The Spine Journal - (2014) -

Clinical Study

Extended costotransversectomy to achieve circumferential fusion forpathologies causing thoracic instability

Sarat Poodipedi Chandra, MCha,*, Shashank Ravindra Ramdurg, MCha, Nilesh Kurwale, MCha,Avnish Chauhan, MPhila, Abuzer Ansari, MPhila, Ajay Garg, MDb, Chitra Sarkar, MDc,

Bhawani Shankar Sharma, MChaaDepartment of Neurosurgery, CN Center, Ansari Nagar, All India Institute of Medical Sciences (AIIMS), New Delhi, India

bDepartment of Neuroradiology, CN Center, Ansari Nagar, All India Institute of Medical Sciences (AIIMS), New Delhi, IndiacDepartment of Neuropathology, CN Center, Ansari Nagar, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Received 16 July 2013; revised 21 October 2013; accepted 30 December 2013

Abstract BACKGROUND CONTEXT: Conventional c

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ircumferential stabilization for pathologies causinginstability of the thoracic spine requires a two or even a three-staged procedure. The authors presenttheir tertiary care center experience of single-staged procedure to establish a circumferential fusionthrough an extended costotransversectomy approach.OBJECTIVE: To demonstrate neural canal decompression, removal of the pathology, achieve cir-cumferential fusion, and correcting the deformity through a single procedure.STUDY DESIGN: Prospective and observational.PATIENT SAMPLE: Forty-six patients with pan thoracic column instability due to variouspathologies.OUTCOMEMEASURES: Neurologic condition was evaluated using American Spinal Injury As-sociation and Eastern Cooperative Oncology Group grading systems. Outcome was evaluated withregard to the decompression of neural canal, correction of deformity, and neurologic improvement.All patients were evaluated for neural canal compromise and degree of kyphosis preoperatively,early, and late postoperatively.METHODS: All patients had severe spinal canal compromise (mean, 59%69%) and loss of ver-tebral body height (mean, 55%610%). A single-stage circumferential fusion was performed (four-level pedicle screw fixation along with a ventral cage fixation after a vertebrectomy or corpectomy)through an extended costotransversectomy approach.RESULTS: The pathologies included trauma (21), tuberculosis (18), hemangioma (2), aneurysmalbone cyst (1), recurrent hemangioendothelioma (1), solitary metastasis (1) and plasmacytoma (1),and neurofibromatosis (1). Thirty-five of 46 patients (76%) demonstrated improvement in the per-formance status. The major complications included pneumonitis (3), pneumothorax (3) and neuro-logic deterioration (3; improved in two), deep venous thrombosis (2), and recurrent hemoptysis (1).No implant failures were noted on last radiology follow-up. There were two mortalities; one be-cause of myocardial infarction and another because of respiratory complications.CONCLUSIONS: The following study demonstrated that extended costotrasversectomy approach isa good option for achieving single-staged circumferential fusion for correcting unstable thoracic spinedue to both traumatic and nontraumatic pathologies. � 2014 Elsevier Inc. All rights reserved.

Keywords: Spinal compression; Spinal instrumentation; Circumferential fusion; Thoracic spine; Tuberculosis; Trauma;

Hemangioma

status: Not applicable.

s: SPC: Grant: Ministry of Science and Technology

oject (D (approx), Paid directly to institution); Re-

tigator Salary): salary for research fellow and data

Bper year for both, Paid directly to institution); Re-

Materials): salary for research fellow and data entry

r year for both, Paid directly to institution). SRR:

K: Nothing to disclose. AKC: Nothing to disclose.

AA: Nothing to disclose. AG: Nothing to disclose. CS: Nothing to disclose.

BSS: Nothing to disclose.

The disclosure key can be found on the Table of Contents and at www.

TheSpineJournalOnline.com.

Disclosure of funding: Nil.

* Corresponding author. Room 7, 6th floor, CN Center, AIIMS, Ansari

Nagar, New Delhi 110029, India. Tel.: 91-11-26594494, 91-11-26234446.

E-mail address: saratpchandra3@gmail.com (S.P. Chandra)

nt matter � 2014 Elsevier Inc. All rights reserved.

16/j.spinee.2013.12.028

2 S.P. Chandra et al. / The Spine Journal - (2014) -

Introduction earlier reports [3–6], where it has been used mostly for meta-

A three-column disruption of thoracic spine with severecanal compression requires a ‘360�’ circumferential to opti-mize stabilization. Conventionally, a thoracic circumferen-tial fusion is established by undertaking at least twoseparate approaches; a dorsal approach to achieve pediclefixation, followed by a ventral transthoracic approach toplace a ventral instrumentation like a cage or any otherventral fixation device. Often a dorsal re-exploration (thirdprocedure) is required to secure the cage firmly by compress-ing the rod/screw construct posteriorly. Development ofexpandable cages does not require the latter procedurenow. However, the major shortcoming of expandable cagesas compared with mesh may be higher rates of subsidenceand lower rates of bone fusion because of smaller contactarea and absence of adequate space to place bone grafts[1,2]. Additionally, some patients who require circumfer-ential fusion may be poor candidates for an anteriortransthoracic approach because of poor pulmonary function,previous surgery, or radiation therapy. It would be of advant-age to use a single approach that can access both ventral anddorsal regions of the thoracic spine simultaneously. The au-thors propose a single-stage extended costotransversectomyas an alternate surgical approach to achieve a circumferentialfusion for three-column pathologies. This is quite similar tosingle-stage posterolateral transpedicular approach (PTA)reported earlier but with some modifications. Unlike the

Fig. 1. (A) shows the position of the patient with incision marked. Note that th

resection of an adequate length of the rib, which in turn allows adequate retraction

from the anterior border of the vertebra till the spinous process. Note that a hemi c

may be also performed with this exposure. (C) Shows the extent of the access to

Use of a high speed drill (C,E) under a microscope is necessary to avoid injury to t

to avoid CSF leak (D). (D) After placement of both ventral and dorsal instrumen

accessibility of both regions with this approach. Inset: The ribs being attached b

static tumors, in the present series it has been used in a widevariety of pathologies [3–8].

Clinical materials and methods

Between 2004 and 2011, a total of 194 instrumentedfusions of the thoracic spine were performed, of which 46cases underwent circumferential fusion of the thoracicspine using the extended costotransvectomy approach(Fig. 1). The age of the patients ranged from 11 to 62 yearswith a mean of 32.5 years; 28 patients were males.

Inclusion criteria

1. Presence of three-column instability: This was as-sessed according to the three-column scheme of Denis[9]. This was determined by performing both plainroentgenograms and computed tomography (CT) scanwith bone windows. Although a significant number ofpatients were of nontraumatic etiology (25 patients);the same principle was used to determine the columnsinvolved. Only patients with three-column disruptionwere considered for extended costotransversectomyand circumferential fusion.

2. Absence of severe osteoporosis: This was ruled outby examining the plain roentgenograms and CT

e transverse incision is almost as long as the vertical incision. (C) Allows

of the pleura anteriorly (B). This provides an optimal field of vision (G, B)

orpectomy is usually adequate, however if required a complete corpectomy

the anterior and posterior limits of the vertebral body using this approach.

he dura. The thoracic root should be cut at least 4-5 cm from the dura (C,D)

tation. Note the adequate space of the cage from the dura and the ease of

ack with mini plate and screws.

3S.P. Chandra et al. / The Spine Journal - (2014) -

scans. In suspected cases with presence of risk fac-tors, a bone densitometry was performed. Only thosepatients with T-scores higher than �2.0 were consid-ered for surgical intervention.

3. Absence of any contraindications like severe medical,cardiac illness or severe restrictive chest disease.

4. Patients with American Spinal Injury Association(ASIA) score of A suggesting poor prognosis.

Clinical assessment

Functional outcome was assessed using the [10] ASIAimpairment score, and performance status was assessedusing the Eastern Cooperative Oncology Group (ECOG)grading system [11]. Overall, ASIA scores were A (n50),B (n520), C (n518), and D (n58). Correspondingly,ECOG scores were 1 (5 patients), 2 (11 patients), 3 (19 pa-tients), and 4 (11 patients) (Table).

Pain self-assessment was based on a visual analog scalefrom 0 to 10. As described by Serlin et al. [12], 0 to 4 rep-resents mild pain; 5 to 6, moderate pain; and 7 to 10, severepain. All with trauma had presented with significant painexcept two patients (Table). All the rest 40 patients hadsevere pain and 4 had moderate pain. Pain was particularlya feature of inflammatory pathologies like tuberculosis(14/18 had severe pain).

Radiologic assessment

Preoperative radiographic evaluation included magneticresonance imaging and plain radiographs and CT scan inall patients. Bone densitometry was performed in selected

Table

Summary of case series (n546)

Characteristics

Number/percentage

of patients

Mean age (y) 32.5 (11–62)

Sex ratio (male:female) 28:18

ASIA [8] score

A 0

B 20

C 18

D 8

Mean ASIA

ECOG [9] score

1 5

2 11

3 19

4 11

Pain score

0–7 6

7–10 40

Mean spinal canal compromise 59.2%69.12%

Mean loss of vertebral height 55.19%610.29%

Improvement in ECOG score after surgery 32 (70%)

Improvement in ASIA score after surgery 35 (76%)

ASIA, American Spinal Injury Association; ECOG, Eastern Coopera-

tive Oncology Group.

patients. In all patients, 50% or more of the vertebral bodywas affected by the pathology, either traumatic or neoplastic.Twenty-two patients had severe kyphosis (O20%). Involve-ment of all three columns was documented on imaging. Ofthe 21 cases of trauma, 14 were Type A fractures and 7 TypeC fractures. In both the types, CT bone window demonstra-ted involvement of the posterior element as well (Fig. 2). Theother pathologies included tuberculosis (18), hemangioma(2), aneurysmal bone cyst (1) (Fig. 3), recurrent heman-gioendothelioma (1), solitary metastasis (1) and plasmacyto-ma (1), and neurofibromatosis (1).

Both patients with vertebral hemangiomas had completevertebral involvement with significant soft tissue compress-ing the cord. The patient with an aneurysmal bone cyst in-volved both, ventral and dorsal elements (Fig. 3). Shepresented with a postlaminectomy (done elsewhere) patho-logical fracture: severe body collapse, with cord compres-sion and severe kyphosis (Fig. 3). The patient withrecurrent hemangioenthelioma had a two-level extradural/intradural tumor with destruction of all three columns. Heunderwent a biopsy outside and then was referred to us.After embolization, he underwent a tumor excision fol-lowed by a circumferential fusion. The patient of solitaryplasmacytoma presented with pathological fracture of allthree columns. The patient with neurofibromatosis had mul-tiple cutaneous lesions with severe collapse of D8/D9 levelwith kyphosis and cord compression.

Surgical technique

All patients underwent surgery in prone position with aflexion of about 40� provided at the hip. The patients werewell strapped to the table to allow adequate lateral tilting. Amidline vertical incision with a horizontal ‘‘T’’ provided to-ward the side requiring maximal decompression was given(Fig. 1). A four-level pedicle screw purchase was obtained,two above and two below the level of the corpectomy, andfixation was performed. The horizontal limb was thenopened and about 10 to 12 cm of the rib was exposedand excised on one side only from the transverse processmedially. This length of rib was replaced after the surgicalprocedure. The length of rib resection was much more thanwhat has been earlier described for conventional PTA. Theunderlying principle was to provide an adequate pleural re-traction up to the anterior border of the vertebral body(Fig. 1). Tilting the table to the opposite side of the horizon-tal exposure brought the visual field right up to the anteriorborder of the vertebrae. The rest of the surgery was per-formed under the microscope, drilling first the transverseprocess, then the pedicles, and finally going up to the body.The unilateral dorsal nerve root was cut and sharply dividedto avoid cord traction. The pleura was protected with wetcottons and then carefully dissected off the vertebral body.Once this was done, a complete lateral view of the body isobtained. In cases of solitary metastasis and plasmacytoma,an en-bloc vertebrectomy was performed. This was made

Fig. 2. A patient with a burst fracture D12 with a retropulsed fragment into the spinal canal (Case 3). (A) Note the tilt to one side because of fracture on one

side of the body. (B) Shows magnetic resonance imaging, T2 sequence sagittal section. (C) Computed tomography (CT) scan with bone windows with sagittal

reconstruction showing the retropulsed fragment into the canal. Note that the canal is compromised by more than 50%. (D) Showing the same as (C) on axial

section. (E) At a slightly lower section, showing the fracture at the spinous process indicating a three-column instability. After surgery, (F) CT scan on coronal

reconstruction showing the laterally placed cage and screws in situ. (H) Shows CT scan on axial section showing the degree of bone removal. Note that in this

case, only a hemicorpectomy was performed. This was sufficient to correct the deformity, providing neural decompression and adequate stabilization, while

preserving the healthy part of the vertebral body.

4 S.P. Chandra et al. / The Spine Journal - (2014) -

possible by freeing the pedicle on both sides and then sep-arating the body from the disc spaces above and below. Inboth hemangioma and hemagioendothelioma, corpectomywas performed after embolization. In aneurysmal bonecyst, all cases of trauma and tuberculosis, the affected ver-tebral body was drilled. Here, the body and the pediclewere then drilled until a thin shell of cortical bone is leftagainst the dura that may be then removed with a 1 mmKerrison or a fine dissector. A complete or partial corpec-tomy was then performed depending on the pathology.

In cases of trauma usually it sufficed to remove the com-pressing bone fragments and perform a partial corpectomy(Figs. 1 and 2). In tuberculosis, the cold abscess was firstdrained out. After this, the transverse process, the rib head,and the pedicles were drilled out to gain ventral access. Ifrequired, bilateral pedicles were drilled. The soft granula-tion tissue was adequately decompressed from the dura.For tuberculosis, the autologous bone was harvested fromthe iliac crest and not from the local site. After vertebrec-tomy/corpectomy, the pedicle screws were then distractedand a mesh cage packed with autologous bone (harvestedfrom transverse process and medial part of the rib) wasplaced between the upper and lower vertebral bodies. Itwas then fixed securely by compressing the pedicle screwsagain posteriorly. In patients with severe kyphosis, it wasnecessary to ‘‘break’’ the spine by drilling the laminae,pedicles, and the body. Once this was done, the kyphosis

was gradually corrected on table and fixation performedas described previously.

The rib was replaced and fixed by titanium miniplateand screws. An intercostal drain was placed if there wereany tears in pleura. When performing this technique, thetrapezius and rhomboids were divided leaving a musculo-tendinous cuff along the spine. After this, the scapula couldbe easily retracted forwards.

Follow-up evaluation

All patients underwent a physical therapy and rehabilita-tion as well as active chest physiotheraphy. Postoperativeimaging consisted of plain roentgenograms and magneticresonance imaging if required. Follow-up visits werescheduled at 3, 6, and 12 months and then annually. Postoperative follow up imaging consisting good quality digitalX-rays and plain CT scans were performed at follow-up, atleast after 6 months. Magnetic resonance imaging was per-formed if indicated.

Results

The mean operating time was 7.8 hours and blood losswas 2.661.3 L. The mean period of follow-up was32611.6 months (range: 24–64 months). In three patients,

Fig. 3. A 11-year-old female with a pathological fracture from a postlaminectomy aneurysmal bone cyst at D5, 6 level (Case 7). (A) Showing the pan

vertebral expansion of the cortical bone. (B) Showing computed tomography (CT) scan after laminectomy elsewhere after which developed a pathological

fracture (C). (D) Magnetic resonance imaging (MRI) T2 sequence sagittal and (E) T1 sequence showing severe kyphosis and neural compression. (F) After

surgery, adequate neural decompression was achieved and the deformity was corrected (CT bone window with sagittal reconstruction). (G) Shows a 3D CT

scan reconstruction with adequate correction of the deformity. Also note the two ribs have been attached back with miniplate and screws to prevent flail chest

because the rib excision in this procedure is much more than what is performed in a conventional dorsolateral transpedicular approach. (H) Shows the post-

operative MRI with multiple artifacts but showing adequate neural decompression.

5S.P. Chandra et al. / The Spine Journal - (2014) -

follow-up was obtained telephonically as they could not re-port to the outpatient clinic because of disability. All pa-tients achieved immediate stability. Thirty-five of 46patients (76%) showed different degrees of neurologic im-provement on ASIA scoring. Among these, six patients(6%) improved to ASIA E after the surgery. Five remainedstatic as compared with the preoperative status. The rest 24patients (70%) demonstrated different degrees of improve-ment. On evaluation of ECOG status, 70% patients demon-strated improvement from their preoperative scores (Table).Eight patients did not show any improvement, and threepatients deteriorated after surgery. Of these only one patientdid not improve on long-term follow-up. This patient hadneurofibromatosis, with severely compressed cord and de-formity at D8/D9 level. Although the decompression ofthe canal was satisfactory, it is likely that deterioration oc-curred because of handling of the thin cord during surgery.

Complications

The major complications included pneumonitis in threepatients, pneumothorax in three (two related to central ve-nous line insertion in the neck and one due to ineffectiveprimary closure of the pleural rent at surgery), and deterio-ration in three (two improved). Pleural tear was noted in sixpatients and five required intercostal drainage. Deep veinthrombosis was noted in two patients. One patient suffered

from haemoptysis because of piercing of a screw (about 1cm) into lung. This gradually improved with medical treat-ment and chest physiotherapy. Another patient had a screwbulge through the skin. No intervention was advised. Thisgradually became less prominent once he improved in hisnutritional status. One death occurred on Day 11 becauseof myocardial infarction. Another case was noted after 25days in a patient who had pneumonitis and poor chestexpansion and was ventilator dependent and paraplegic.

Discussion

Restoration or maintenance of spinal stability is consid-ered as an important objective in the surgical managementof patients with spinal pathologies [13]. A pan columninstability with or without rotational injury will require in-strumented fixation, both ventrally and dorsally (circumfer-ential fusion), to achieve optimal stabilization. These aremajor surgeries and often require a two-stage procedure.In addition, these procedures are time consuming and areassociated with major surgical morbidities and mortality.One-stage approach that provides access to both ventraland dorsal regions simultaneously is preferable to multi-stage approaches.

Larson et al. [6] in 1976 demonstrated the utility of lateralextracavitory corridor for dealing with anterior pathologies

6 S.P. Chandra et al. / The Spine Journal - (2014) -

compressing the thecal sac. In his series of 62 patientsconsisting mainly traumatic closed vertebral fractures andgunshot injuries, anterior dural decompression was achievedin all cases. However, vertebral fusion procedures were donein only 26 cases. In our study, the main focus of surgery wasto achieve the circumferential fusion rather than only neuraldecompression; a fact accounting to technical variations inthe wide exposure and amount of bone resection. Few otherauthors also reported similar corridor in dealingwith anteriorpathologies of vertebral column with minor technical modi-fications [14,15]. Our approach resembles to the techniquedescribed earlier in these studies with little variation in softtissue exposure and amount of bone removal. However, weprefer to call it extended costotransversectomy approach be-cause of its informative nomenclature.

Resnick and Benzel [16] reviewed 33 patients under-going single-stage circumferential fusion for thoracolumbarfractures, with focus on morbidity and operative complica-tions in single-stage against sequential ventral and dorsalfusions. Eleven patients developed respiratory complica-tions; however, there was no mortality or neurologic com-promise. Authors concluded in favor of single-stagecircumferential fusion. In our patient group, respiratorycomplication predominated with one mortality because ofpneumonia.

Circumferential techniques with en-bloc vertebrectomyfor spinal fusion have been widely used to treat metastasescases [3,4,7,8,17–21]. The benefits of single-stage PTA todecompress the spine circumferentially and place instru-mentation were evaluated in 140 patients with spine meta-stases. Improvement or stabilization of neurologic statusalong with postoperative pain improvement was noted in96% of the patients [20]. We feel that extended costotras-versectomy may be of a greater advantage, especially totackle all pathologies [22]. The main difference here isthe resection of the rib and transverse process that allowsa lateral access to the pedicle and vertebral body. ‘‘Ex-tended costotransversectomy’’ involves a much larger re-section of the length of the rib that may be replaced aftersurgery. This provides a better exposure especially to theanterior border of the vertebral body that may be further op-timized by tilting the table to the opposite side so that thesurgeon’s line of vision is now parallel to the posterior bor-der of the vertebral body (Fig. 1). Such an approach, wefeel, becomes optimal to deal with both neoplastic and non-neoplastic pathologies.

Posterolateral approaches have also been used success-fully for the management of metastatic disease affectingthe thoracic spine [4,7,13,17–21,23]. Patients are sparedthe morbidity associated with transcavitary approaches,while receiving the benefit of complete vertebrectomyand circumferential reconstruction in a single-stage proce-dure [17].

A few more studies have evaluated the use of circumfer-ential fusion for the treatment of chronic back pain, frac-tures, and spondylolisthesis. Grob et al. [24] assessed 74

patients with circumferential fusion of the lumbosacralspine after a mean follow-up period of 49.8 months. Itwas noted that the technique was favorable in more than50% patients with instability and deformity of all three col-umns, such as fractures and spondylolisthesis. They con-cluded that optimal stability with satisfactory reduction ofthe deformity could be achieved with this procedure,wherein the one-stage operation proved to be superior, withless complications and a shorter hospital stay [24,25].

Our study involves a wide range of pathologies that weretreated with the extended costotransversectomy along withcorpectomy/vertebrectomy and instrumented fusion, bothventrally and dorsally. Conventional costotransversectomywas a relatively simple procedure that was originally intro-duced for removal of cold abscess along with debridementof necrotic bone material in tuberculosis [26]. Over years,the technique underwent several modifications and becameone of the standard procedures to approach the ventral as-pect of thoracic vertebrae [22,27]. To the best of our knowl-edge, the nomenclature ‘‘extended costotransversectomy’’has not been used till date, even though the procedure itselfmay have been performed with various modifications dis-cussed previously. We have preferred to call it ‘‘extended’’because the principles of approach remain the same as de-scribed earlier. However, the length of rib resection is larg-er, the degree of soft tissue dissection is more, and theexposure is also much larger. A ‘‘T’’ skin incision dramat-ically increases the overall exposure and allows the longlength of rib resection. This allows the surgeon to maintaina horizontal line of vision at the level of the vertebralbody (Fig. 1). This provides enough space to perform ver-tebrectomy in cases with metastasis and also for piecemealcorpectomy for other pathologies. It also provides simulta-neous excellent approach to both anterior and posteriorparts of the spine. Our study has demonstrated the safetyand efficacy of this procedure for several different patholo-gies. We do admit that presently there is an increasingavailability of less invasive procedures like minimally inva-sive surgical techniques that may be of better advantagethan the described technique [28]. However, minimally in-vasive techniques require a steep learning curve and exper-tise especially to correct severe deformities described in thearticle.

In the present series, pain improved in all cases and spi-nal stability was also achieved in all the treated cases. Theneurologic improvement as denoted by the ASIA andECOG scores was noted in 76% patients postoperativelyand sustained or further improved in 41% of patients,who were followed-up to a mean of 22637.6 months.

A recent meta-analysis (Yajun et al. [29]) reported thatalthough the number of complications was on the higherside when circumferential fusion was compared with post-erolateral fusion, significant differences were noted in thefusion rates (92.4% and 85.7%, respectively) and the reop-eration rate (11.7% and 21.5%, respectively). Additionally,no significant difference was found in the operating time.

7S.P. Chandra et al. / The Spine Journal - (2014) -

Our article is one of the largest case series to report thebenefits of circumferential fusion using an extended costo-transvesectomy for a wide range of pathologies causingthoracic spine instability. The extended costotransversectomyapproach can, therefore, help achieve all the followingthrough a single procedure in different kinds of pathologies:neural canal decompression, removal of the pathology, cir-cumferential fusion, and correcting the underlying deformity.

Conclusion

The single-stage anterior and posterior stabilizationthrough an extended costotrasversectomy approach is an ef-fective procedure to achieve immediate three-column stabil-ity, especially in patients with severe deformity, instability,and neural canal compression at the thoracic spine. One ofthe drawbacks may be the steep learning curve associatedwith this technique. It requires significant experience inspine surgeries before getting adapted to this procedureand this may limit its widespread use. Nevertheless, this pro-cedure may be used in a wide variety of pathologies.

Acknowledgments

Part of the work has been supported by a grant from De-parment of Biotechnology, Ministry of Science and Tech-nology, India.

Ethical approval: Patients’, for reproduction for the ma-terial, photographs have been taken. Institute’s ethics com-mittee consent for the study was taken prior to performingthe study. The study followed the guidelines laid down byIndian Council of Medical Research (ICMR).

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