravertebral-intercostal blocks, in conjunction with nonsteroidals such as Toradol (Hoffman-LaRoche Inc, Nutley, NJ), reduces the need for postoperative narcotics and facilitates patient mobilization. Chronic incisional or dermatomal pain may require evaluation by a chronic pain specialist or surgical neurolysis in select refractory cases.

The 30-day mortality rate of 2.8% was relatively low. Underlying malignancy was present in 54% of patients who died within 90 days of surgery. This may be related to complications from progression of malignancy and the poor physical status of these patients. The main indications for intervention in this group included motor and sensory deficits secondary to nerve root or spinal cord involvement. Given the debilitated state and higher death rate observed in patients with underlying malignancy, perhaps spine surgery should be limited to those patients who develop neurologic symptoms. Although not frequently performed in this cohort, a thoracoscopic approach may possibly decrease perioperative complications and noncancer-related death among patients with underlying malignancy.

Wound infection is often controlled with antibiotic therapy and may require local incision and drainage. Empyema is a dreaded complication of anterior spine exposure, especially in cases of reconstruction using prosthetic material. During the workup and intervention, every attempt should be made to determine whether any communication exists between the empyema cavity and the spinal instrumentation. Effective management should begin with tube thoracostomy and may result in video-assisted thoracostomy or redo thoracotomy with wide irrigation and drainage. Antibiotic therapy is tailored to the offending organism(s). Due to these measures, the need to remove infected hardware is now rarely reported.

Chylothorax may also complicate anterior spine exposure, particularly when exposure occurs along the lower aspect of the thoracic spine during right-sided approaches [29, 30]. This may progress to severe electrolyte abnormalities and sepsis if not definitively addressed in a timely fashion. The management should include bowel rest and total parental nutrition. However, many advocate early operative intervention [31, 32]. Lymphangiographic embolization may avoid redo thoracotomy in select cases [33].

Despite the potential for perioperative complications, the incidence of severe morbidity and mortality is low. When carefully coordinated by the thoracic or general surgeon and the spine specialist, anterior spine exposure is an effective approach. A general knowledge of the cervicothoracic anatomy and the relation between the vertebral column and the thoracic cage is key to operative planning. Somatosensory-evoked potential monitoring is an effective means of guiding exposure of the target lesion and avoiding the potential for spinal cord ischemia. Although perioperative complications do exist, they can in most cases be appropriately managed.

While not frequently used in our patient group, thoracoscopic spine exposure will play a greater role in the management of vertebral pathology, especially single level disc herniation. This approach will likely result in lower blood loss, less postoperative pain, fewer respiratory complications, improved wound healing, and faster recovery.

As the population ages and as society becomes more physically active, an increased number of patients will undergo cervical and thoracic spine operations. It is important that thoracic surgeons remain actively involved in the perioperative evaluation of and planning for anterior spinal approaches. Formal education in the proper techniques of open anterior cervical, thoracic, and lumbar spine exposure should become incorporated into thoracic training programs. Training in thoracoscopic approaches to the thoracic spine is also encouraged.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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