Minimally Invasive Thoracic Spine Surgery PDF
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Minimally Invasive Thoracic Spine Surgery Sang-Ho Lee Junseok Bae Sang-Hyeop Jeon Editors 123 Minimally Invasive Thoracic Spine Surgery Sang-Ho Lee • Junseok Bae Sang-Hyeop Jeon Editors Minimally Invasive Thoracic Spine Surgery Editors Sang-Ho Lee Junseok Bae Wooridul Hospital Wooridul Hospital Seoul, Korea (Republic of) Seoul, Korea (Republic of) Sang-Hyeop Jeon Wooridul Hospital Busan, Korea (Republic of) ISBN 978-981-15-6614-1 ISBN 978-981-15-6615-8 (eBook) https://doi.org/10.1007/978-981-15-6615-8 © Springer Nature Singapore Pte Ltd. 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore Foreword Disorders of the thoracic spine are important and have a significant and mea- surable impact on health-related quality of life. Spinal disorders involving the thoracic spine include congenital and developmental deformity, degenerative disorders, neoplastic disease, infectious and inflammatory disorders, and trauma. Surgical approaches to the thoracic spine are important for decom- pression of the neural elements, realignment of the spine, and stabilization of the thoracic spine. Surgical approaches to the thoracic spine are challenging and may involve significant morbidity due to the anatomic barriers of the chest wall and mediastinum and the relatively narrow diameter of the spinal canal relative to the spinal cord. Professor Lee and Bae’s textbook Minimally Invasive Thoracic Spine Surgery offers valuable teaching and lessons regard- ing safe and effective management of spinal disorders involving the thoracic spine using a minimally invasive approach. The thoracic spine is the longest and least mobile region of the spinal col- umn. Optimal management of disorders of the thoracic spine begins with an accurate diagnosis. The spectrum of disorders affecting the thoracic spine includes congenital and developmental deformities, degenerative patholo- gies, tumor, and infection. The clinical and radiographic evaluation of patients with thoracic disorders is well covered in the textbook and offers important pearls for the clinician reader. Radiographic evaluation of the thoracic spine and spinal canal is important to assess significant cord compression, the pres- ence of ossification of the intervertebral disc, and ligaments including the posterior longitudinal ligament and the interlaminar ligaments. The book includes important information regarding clinical and radiographic evalua- tion, differential diagnoses, and pathologies that guide an evidence-based approach to management of thoracic disorders. The heart of the textbook involves a comprehensive overview of surgical strategies for the management of specific spinal disorders using a minimally invasive approach. Dorsal, ventral, and lateral approaches to the thoracic spine may be compromised by anatomic barriers of the chest wall and medi- astinum and the relatively small diameter of the thoracic spinal canal. The spinal cord is especially susceptible to compromise in many disorders of the thoracic spine due to the relatively narrow anatomy of the thoracic spinal canal and the kyphotic alignment of the thoracic spine region. Surgical approaches to the thoracic spine require knowledge of the anatomy of the thorax, including the lungs and mediastinum, the blood supply to the thoracic spine, and the corridors to safely access the thoracic canal with limited retrac- v vi Foreword tion of the spinal cord. The textbook offers important and useful information regarding anesthesia, patient positioning, intraoperative imaging, and postop- erative management. Anesthetic considerations that are unified with the tho- racic spine include single lung ventilation during anterior and lateral approaches and optimization of intravenous anesthetics to facilitate neural monitoring. The detailed descriptions of minimally invasive surgical approaches to decompression and instrumentation of the thoracic spine are exceptionally instructive and valuable. The sections on specific surgical approaches and techniques are thorough and well written with excellent case examples. The surgical techniques chapters offer tremendous and insightful information to improve the surgical techniques of all readers. Professor Lee and Bae and the contributing authors of the textbook Minimally Invasive Thoracic Spine Surgery have created an important and valuable resource for clinicians and surgeons who treat patients with disor- ders of the thoracic spine. The textbook is transformational in guiding an evidence-based approach to optimal evaluation and management of disorders of the thoracic spine. Sigurd Berven Department of Orthopaedic Surgery UC San Francisco San Francisco, CA, USA Foreword In the last 10 years, the use of minimally invasive surgical techniques has revolutionized spinal care. This is particularly apposite in respect of surgery to the thoracic spine as there are significant potential risks of damage to spi- nal cord function during most open procedures. Anything that mitigates these risks will enhance patient safety and lessen any fears that the operating sur- geon may have of rendering any of their patients paraplegic. Sang-Ho Lee, Junseok Bae, and Sang-Hyeop Jeon now bring to the world literature a com- prehensive book which outlines current “state-of-the-art” techniques for the treatment of thoracic pathology. In early chapters, the reader is guided through the essential knowledge required for safe access to the spine. Those learning about minimally invasive surgery for the first time will pick up much valuable information and more experienced practitioners will find that some of the clear recommendations will be of significant benefit to their practice. In the remainder of the text, the authors succinctly describe methods by which the surgeon will cope with common and rare surgical entities, backed up by excellent color illustrations and literature references. Rightly, reflecting the author’s considerable experi- ence, there is an appropriate emphasis on the place of full spinal endoscopy. Important as its place now is and will be in the future, endoscopy is not con- sidered “all inclusive.” There are interesting chapters on trauma and tumor management using other technologies and the reader will be drawn to the methods of regaining an erect and normal posture in those afflicted by painful osteoporosis, post-traumatic vertebral collapse, and other spine deformities. Thoracic spine disorders are responsible for a great deal of misery, and anything that allows safer surgery is to be welcomed. The clear descriptions of the multiplicity of thoracic disorders are without comparison. I am sure that this book will become a reference text for all surgeons wishing to move away from outmoded treatments to the newest innovative procedures in spi- nal care. J. N. Alastair Gibson Department of Orthopaedic Surgery The Spire Murrayfield Hospital Edinburgh Edinburgh, UK vii Foreword It is a great pleasure and an honor for me to write a foreword to Prof. Sang-Ho Lee’s textbook Minimally Invasive Thoracic Spine Surgery. This well-struc- tured and organized textbook deals with almost all the techniques available to approach the thoracic spine from any side in less aggressive but highly effec- tive approaches compared with the traditional open techniques. This book is a perfect summary of how quickly spine surgery has evolved during the past few decades. Since Hiiikata and Kambin’s early publications in the mid-1970s dealing with percutaneous lumbar disc treatment, decades of continuous evolution in the field of minimally invasive or, even better, adequately invasive spine sur- gery have passed. Not only visualization but also special instruments or appa- ratus has widened the indications for less invasive treatment for degenerative disease, trauma, tumor, infection, or deformities of the spine. The main goal of minimally invasive techniques is to reduce the approach trauma to a minimum while achieving maximal effectivity at the site where the pathology is located, keeping intact the physiological function of as much structures as possible. Although endoscopic or endoscopic assisted techniques are established techniques in almost all surgical fields, it still has to fight to be considered as an alternative to classic approaches in spine surgery. The vast majority of surgeons consider just a small skin incision a minimally invasive step; for those who are not trained in these techniques, this can lead to “less effective” or “failed spinal surgery.” If we just take few minutes to think why this is so, many questions arise in my mind: – Why are we using extreme expensive instruments like navigation, mon- itoring, and robotic combined with techniques that are 50 years old and have never been improved or updated? – Why do most surgeons skip the option of endoscopy when advising their patients about surgical options? – Why do we always read about how steep the learning curve for endo- scopic techniques is but never read similar comments for vertebrec- tomy or complex instrumentation techniques in spine surgery? – Why are anterior approaches to the lumbar or thoracic spine so danger- ous but cervical and transoral techniques are considered “doable?” – Why are not minimally invasive procedures part of the curricula during residency? ix x Foreword The listing of questions and possible answers could be endless and prob- ably would never find a consensus. However the most effective, less disrup- tive, and safest technique should always be the first recommendation to our patients when discussing surgical indication and techniques. Many of the chapters in this book deal with those questions and probably can answer them, serving as a guide for young spine surgeons—not only in practice but also in arousing her/his curiosity and, as many of us did, to start thinking, investigate, and after careful research and tests develop new approaches as well. The peri- and intraoperative high-quality planning, including robotics and navigation when combined with minimally invasive techniques, will push the envelope further forward in the next few years. Probably the fascination of reaching and treating deep-seated spinal dis- eases using less disruptive but equally effective techniques when compared to classic open procedures, mixed with a big portion of respect, will drive the next generations to spread even more minimally invasive techniques in daily practice. Prof. Sang-Ho Lee’s book is a big step in the right direction. He and his coeditors have to be congratulated for summarizing and updating spine sur- geons with the latest minimally invasive approaches to the thoracic spine, thus expanding not only our horizon but also the options we have to help our patients in daily practice. Daniel Rosenthal Neurosurgical Section Hochtaunus Kliniken Bad Homburg, Germany Preface Small is beautiful for thoracic spine surgery The incidence of thoracic spine disease is increasing nowadays by routine screening of cervical-thoracolumbar MRI. You need more active, positive, and more prompt causal treatment to save your patients from intractable back pain and progressive weakness of legs due to thoracic spine diseases, such as herniated thoracic discs or thoracic stenosis. The available free space of the spinal canal of the thoracic spinal cord is very limited so that during the operation the safe margin for not touching the spinal cord is narrow. That is why a small microscopic or endoscopic surgery as a causal treatment for thoracic spine disease is more efficacious and more successful than a big surgery. Because it is truly minimally invasive and the duration of surgery is quite short, blood transfusion is not required. Because it is safer and has fewer side effects and complications, patients who undergo this less invasive thoracic surgical treatment are more sportive and have more life span than those who undergo maximally invasive surgery. The traditional radical thoracic surgery for neurologic decompression requires extensive resection of the vertebral and rib bones, which leads to fusion surgery to prevent postoperative instability. That is why so many sur- geons delay decompression surgery until their patients have profound gait disturbance. However, causal treatment needs earlier thoracic decompression at the stage of unbearable back pain and radiculopathy for prevention of walking difficulty. Because the delay in performing decompression in the thoracic spine eventually causes myelopathy, it might be difficult to get back to normal daily activity. When you are well trained in the discipline of the minimally invasive sur- gical procedures for the thoracic spine, you can perform thoracic decompres- sion at an early stage before your patients develop leg weakness, paraparesis, and paraplegia. For the safe and successful practice of endoscopic decompression instead of wide-open surgery, you need small bipolar radiofrequency, delicate side- firing Holmium-YAG laser, and high-speed endoscopic diamond drill. With the help of foraminoplastic thoracic endoscopic decompression, it is possible xi
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