Abstract
With advances in surgical technique and instrumentation, the anterior approach to the thoracolumbar spine becomes more popular. Anterior approach is considered particularly when ventral decompression of neural structures is needed, providing optional stability by fusing the involved segment with instruments specially designated for that purpose. The usual approach is done through a 10th or 11th rib thoracotomy, opening of the pleural cavity and a semilunar cut at the periphery of the diaphragm, in order to expose the anterolateral aspect of the vertebral column. This technique involves the risk of phrenic nerve injury and diaphragmatic paralysis combined with morbidity of the chest tube. A variant of that technique is the retrodiaphragmatic approach, which provides the surgeon with the advantages of ventral exposure, potentially avoiding the morbidity of the standard transpleural thoracotomy.
Methods: During a three-year period, all patients with major anterior pathology at the T11, T12 or Ll level, were operated using the retrodiaphragmatic anterior approach. This involved an 10th or 11th rib thoracotomy with the patient in a lateral decubitus position. Following rib resection, blunt dissection of the diaphragm from the chest wall was performed without its surgical incision. The parietal pleural was mobilized medially and left intact and the thoracolumbar spine was exposed for the procedure. In case of a major pleural defect, a chest drain was inserted.
Results: Fifteen patients (10 males and 5 females, mean age: 32.6y) made up by study group. This included six patients who had a thoracolumbar fracture, five patients who were diagnosed as having idiopathic scoliosis and four patients who presented with metastatic disease in the thoracolumbar region. Adequate decompression was achieved in all patients as well as stable fixation of the involved segment. Mean operating time was 4.5 hours, average hospitalization length was six days. Three patients (20%) required a chest drain following the procedure. The drain was removed within three postoperative days of the operation. In five cases (40%) blood transfusion was required. Mainly for the underlying disease. The average decrease in the hemoglobin values, in the patient subgroup not requiring blood transfusion, was 3mg% at discharge comparing to the preoperative level. No intra-operative complications related to the surgical technique or instrumentation, were noted, nor any case of mortality. Complications such as respiratory distress, neurological damage, infection, hardware loosening or failure, pseudoarthrosis or hernia in scar were not observed during the post operative follow-up.
Conclusion: The retrodiaphragmatic approach to the thoracolumbar spine is safe and technically easy to apply in cases where ventral exposure of the spine is needed. This technique spares the need for diaphragmatic incision and in most cases, leaves the pleural cavity intact.
The abstracts were prepared by Orah Naor. Correspondence should be addressed to him at the Israel Orthopaedic Association, PO Box 7845, Haifa 31074, Israel.
