Retroperitoneal Extrapleural Approach for Corpectomy of the First Lumbar Vertebra : Technique and Outcome

Abstract

Objective: Corpectomy of the first lumbar vertebra (L1) for the management of different L1 pathologies can be performed using either an anterior or posterior approach. The aim of this study was to evaluate the usefulness of a retroperitoneal extrapleural approach through the twelfth rib for performing L1 corpectomy.

Methods: Thirty consecutive patients underwent L1 corpectomy between 2010 and 2016. The retroperitoneal extrapleural approach through the 12th rib was used in all cases to perform single-stage anterior L1 corpectomy, reconstruction and anterior instrumentation, except for in two recurrent cases in which posterior fixation was added. Visual analogue scale (VAS) was used for pain intensity measurement and ASIA impairment scale for neurological assessment. The mean follow-up period was 14.5 months.

Results: The sample included 18 males and 12 females, and the mean age was 40.3 years. Twenty patients (67%) had sensory or motor deficits before the surgery. The pathologies encountered included traumatic fracture in 12 cases, osteoporotic fracture in four cases, tumor in eight cases and spinal infection in the remaining six cases. The surgeries were performed from the left side, except in two cases. There was significant improvement of back pain and radicular pain as recorded by VAS. One patient exhibited postoperative neurological deterioration due to bone graft dislodgement. All patients with deficits at least partially improved after the surgery. During the follow-up, no hardware failures or losses of correction were detected.

Conclusion: The retroperitoneal extrapleural approach through the 12th rib is a feasible approach for L1 corpectomy that can combine adequate decompression of the dural sac with effective biomechanical restoration of the compromised anterior loadbearing column. It is associated with less pulmonary complication, no need for chest tube, no abdominal distention and rapid recovery compared with other approaches.

Keywords: Lumbar vertebrae; Spinal fusion; Spine.

Fig. 1.

A and B : Magnetic resonance imaging (sagittal and axial views) showing a traumatic L1 fracture with evident spinal canal compression. C : CT scan (axial view) of the same patient showing a bony fragment inside the spinal canal. D and E : Postoperative follow-up CT scan (sagittal and axial views) showing an L1 corpectomy with vertebral reconstruction using an iliac bone graft with evident spinal canal decompression. F : Postoperative follow-up CT scan with 3D reconstruction (AP view) showing spinal instrumentation using an anterolateral plate extending from D12 to L2. CT : computed tomography, AP : anteroposterior.

Fig. 2.

A : Magnetic resonance imaging (sagittal view) showing a traumatic L1 fracture. B and C : CT scan (sagittal and axial views) of the same patient showing spinal canal compression with a large bony fragment compromising the spinal canal. D : Intraoperative view after retraction of the peritoneum anteriorly (arrowhead) and the psoas muscle posteriorly (arrow) showing the cavity created after corpectomy. E : Intraoperative view showing the insertion of titanium mesh filled with bone into the corpectomy site. F : CT scan (axial view) showing satisfactory spinal canal decompression. G : Postoperative follow-up CT scan with 3D reconstruction (AP view) showing the L1 corpectomy with reconstruction using titanium mesh and spinal instrumentation using an anterolateral plate extending from D12 to L2. CT : computed tomography, AP : anteroposterior.

Fig. 3.

A-C : CT scan (sagittal, axial and coronal views) showing an L1 osteolytic lesion in a patient with a previous posterior spinal surgery. D : Magnetic resonance imaging (sagittal view) showing the L1 neoplastic lesion compromising the spinal canal. E : Plain X-ray (AP views) showing evidence of L1 corpectomy with reconstruction using bone cement together with spinal instrumentation using transpedicular screws two levels above and two levels below the lesion, which was diagnosed as hemangioma. F : CT scan with 3D reconstruction (lateral view) of the same patient. CT : computed tomography, AP : anteroposterior.

Fig. 4.

ASIA impairment scale of all patients both pre- and post-operatively.

Fig. 5.

Outcome of patients with regard to the etiology.