SURGICAL INDICATIONS AND COMPLICATIONS OF CAPENER TECHNIQUE (COSTO-TRANSVERSECTOMY). TRANSVERSECTOMY). Patricia Álvarez González, Javier Pizones Arce, Felisa SánchezS nchez-mariscal, Lorenzo ZúñZ úñiga Gómez, G Enrique Izquierdo NúñN úñez. HOSPITAL UNIVERSITARIO DE GETAFE, MADRID. SPAIN. docalvarez@gmail.com
Objective and Background data The objective of this study is to describe surgical indications and complications of costo-transversectomy transversectomy. This technique was described by Capener in 1954, it was called lateral rhachotomy. It was performed to drain tuberculous abscess. Methods N.Capener. JBJS 1954; 36 B: 173-9. Retrospective case series of 24 patients operated from 2005 to 2009. Mean age 60 years (17-84). There were 13 women and 11 men. Most of the patients had severe co-morbidities (table 1).
SURGICAL TECHNIQUE: Posterior midline exposure two to three levels above and below lesion, dissection at level of lesion exposing transverse process, costotransverse articulation and medial 5 cm of ribs. Placement of pedicle screws at proximal and distal levels. Bilateral or unilateral costotransversectomy and rhacothomy at one or more levels. After temporary rod stabilization, laminectomy and discectomy/ corpectomy are performed to permit circumferential decompression.
Reconstruction of the anterior thoracic spine with cage and graft. After that, posterior reconstruction with two rods.
Results There were 11 cases of spondylodiscitis,, 7 spinal tumours, 4 kyphosis/kyphoscoliosis,, 1 acute fracture with spinal cord compression, 1 thoracic disk herniation (table 1). There were 17 patients with spinal cord compression and neurological impairment before surgery. Neurological improvement of at least 1 Frankel grade was achieved in 9 cases. There were no cases of neurological deterioration after surgery (table 1). All of the patients received posterior instrumentation with two titanium rods. The average of fused levels was 8 (4-15). Titanium mesh or PEEK cages were used as an anterior support in 19 cases, and tricortical iliac autograft in 2 (table 2).
Results Bilateral costo-transversectomy transversectomy was done in 7 cases, right approach in 10 and left in 7. Costo- transversectomy was performed at one level in 4 cases, two levels in 10, and three levels in 10 (table 2). 10 cases were located in the upper-thoracic spine (T1- T4), 5 in mid-thoracic (T5-T8) T8) and 9 in low-thoracic (T9-T12) T12) (table 2). Pedicle subtraction osteotomy (PSO) was done in 2 cases, corpectomy in 17 cases, thoracic discectomies in 4, and 1 spinal cord decompression in vertebral rotatory subluxation (case 23). None of the patients requiered a chest tube in inmediate postoperative (except case 19). Blood loss averaged 2430 ml (900-4500). Mean surgical time 6.3 hours (4-10). Hospital length of stay 36,8 days (10-100). 100).
Results. Complications. There were postoperative complications in 15 patients (62.5%) (see table 3): Pleural effusion in 6 cases (all( of them requiered chest tube insertion). 5 patients required Intensive Care Unit (ICU) admission due to postoperative complications. 7 patients required surgical intervention: 5 debridement and closure due to wound dehiscence or infection and 2 proximal extension of fusion due to pull-out of instrumentation. Patients #20 and #23, needed a third operation: debridement and removal of material due to infection. Patient #23 suffered from sepsis. There were 2 acute atrial fibrillation, patient #14 had a cardiopulmonary arrest but she recovered after cardiopulmonary resuscitation. Patient #3 and #13 had pneumonic sepsis; patient #13 (with severe chronic obstructive pulmonary disease), died.
n. Age Comorbidity Diagnosis Frankel pre Frankel pos 1 75, F Hypothyroidism, metastases in long bones Metastatic renal cell carcinoma D D 2 77, M Vertebral metastases, aortic insufficiency, hypertension Metastatic prostate cancer D D 3 52, M Chronic liver disease, syphilis Thoracic disk herniation A D 4 22, F - Giant cell tumour D D 5 59, M Arterial hypertension Metastatic lung carcinoma E E 6 33, M Ankle and scrotal tuberculous abcess Pott disease and epidural abcess C C 7 44, F - Metastatic breast cancer E E 8 47, M Obesity Unknown tumour metastases B B 9 64, F Hypertension, severe osteoporosis Postraumatic kyphosis E E 10 33, M Kniest syndrome, complete postraumatic paraplegia Congenital kyphosis A A 11 71, F Cerebrovascular disease, hypertension, osteoporosis Pyogenic spondylodiscitis E E 12 78, F Parkinson disease, severe osteoporosis Pyogenic spondylodiscitis E E 13 61, M Obstructive pulmonar disease, diabetes, hypertension Thoracic fracture, cord compression C C 14 78, F Cerebrovascular disease, dementia Pyogenic spondylodiscitis B C 15 17, M asthma Congenital kyphoscoliosis E E 16 84, F Myocardiopathy, arterial hypertension Pyogenic spondylodiscitis E E 17 59, M Acute myeloid leukemia Fungal spondylodiscitis D E 18 61, F Arterial hypertension Pott disease D E 19 67, F Arterial hypertension Pott disease D E 20 74, F Coronary heart disease, hypertension Pyogenic spondylodiscitis D E 21 68, F Parkinson disease, hypertension Pott disease C E 22 71, M Aortic aneurysm, arrythmia, pulmonar disease, renal failure Pyogenic spondylodiscitis A A 23 45, M Restrictive pulmonary disease, neurofibromatosis Kyphoscoliosis, rotatory subluxation B D 24 69, F Multiple myeloma Myeloma A B
n. Approach Costotransversectomy level Corpectomy level Discectomy level Fusion levels Anterior support 1 bilateral T11-T12 T12 T11-L1 T9-L3 Titanium mesh 2 left T3-T4-T5 T4 T5 T3-T6 C7-L4 Titanium mesh 3 left T9-T10-T11 - T9-T11 T8-L1-4 bilateral T1 T1 Anterior approach C4-T4 Titanium mesh 5 bilateral T1-T2-T3 T2 T1-T3 C7-T4 Titanium mesh 6 right T8-T9 T8 T9 T7-T10 T6-L1 Tricortical iliac 7 bilateral T2-T3 T2 T1-T3 C7-T5 Titanium mesh 8 left T2-T3-T4 T3 T2-T4 C7-L1 Titanium mesh 9 bilateral T12 PSO T12 - T10-L2-10 right T12 PSO T12 T11-T12 T8-L2 PEEK cage 11 left T11-T12 - T11-T12 T7-S1 (prev.t12-s1) Titanium mesh 12 left T11-T12 T11 T10-T12 T8-L3 Titanium mesh 13 left T4-T5 T4 T5 T3-T6 T1-T9 Titanium mesh 14 left T5-T6-T7 T6 T7 T5-T8 T3-T10 Titanium mesh 15 bilateral T9-T10-T11 T11 T10-T12 T7-L3 PEEK cage 16 left T12 - T12-L1 T10-L3 PEEK cage 17 right T6-T7-T8 T7 T6-T8 T3-T12 Titanium mesh 18 right T2-T3 T2 T3 T1-T4 C6-T8 Titanium mesh 19 right T1-T2 T1 T2 C7-T3 C6-T7 Tricortical iliac 20 left T9-T10 - T9-T10 T1-L1 Titanium mesh 21 right T2-T3-T4 T2 T1T3 C6-T12 Titanium mesh 22 left T7-T8-T9 T8 T7-T9 T4-L2 Titanium mesh 23 right T5-T6-T7 parcial T5 T6 T7 parcial T4-T8 T2-T11-24 bilateral T2-T3 T2 T1-T3 C6-T6 Titanium mesh
n. Intraop complic. Postop complications Medical interv. Surgical intervention 1 Dural tear Pleural Effusion (PE), wound infection Chest tube Debridement 2 - Pleural effusion (PE), respiratory failure Chest tube, ICU - 3 - PE, hepatic encephalopathy, neumonia, sepsis Chest tube, ICU - 4 - PE, septic thromboflebitis of central venous catheter Chest tube - 5 - PE Chest tube - 6 Neuromonitoring - - - 7 - Wound seroma - - 8 - Wound infection - Debridement 9 Pleural tear Acute atrial fibrillation Cardioversion - 10 - - - - 11 - Pull-out of instrumentation, urinary tract infection - Proximal Extension of Fusion (PEF) 12 - Wound dehiscence - Debridement and closure 13 - Neumonia, sepsis, respiratory failure, death ICU - 14 - PE, acute atrial fibrillation, cardiopulmonary arrest Chest tube, ICU - 15 - - - - 16 - - - - 17 - - - - 18 - - - - 19 Pleural tear (tube) Wound dehiscence - Debridement and closure 20 - Pull-out of instrumentation, wound infection - PEF, debridement.and parcial removal of material 21 - - - - 22 - - - - 23 - Pull-out, wound infection, heart failure, sepsis ICU Debridement and closure, removal of material 24 - - - -
E 45-year old patient (#23) developed neurological impairment Frankel B, after performing a hyperextension movement of his arms. Past medical history: Neurofibromatosis type 1, scoliosis operated at the age of 12, restrictive pulmonary disfunction. Paraplegia was due to vertebral rotatory subluxation in severe dystrophic kyphoscoliosis (Images A, B, C). Right costotransversectomies and instrumentation were performed, and spinal cord decompression was achieved (Image D). Protrusion of instrumentation caused wound dehiscence and the patient needed plastic surgery closure 15 days after first surgery. 15 days later, the patient suffered from sepsis and required ICU admission and a third operation (debridement and removal of material) due to deep wound infection (Images E, F). The patient improved his neurological impairment after surgery, Frankel D, and he is able to walk with orthotic devices and crutches. A B C D
Conclusions Thoracic corpectomies or discectomies have tradicionally been performed through an anterior approach or a combined anterior- posterior approach. Patients who cannot tolerate anterior thoracic procedures with significant pulmonary comorbidity or those in whom a salvage procedure is the only palliative alternative, this technique may serve as a preferred option. Costo-transversectomy transversectomy is a demanding technique, it leads to sufficient exposition of the anterior aspect of the spinal canal avoiding an anterior approach. Indications: Kyphotic deformities, thoracic disc herniation,, infective, traumatic or neoplastic lesions of the vertebral body that lead to vertebral body destruction, instability and neurologic deficit. But it is not free of complications, particularly in patients who have severe co-morbidity.