Spinal cord decompression: an endoscopically assisted approach for metastatic tumors

Study design: The paper describes a technique for complete vertebrectomy an d spinal cord decompression, followed by a formal anterior column reconstru ction, using endoscopic instruments. This procedure is indicated for patien ts with radioresistant metastasis of the thoracic spine, particularly those involving the upper thoracic segments where a thoracotomy is difficult and carries a high morbidity, and for patients with pulmonary disease who cann ot tolerate a standard thoracotomy. Results in nine consecutive cases are r eported. Objectives: To demonstrate the feasibility and benefits of endoscopically a ssisted decompression and stabilization through a single, extrapleural, pos terolateral approach. Setting: The Cleveland Clinic, Cleveland, Ohio, USA. Methods: Posterolateral decompression of the thoracic spinal cord offers po tential advantages over traditional combined procedures (anterior thoracoto my and posterior instrumentation), including reduced operative time, decrea sed morbidity, and reduced hospital stay. Previous studies have not demonst rated the same neurological benefit for posterolateral decompression as for anterior vertebrectomy and decompression, however, Surgical indications, r ationale and technique for an improved posterolateral approach, augmented b y endoscopic methods, are provided, and initial clinical results are descri bed. Results: Drawbacks to the traditional posterolateral decompressions have in cluded poor visualization of the spinal cord and anterior tumor, poor acces s to tumor on the side contralateral to the approach, and the need to manip ulate the spinal cord to completely remove both adjacent tumor and tumor ad herent to the dura. Transpedicular decompression using endoscopy is describ ed in nine patients. The mean operative time for the combined procedure was 6.0 h, with a mean blood loss of 1677 cc. Neurological recovery and mainte nance were excellent. Inpatient days averaged 6.5, and ICU days averaged 1. 4. Two patients died of disease eight and 14 months post-op, and seven were living, with disease, 3-36 months after surgery. Conclusions: Endoscopically assisted decompression can reduce morbidity, ho spitalization, and treatment costs while matching the efficacy of tradition al combined procedures. Endoscopy provides a readily available and easily a pplied tool that dramatically improves the surgeon's vision, providing ligh t, magnification, and a direct view of remote structures.