Prevalence of pleural injury in an extrapleural approach to adolescent idiopathic scoliosis and association of pleural injury with postoperative respiratory function.

BACKGROUND: The prevalence of pleural injury during surgery for adolescent idiopathic scoliosis using an extrapleural approach and the association of pleural injury with postoperative pulmonary function remain unclear. We sought to determine the prevalence of pleural injury associated with an extrapleural approach to adolescent idiopathic scoliosis, and to determine any difference in respiratory function between patients with or without pleural injury. METHODS: Data from consecutive patients with scoliosis of the thoracolumbar/lumbar spine who underwent anterior spinal fusion using an extrapleural approach were assessed in this retrospective study. We had diagnosed and treated pleural injury according to our algorithm. Pre- and postoperative values of pulmonary function tests and postoperative change rates were compared between patients with and without pleural injury. FVC, %FVC, FEV1.0, and FEV1.0% were evaluated from pulmonary function tests. RESULTS: We included data from 51 patients with adolescent idiopathic scoliosis (45 female and 6 male) with a mean age of 17.2 ± 3.5 years in this retrospective study. The group with pleural injury comprised 31 patients and the group without 20. Therefore, the prevalence of pleural injury during an extrapleural approach was 61%. We found no significant differences in preoperative FVC, %FVC, FEV1.0, and FEV1.0% between the groups. We found no significant differences in FVC, %FVC, FEV1.0, and FEV1.0% between the groups at 3 months or 1 year postoperatively. Furthermore, we found no significant differences in the postoperative change ratio of FVC, %FVC, FEV1.0, and FEV1.0% between the groups. CONCLUSION: The prevalence of pleural injury associated with an extrapleural approach to scoliosis was 61%. Pleural injury was not associated with a decrease in postoperative pulmonary function in patients with scoliosis treated using an extrapleural approach.

[Surgical treatment of herniated thoracic discs using transthoracic extrapleural approach]. / Khirurgicheskoe lechenie gryzh grudnykh mezhpozvonkovykh diskov s ispol'zovaniem transtorakal'nogo ekstraplevral'nogo dostupa.

OBJECTIVE: To analyze the results of herniated thoracic disc resection via transthoracic extrapleural approach. MATERIAL AND METHODS: The study included 16 patients with 18 symptomatic herniated thoracic discs wo underwent transthoracic extrapleural surgery. In 11 cases, clinical pattern of disease was represented by myelopathy with radicular or axial pain syndrome. Five patients had radiculopathy alone. Median localization of hernias was observed in 8 (44.4%) cases, paramedian hernias - in 10 (55.6%) cases. There were 10 (55.6%) ossified hernias, 5 (27.7%) giant, 10 (55.5%) large and 3 (16.6%) medium hernias. RESULTS: In most patients, VAS score of pain syndrome decreased by 2-6 points (mean 3.6). In 4 patients, this value remained the same. Among 11 patients with myelopathy, regression of conduction disorders in 1 year after surgery was achieved in 9 (82%) cases including complete recovery in 6 (55%) patients (Frankel E, Nurick - 0-I). In 2 patients, neurological status was equal to preoperative one. In all cases, the follow-up examination confirmed total removal of compressive substrate and found no signs of spine instability. Surgery time varied from 80 to 210 min (mean 161), blood loss - from 300 to 800 ml (mean 378 ml). Two patients had transient neurological deterioration. There was damage to dura mater in 4 cases. Intercostal neuralgia was observed in 3 patients. CONCLUSION: While retaining the advantages of open thoracotomy, transthoracic extrapleural approach is less traumatic, allows complete spinal cord decompression, minimizes the risk of iatrogenic spinal cord injury and avoids certain postoperative complications.

Conservative Management of Major Anastomotic Leaks Occurring after Primary Repair in Esophageal Atresia with Fistula: Role of Extrapleural Approach.

AIMS: We are reporting single-institution's experience regarding the role of conservative management in 38 cases of minor and major anastomotic leaks [AL] occurring after primary surgery of esophageal atresia [EA] with tracheo-esophageal fistula [TEF] during last 17 years between 2000 and 2017. In this retrospective review, we are sharing our experience and protocol of management of AL with more emphasis to evaluate: (a) role of conservative treatment in major AL (b) role of extra-pleural approach in enhancing the success rate in conservative treatment in major AL (c) to define the criteria for major & minor leaks and (d) to evaluate the role of ventilation in primary EA surgery to control AL. METHODS: All these cases were operated through extra-pleural approach and out of total 203 cases, 38[18.7%] developed anastomotic leaks. In 29 of the 38 cases [14.3%], leak was minor and in 9 cases [4.4%] the leak was a major one. All these cases of leaks were managed conservatively. RESULTS: All cases of major and minor leaks showed spontaneous healing except one case of minor leak that died before healing due to major cardiac anomaly. For minor leaks, average healing time was 9.5 days while for major leaks it was 17.4 days. Overall mortality was 14.8% and there was no mortality directly attributable to major or minor leak. During follow up, the incidence of stricture was 40% in cases having anastomotic leaks, while in cases without a leak, the incidence of stricture was 23.3%. These all cases of stricture responded to regular dilatations. CONCLUSION: We believe in cases of major AL, where primary repair is done by EP approach, a conservative treatment should be the treatment of choice. With this conservative approach of management of major AL, we not only save the native esophagus, the best conduit, but there is also less morbidity and mortality.

[Rationale and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable thoracolumbar fractures: Experience in 86 consecutive patients]. / Fundamentos y complicaciones del abordaje anterolateral extrapleural-retroperitoneal en fracturas inestables toracolumbares: experiencia en 86 pacientes consecutivos.

OBJECTIVES: To describe the rationale, pros and cons, and complications of the anterior-lateral extrapleural retroperitoneal approach for unstable (TLICS>4) thoracolumbar fractures. PATIENTS AND METHODS: Clinical and radiological data and outcomes from a cohort treated surgically via said approach were retrospectively reviewed. All patients were operated on exclusively by 5 neurosurgeons trained in spine surgery. RESULTS: Between June 1999 and December 2015, 86 patients underwent surgery (median age 42years, most common level: L1). Approximately 32.5% presented with a preoperative neurological defect. After surgery (mean duration: 275minutes), 75.6% presented with no neurological sequelae and only one-third required blood transfusion. Median postoperative stay was 7days. Correction of kyphosis was considered adequate and suboptimal but acceptable in 91% and 9% of the patients, respectively. Complications occurred in 36 patients, the majority being transient. We observed failure of the construct in 2 cases (collapse of an expandable cage and extrusion of a locking screw). No infections, vascular or visceral lesions, permanent neurological worsening or mortality occurred during hospitalisation. One patient ultimately needed additional posterior fixation due to persistence of pain. Median follow-up was 252days (27.9% was lost to follow-up). CONCLUSIONS: The extrapleural extraperitoneal approach provides solid anterior reconstruction, allows wide decompression of the spinal canal, and permits adequate and long-lasting correction of kyphosis. The rates of infection, construct failure, need for reoperation and vascular or visceral lesions are minimal.

The left anterior extrapleural approach for innominate artery transection in a patient with tracheostomy and a neurological disorder.

Although innominate artery transection for innominate artery compression of the trachea is recently used for prevention of life-threatening complications (e.g. massive bleeding and obstructive apnoea) in patients with neurological disorders, pre-existing tracheostomy poses a risk of mediastinal infection with sternotomy. We successfully performed innominate artery transection on such a patient via the left anterior extrapleural approach without sternotomy after confirming the anatomical configuration on three-dimensional multidetector row computed tomography angiography.

Abordaje posterolateral extracavitario a la columna torácica y hernia medular transdural idiopática: reporte de caso y revisión de la bibliografía / Posterolateral approach to the thoracic spine and idiopathic transdural medullary hernia: case report and literature review

OBJETIVO: describir la resolución quirúrgica de un caso de hernia medular transdural. Descripción: Paciente de 33 años de edad con antecedentes de historia progresiva de debilidad motora de 6 meses de evolución. Al examen se constató paraparesia asimétrica con anestesia por debajo del dermatoma T8, constituyendo un síndrome de Brown Sequard. En las imágenes de resonancia magnética se observó herniación ventral de la medula espinal a nivel T7-8. INTERVENCIÓN: se realizó abordaje extrapleural posterolateral a la columna torácica. Con técnica microquirúrgica se encontró el defecto dural en la duramadre ventral, y la herniación medular correspondiente en el nivel T7-8. Se encontraron, asimismo, cuerpos osteocartilaginosos en dicho nivel. Se procedió a disecar la interface médula espinal del defecto dural, ampliando el mismo y liberando la médula espinal, sin necesidad de retracción medular por esta vía. Luego de reponer en su correcta posición a la médula se procedió al cierre dural primario con microsutura. CONCLUSIÓN: las hernias medulares transdurales torácicas el abordaje posterolateral extracavitario es una opción válida, permitiendo tener una mejor visión microquirúrgica de la duramadre ventral, con la ventaja de no requerir tracción ni rotación neural como se requiere en el caso de la laminectomía tradicional

OBJECTIVE: to describe the successful surgical repair of idiopathic transdural spinal cord herniation DESCRIPTION: the patient was a 33-year-old female with a 6-month history of progressive motor weakness. Neurologic examination revealed asymmetric paraparesis with anesthesia below the T8 dermatome, consistent with Brown-Séquard Syndrome. Magnetic resonance imaging (MRI) of the thoracic spine demonstrated a spinal cord that was displaced and herniated ventrally, with loss of the normal overlying cerebrospinal fluid space between T7 and T8. INTERVENTION: a lateral extra-pleural approach was used to access the thoracic spine. With microsurgery, we identified a defect in the ventral dura, with transdural spinal cord herniation. Osteocartilaginous bodies also were observed. Microsurgical un-tethering of the spinal cord herniation was performed along with primary repair of ventral dural defect. To un-tether the herniation without spinal cord manipulation, an incision was made on one side of the defect; with this maneuver, the diameter of the defect was increased, avoiding any traction on neural structures. Once the herniated spinal cord was freed, the ventral dura was repaired via non-interrupted closure. CONCLUSION: the posterolateral extra-pleural approach is a good option to treat spinal cord herniation in the thoracic spine, providing a better optical corridor to detect ventral dural defects than with a thoracic laminectomy, and avoiding any neural traction or rotation

Removal of a T1-2 Neurilemmoma by Lateral Parascapular Extrapleural Approach

The authors report a case of T1-2 neurilemmoma removed by lateral parascapular extrapleural approach. A 28-year-old man was presented with smooth, well-marginated radiopaque mass in left superior mediastinum on plain chest X-ray. Magnetic resonance imaging revealed a sharply marginated isosignal lesion in the left thoracic inlet on T1 weighted image and strong enhancement on T1 enhanced image. A 15cm length hockey stick skin incision was made from C7 to T9 level. A 2x3cm sized orange colored soft tissue mass was detected over the pleura. The intercostal nerve, subclavian artery, and internal carotid artery were adherent with mass. After gentle dissection, the tumor was removed from nerve bundle. Pathologic examination of tumor revealed a neurilemmoma. The patient was discharged 3 weeks after operation without neurologic deficit.

Radical Surgical Treatment of Thoracic Spinal Tuberculosis by Extrapleural Approach / 대한정형외과학회잡지

A total 12 cases of tuberculous spondylitis of thoracic spine had been treated by anterior decompression and interbody fusion through extrapleural approach from March, 1979 to June, 1980. In this study, six impending or complete paraplegics were included. Prognosis of paraplegia depends on its grade, duration and local pathology. Extrapleural approach seems to offer the following advantages over all the other ones; lesser risk, no Iimitation of surgical fleid, less chance of contaminating pleural cavity, less postoperative complications, especially indicated for the elderly paraplegics of Incomplete or complete type and less cumbersome Immediate postoperative care.