One-stage surgical treatment of upper thoracic spinal tuberculosis by posterolateral costotransversectomy using an extrapleural approach.

BACKGROUND: Due to the complexity of the anatomical structure and the difficulty of exposing the surgical area, the surgery for spinal tuberculosis in the upper thoracic vertebra (above T6-T7) is complicated and the prognosis is not good. This study aimed to investigate the clinical effects of posterolateral costotransversectomy using an extrapleural approach in patients with upper thoracic spinal tuberculosis. METHODS: This was a retrospective analysis of 132 patients (including 78 males and 54 females) with upper thoracic spinal tuberculosis who underwent one-stage internal fixation and debridement followed by combined interbody and posterior fusion via posterolateral costotransversectomy using an extrapleural approach. The age ranged from 23 to 82 years (54.5 ± 13.2 years). Lesion segments were distributed from T2 to T7. According to Frankel's spinal cord function evaluation, there were 2 cases of grade A, 6 of grade B, 6 of grade C, 12 of grade D, and 106 of grade E. The preoperative Cobb angle was 16-40° (29.1° ± 6.5°). Operation time, bleeding volume, incision healing, bone graft fusion, deformity correction, and improvement of nerve function were analyzed. RESULTS: The operation time ranged from 2.8 to 4.1 h (3.4 ± 0.3 h), and blood loss ranged from 350 to 550 mL (460 ± 47 mL). All incisions healed in the first stage. The bone graft fusion time was 3-6 months (median of 4 months). There was no loosening or broken of the internal fixation. The C-reactive protein and erythrocyte sedimentation rate were significantly improved at the end of follow-up in comparison with before surgery. The Cobb angle of the fusion segment was corrected and ranged from 5° to 17° (average of 10.7° ± 3.3°) at the end of follow-up. The nerve function of all patients improved at different degrees by the time of the last follow-up. In the last follow-up, the Frankel grade distribution was 1 case in B grade, 2 cases in grade C, 6 cases in grade D, and 123 cases in grade E. CONCLUSION: Posterolateral costotransversectomy using an extrapleural approach is a safe and effective surgical method that can expose the upper thoracic spine lesions and reduce trauma.

En bloc resection and reconstruction of a huge chondrosarcoma involving multilevel upper thoracic spine and chest wall: case report.

BACKGROUND: En bloc resection of malignant tumors involving upper thoracic spine is technically difficult. We surgically treated a patient with grade 2 chondrosarcoma involving T1-5, left upper thoracic cavity, and chest wall. CASE PRESENTATION: A 37 years old, male patient was referred to our hospital for a huge lump involved left shoulder and chest wall. In order to achieve satisfied surgical margins, anterior approach, posterior approach, and lateral approach were carried out sequentially. After en bloc tumor resection, the upper thoracic spine was reconstructed with a 3D-printed modular vertebral prosthesis, and the huge chest wall defect was repaired by a methyl methacrylate layer between 2 pieces of polypropylene mesh. Postoperatively, the patient suffered from pneumonia and neurological deterioration which fully recovered eventfully. At 24 months after operation, the vertebral prosthesis and internal fixation were intact; there was no tumor local recurrence, and the patient was alive with stable pulmonary metastases. CONCLUSION: This case report describes resection of a huge chondrosarcoma involving not only multilevel upper thoracic spine, but also entire left upper thoracic cavity and chest wall. Although with complications, en bloc tumor resection with combined surgical approach and effective reconstructions could improve oncologic and functional prognosis in carefully selected spinal tumor patients.

Pure distraction injury of T1-2 with quad fever.

INTRODUCTION: We report a pure distraction injury of the upper thoracic spine and uncontrolled hyperthermia without an infectious cause. Quad fever appears in the first several weeks to months after a cervical or upper thoracic SCI and is characterized by an extreme elevation in body core temperature beyond 40 °C without an infectious cause. Discriminating between infectious and noninfectious causes is important, and a thorough clinical assessment is required. MATERIALS AND METHODS: A 52-year-old male visited the emergency room complaining of back pain with complete paralysis [American Spinal Injury Association (ASIA) A] of both lower extremities after a pedestrian-motor vehicle accident. He had trouble breathing due to a hemothorax and flail chest caused by fractures of the right second to eleventh and left fourth to seventh ribs. A computed tomography scan revealed severe distraction of the T1-2 intervertebral space. A magnetic resonance image showed signal changes in the spinal cord and a clean-cut margin between the T1-2 disc and T2 body. The neurological level of injury was C8 upon the initial neurological assessment. Emergency surgery was performed. C6-T3 posterior instrumentation and an autologous iliac bone graft were performed. RESULTS: After surgery, the core temperature increased gradually to above 38.0 °C on post-trauma day 4 and increased to 40.8 °C on post-trauma day 7. None of the repeated aerobic, anaerobic, or fungal cultures of the blood, tracheal aspirate, line tips, urine, or stool was positive until post-trauma day 21, when Candida tropicalis was identified in the urine culture. On post-trauma day 63, the blood pressure, pulse, and body temperature stabilized and the patient was transferred to the general ward. At post-trauma year 6, the injury state was still complete and the neurological level of injury was changed to C4. CONCLUSIONS: Based on the Grand Round case and relevant literature, we discuss the case of pure distraction injury of T1-2 with quad fever. Spinal surgeons should be knowledgeable regarding quad fever as well as the differential diagnoses and treatment strategies.

A novel muscle-sparing high thoracotomy for upper thoracic spine resection and reconstruction.

PURPOSE: High thoracotomy allows access to the anterior cervicothoracic and upper thoracic vertebrae; however, traditional techniques transect shoulder girdle muscles, leading to postoperative shoulder dysfunction. Muscle-sparing techniques diminish this concern, but often sacrifice the quality of exposure. We describe a novel muscle-sparing, high thoracotomy approach for the treatment of ventral cervicothoracic and upper thoracic spine lesions. METHODS: A novel muscle-sparing, high thoracotomy approach is described, utilizing a midline posterior incision with lateral extension from the lateral decubitus position. Five patients are presented to illustrate the application of this technique in thoracic tumors with intimate spinal involvement. RESULTS: The muscle-sparing, high thoracotomy approach afforded gross total resection and spinal reconstruction in five consecutive patients, including stage IV lung carcinoma with invasion of the T5 and T6 vertebral bodies, two malignant fibrous histiocytomas causing thoracic cord compression, a metastatic T6 lesion of unknown primary with associated cord compression; and a Pancoast tumor. All patients seen at 6 months had full symmetric shoulder range of motion postoperatively. CONCLUSIONS: The described muscle-sparing, high thoracotomy approach provides excellent exposure of the ventral cervicothoracic and upper thoracic spine without the morbidity associated with the transection of shoulder girdle muscle bellies. This technique is particularly useful in patients with primary malignant bone tumors requiring en bloc excision and metastatic tumors with large soft tissue components.

Ideal T1 laminar screw fixation based on computed tomography morphometry.

BACKGROUND: The application of laminar screws is an alternative fixation for the first thoracic vertebra (T1). This paper is to determine the anatomical characteristics for adequate laminar screw fixation, and present a modified method of sagittal reconstruction of T1 to provide more accurate measurements. METHODS: Computed tomography (CT) images of 62 patients (32 males, 30 females) were used for the analysis. The following parameters of the T-1 lamina were measured using Mimics software: lamina length, axis angle, minimal outer cortical width, cancellous width, minimal outer cortical height, cancellous height, and spinous process height. Right or left modified sagittal reconstructions (parallel to right or left screws) were innovatively used for measurement. RESULTS: There were no significant differences between the left and right sides for each measurement performed (P > 0.05), but significant differences were detected between males and females (P < 0.05). The mean length of the T1 lamina was 32.8 mm of the T1 minimal outer cortical width was 7.4 mm, and 3.8% of males had a minimal outer cortical width < 5 mm, while 8.6% of females had a minimal outer cortical width < 5 mm. The mean minimal outer cortical height was 10.8 mm, and 1.9% of males had a minimal outer cortical height < 9 mm, while 7.7% of females had a minimal outer cortical height < 9 mm. CONCLUSION: This study suggests there are no anatomical limitations for T1 laminar screw placement in most people. The modified sagittal reconstruction method described allows for easy and precise measurement to aid in the insertion of laminar screws in T1, and gives good visualization of laminar screw insertion direction.

Percutaneous Kyphoplasty via Transverse Process-Rib-Pedicle Approach for Upper and Middle Thoracic Osteoporosis Fracture with Pedicle Stenosis.

OBJECTIVE: To explore the clinical effect of percutaneous kyphoplasty (PKP) via process-rib-pedicle approach for upper and middle thoracic osteoporosis fractures with pedicle stenosis. METHODS: This study is a retrospective observational study. In this study, we retrospectively analyzed the data of 62 patients with upper thoracic vertebral bone loss compression fracture treated via the process-rib-pedicle pathway PKP at the First Affiliated Hospital of Soochow University from January 2020 to December 2022. The patients were divided into group A (unilateral PKP, 38 cases) and group B (bilateral PKP, 24 cases). The aspects of surgical safety, clinical efficacy, and radiological outcome were investigated. RESULTS: All 62 patients successfully completed the surgery without any spinal cord, nerve, or vascular injury, and there were no complications such as infection and vascular embolism. The differences in visual analog scale scores（P < 0.05）, Oswestry disability index functional index（P < 0.05）, and Cobb angle（P < 0.05） were significant when comparing preoperative and postoperative periods, and the differences were not significant when comparing the postoperative periods (P > 0.05). There were no statistically significant differences in days of hospital stay (P = 0.653) and the rate of bone cement leakage (P = 0.537) between the 2 groups. CONCLUSIONS: For upper middle osteoporotic thoracic vertebral fractures with pedicle stenosis, puncture via the process-rib-pedicle path is a safe and reliable puncture route, and more than 2.5 ml of cement can achieve good clinical outcomes, regardless of bilateral or unilateral PKP.

Upper Thoracic Spine (D2-D3) Fracture With Unilateral Lock Facets Without Associated Neurological Deficits: Case Report & Literature Review.

Introduction: Upper thoracic spine fractures are rare as compared to other spine segments due to anatomical landmarks. If they occur, they are usually associated with paraplegia or any other neurological dysfunction. We report upper thoracic fracture without neurological dysfunction which is a rare entity along with its radiological imaging, and management plan. Case Description: Forty-years old male presented after RTA. CT spine showed T2 vertebral body fracture with dislocation/locking of the right T2-T3 facet joint. The patient underwent surgical fixation and was neurologically intact. Conclusion: Upper thoracic spine fracture is a rare entity due to its anatomical location. And sometimes it is missed as well. Proper imaging should be considered if there is high suspicion and early surgery is warranted to prevent permanent damage.

The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series.

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Oblique radiograph with methylene blue marking: A reliable technique for upper thoracic level localization.

Purpose: Traditionally, plain radiographs are used in intraoperative spinal level localization (SLL), whereas counting vertebrae is often hampered by shoulders and scapulae in lateral views, thus increasing the potential for wrong-level surgery. To improve the localization accuracy, this study evaluated the safety and feasibility of oblique radiographs with methylene blue markings for SLL and explored the optimal angle and height of oblique radiographs. Methods: The clinical data of 33 patients with upper thoracic spine lesions who were operated on in our hospital from January 2021 to April 2022 were retrospectively analyzed. Oblique radiographs with methylene blue markings were used for intraoperative SLL. Results: A total of 33 patients were included in this study. The average BMI was 24.3 ± 0.7 kg/m2. The ipsilateral lamina structures were clearly shown in all cases. The median radiographing times of all the patients was 3, and the median radiographing duration was 2 min and 25 s. The average angle of oblique radiographs was 55.1 ± 3.8°, and the average distance from the skin to the root of the spinous process was 4.9 ± 1.2 cm. Conclusions: Using oblique radiographs with methylene blue markings, not only the bone structure of an upper thoracic spine can be revealed clearly, but also the positioning deviation of traditional needle localization can be avoided. The lesion segment can be precisely located by this technology during surgery. Our angle of oblique radiographs and height determination method can be used to reduce the radiation exposure and shorten the operation time.

The effect of pedicle screw instrumentation at a young age on upper thoracic vertebra and canal development.

BACKGROUND CONTEXT: Pedicle screws are widely used in spinal surgeries. Pedicle screw fixation has shown better clinical effects than other techniques by providing steady fixation from the posterior arch to the vertebral body. However, there are several concerns about the impact of pedicle screw instrumentation insertion on vertebral development in young children, including early closure of the neurocentral cartilage (NCC). The effect of pedicle screw insertion in an early age on further growth of the upper thoracic spine is still unclear. PURPOSE: This study aimed to evaluate the impact of pedicle screw insertion on further growth of the upper thoracic vertebra and spinal canal. STUDY DESIGN: A retrospective case study. PATIENT SAMPLE: Twenty-eight patients. OUTCOME MEASUREMENTS: X-ray and CT parameters including length, height and area of the vertebrae and spinal canal were manually measured. METHODS: Twenty-eight patients who underwent pedicle screw fixation (T1-T6) before the age of 5 years from March 2005 to August 2019 at Peking Union Medical College Hospital were recruited, and records were retrospectively reviewed. Vertebral body and spinal canal parameters were measured at instrumented and adjacent noninstrumented levels and compared using statistical methods. RESULTS: Ninety-seven segments met the inclusion criteria (average age at instrumentation 44.57 months, range from 23-60 months). Thirty-nine segments had no screws, and 58 had at least one screw. There was no significant difference between the preoperative and final follow-up values of the measurement of vertebral body parameters. No significant difference was observed between the growth rates in levels with or without screws in pedicle length, vertebral body diameter, or spinal canal parameters. CONCLUSION: Pedicle screw instrumentation in the upper thoracic spine does not cause a negative effect on the development of the vertebral body and spinal canal in children younger than 5 years old.

The treatment of tuberculosis in the upper thoracic spine using the small incision technique through the third rib.

Background: The complex anatomical structure of the upper thoracic spine makes it challenging to achieve surgical exposure, resulting in significant surgical risks and difficulties. Posterior surgery alone fails to adequately address and reconstruct upper thoracic lesions due to limited exposure. While the anterior approach offers advantages in fully exposing the anterior thoracic lesions, the surgical procedure itself is highly intricate. Although there exist various anterior approaches for the upper thoracic spine, the incidence of upper thoracic spine lesions is relatively low. Consequently, there are limited reports on the treatment and reconstruction of upper thoracic spine lesions using the third rib small incision approach in the context of upper thoracic tuberculosis. Methods: We collected data from four patients with upper thoracic tuberculosis who were admitted to our department between July 2017 and November 2022. The treatment for upper thoracic tuberculosis involved utilizing the third rib small incision approach, which included two cases of thoracic 3-4 vertebral tuberculosis, one case of thoracic 4 vertebral tuberculosis, and one case of thoracic 5 vertebral tuberculosis. Among the patients, three were positioned in the left lateral position, while one was positioned in the right lateral position. Prior to admission, all four patients received a two-week course of oral medication, consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol. After the surgical procedure, they continued receiving anti-tuberculosis treatment for a duration of 12 months. Results: The average duration of the surgical procedure was 150 min, with an average blood loss of 500 ml. One patient exhibited symptoms of brachial plexus injury, which gradually improved after careful observation. All patients experienced primary wound healing, and no complications such as pulmonary infection, respiratory failure, or other adverse events were observed. Additionally, one patient showed elevated transaminase levels, leading to a modification in the anti-tuberculosis drug regimen from quadruple therapy to triple therapy. Conclusion: The treatment of upper thoracic tuberculosis through the third rib small incision technique is a very good surgical approach, which has the advantages of safety and effectiveness.

Cervical Deformity Arising From Upper Thoracic Malalignment.

This study aims to describe the surgical management of cervical deformity arising from outside the cervical spine because of upper thoracic malalignment, using pedicle subtraction osteotomy (PSO). Cervical spine deformity is a complex topic and it can be generally divided into 2 categories, the first category is when the primary deformity is inside the cervical spine and the treatment will focus on the cervical spine itself, whereas the second category is when the primary deformity is outside the cervical spine usually in the adjacent upper thoracic area, the cervical deformity is a compensation for the adjacent malalignment, and thus in this situation, the management will occur in the upper thoracic area. Description of a single surgeon's technique for performing PSO to treat rigid upper thoracic deformity. PSO in the upper thoracic spine is a safe and effective procedure and can result in satisfying clinical and radiological outcome with indirect correction of the compensatory cervical deformity. Cervical deformity arising from upper thoracic malalignment should be dealt with by treating the problem at its origin outside the cervical spine by performing a PSO in the upper thoracic spine.

Analysis of the disc pressure of the upper thoracic spine using pressure-sensitive film: an experimental study in porcine model-implications for scoliosis progression.

There has been few studies focusing on the disc pressure of the upper thoracic spine and it still lacks the quantitative pressure measurement of each spinal disc segment. The aim of this study was to study the pressure changes of intervertebral disc in porcine upper thoracic spine using pressure-sensitive film. Twelve porcine thoracic motion segments were harvested and successively loaded with vertical loads of 100 N, 150 N, and 200 N during 5° of anterior flexion, 5° of posterior extension and 5° of lateral bending. The resulting pressure values were measured. During anterior flexion, the anterior annulus of all segments at all loads showed higher mean pressure values than those during vertical compression, whereas the posterior annulus did not show higher mean values. During posterior extension, the anterior annulus of all segments showed lower mean pressure values than those during vertical compression, whereas the posterior annulus did not show lower mean pressure values. During lateral bending, the annulus of all segments showed higher mean pressure values than those during vertical compression. The posterior thoracic vertebra plays an important role in the motion of the upper thoracic vertebral segment and pressure distribution. During lateral bending, the concave side pressure of the annulus increases obviously, suggesting that asymmetrical force is a contributory factor for scoliosis progression.

Posterior Extensive Circumferential Decompressive Reconstructive Technique in Surgical Treatment of Upper Thoracic Spine Compressive Lesions.

BACKGROUND: Complexity in ventral surgical exposure and presence of scapula and large parascapular musculature during posterior surgery are the main obstacles in operative treatment of upper thoracic spine compressive lesions (UTSCLs), such as trauma, tuberculosis, and neoplasm. Recently, the advantages of combined ventrodorsal surgery could be successfully gained using a 1-stage posterior salvage technique with enough accessibility to all 3 spinal columns. This was a retrospective evaluation of 35 patients with UTSCLs treated by the posterior extensive circumferential decompressive reconstructive (PECDR) procedure. METHODS: Traumatic, tuberculosis, and neoplastic lesions were involved between 2009 and 2012. All patients were examined pre- and postoperatively and during follow-up clinically (pain by visual analog scale), neurologically (sensory and motor deficit by American Spinal Injury Association grading), functionally (Oswestry Disability Index), radiologically (kyphosis correction, loss of correction, and fusion time), and with laboratory investigations in patients with tuberculosis. Two authors plus an independent observer performed the final clinical, neurologic, and radiologic examination. Operative time, hospital stay, blood loss, and complications were documented. RESULTS: The mean follow-up period was 36 ± 5.5 months. Local symptoms, deformity correction, and neurologic recovery significantly improved postoperatively. Solid fusion was evident in 32 cases. No major complications were reported. Three patients developed wound infection and 3 had intercostal neuralgia; both complications were resolved uneventfully and did not influence the outcomes. CONCLUSIONS: Because of difficult ventral exposure, the PECDR technique is a feasible tool for maintained deformity correction, bony fusion, thecal decompression, and functional improvement in surgical treatment of UTSCLs. However, tuberculosis had better satisfactory results than traumatic and neoplastic lesions.

Acute Calcific Discitis or Symptomatic Calcified Schmorl's Node of the Upper Thoracic Spine in an Adult: A Case Report and Literature Review.

We describe a patient with acute calcific discitis following symptomatic Schmorl's node (SN) of upper thoracic spine. A 28-year-old female suffered from sudden severe pain in mid-thoracic, left scapular area, radiating to her chest. Plain radiography of the thoracic spine showed calcification in T3-4 intervertebral disc space. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the spine demonstrated calcification of the T3-T4 nucleus pulposus, migrating into the inferior of T3 vertebral body with reactive bone marrow edema. By conservative treatment with multidrug therapy, the pain subsided and disappeared in 3 months. Follow-up CT scan and MRI of the thoracic spine confirmed complete resolution of calcified SN and reactive bone marrow edema.

Design and Application of Individualized, 3-Dimensional-Printed Navigation Template for Placing Cortical Bone Trajectory Screws in Middle-Upper Thoracic Spine: Cadaver Research Study.

OBJECTIVE: To evaluate the safety and accuracy of use of a 3-dimensional printed navigation template in the placement of a cortical bone trajectory (CBT) screw in the middle-upper thoracic spine. METHODS: Ten human cadavers were included in the study. Sixty CBT screws were placed on 1 side, using the free-hand technique, and 60 CBT screws were placed on the other side, using the navigation template that was designed and printed using data from 10 cadavers. The safety and accuracy of use of the CBT screws were directly evaluated by radiography and computed tomography. RESULTS: Computed tomography revealed that 2 and 3 of 60 screws, placed using the navigation template, were broken in the medial or lateral areas and in the superior or inferior pedicle wall, respectively. Furthermore, 8 screws were broken in the medial or lateral areas and 11 screws were broken in the superior or inferior pedicle wall when the free-hand technique was used. Radiography revealed that 3 screws in zone I, 55 screws in zone II, and 2 screws in zone III were placed using the navigation template. Furthermore, 7 screws in zone I, 45 screws in zone II, and 8 screws in zone III were placed using the free-hand technique. CONCLUSIONS: In this cadaver study, insertion of the CBT screws in the middle-upper thoracic spine with the assistance of the navigation template was safe and convenient.

[BIOMECHANICAL STUDY ON UPPER THORACIC SPINE BASED ON PRESSURE SENSITIVE FILM MATERIALS IN CHINESE MINI PIGS].

OBJECTIVE: To analyze the pressure change and distribution of the intervertebral disc of upper thoracic spine in vertical pressure and 5° flexion, extension, or lateral bending. METHODS: Twelve thoracolumbar spinal specimens were harvested from mini pigs and were divided into 2 groups (n=6). T1, 2, T3, 4, T5, 6, and T7, 8 segments were included in one group, and T2, 3, T4, 5, T6, 7, and T8, 9 segments were included in the other group. The data from both groups represented the complete upper thoracic vertebra data. Biomechanical machine and pressure sensitive film were used to measure the pressure on the vertebral columns under loadings of 100, 150, and 200 N in vertical pressures and 5° flexion, extension, or lateral bending. The pressure change of each intervertebral disc under different loads and in different movement conditions was analyzed. RESULTS: In flexion, the anterior annulus pressure of the upper thoracic vertebra increased (P<0.05), whereas the posterior annulus pressure showed no significant change (P>0.05) or an increasing trend (P<0.05). In extension, the anterior annulus pressure of the upper thoracic vertebra decreased (P<0.05), whereas the posterior annulus pressure decreased (P<0.05) or had no obvious change (P>0.05). In lateral bending, the pressure on the concave side of the annulus increased significantly (P<0.05). CONCLUSIONS: The upper thoracic vertebra has unique biomechanical characteristics under different loadings; moreover, the posterior vertebral structure plays an important role in the movement of the upper thoracic vertebral segment and pressure distribution. In lateral bending of the upper thoracic vertebra, the concave side pressure will increase significantly, which suggests that asymmetrical force is an important cause of scoliosis progression. Gravity plays an important role in the progression of scoliosis.

Biomechanics of the lower thoracic spine after decompression and fusion: a cadaveric analysis.

BACKGROUND CONTEXT: Few studies have evaluated the extent of biomechanical destabilization of thoracic decompression on the upper and lower thoracic spine. The present study evaluates lower thoracic spinal stability after laminectomy, unilateral facetectomy, and unilateral costotransversectomy in thoracic spines with intact sternocostovertebral articulations. PURPOSE: To assess the biomechanical impact of decompression and fixation procedures on lower thoracic spine stability. STUDY DESIGN: Biomechanical cadaveric study. METHODS: Sequential surgical decompression (laminectomy, unilateral facetectomy, unilateral costotransversectomy) and dorsal fixation were performed on the lower thoracic spine (T8-T9) of human cadaveric spine specimens with intact rib cages (n=10). An industrial robot was used to apply pure moments to simulate flexion-extension (FE), lateral bending (LB), and axial rotation (AR) in the intact specimens and after decompression and fixation. Global range of motion (ROM) between T1-T12 and intrinsic ROM between T7-T11 were measured for each specimen. RESULTS: The decompression procedures caused no statistically significant change in either global or intrinsic ROM compared with the intact state. Instrumentation, however, reduced global motion for AR (45° vs. 30°, p=.0001), FE (24° vs. 19°, p=.02), and LB (47° vs. 36°, p=.0001) and for intrinsic motion for AR (17° vs. 4°, p=.0001), FE (8° vs. 1°, p=.0001), and LB (12° vs. 1°, p=.0001). No significant differences were identified between decompression of the upper versus lower thoracic spine, with trends toward significantly greater ROM for AR and lower ROM for LB in the lower thoracic spine. CONCLUSIONS: The lower thoracic spine was not destabilized by sequential unilateral decompression procedures. Addition of dorsal fixation increased segment rigidity at intrinsic levels and also reduced overall ROM of the lower thoracic spine to a greater extent than did fusing the upper thoracic spine (level of the true ribs). Despite the lack of true ribs, the lower thoracic spine was not significantly different compared with the upper thoracic spine in FE and LB after decompression, although there were trends toward significance for greater AR after decompression. In certain patients, instrumentation may not be needed after unilateral decompression of the lower thoracic spine; further validation and additional clinical studies are warranted.

Chance Fracture of the Upper Thoracic Spine in a Child.

We report on a three-year-old girl who fell accidentally from the fourth floor. She suffered multiple trauma, including severe head injury, unstable T2-T3 Chance fracture, pneumothorax with lung contusion and serial rib fractures on the left side, liver laceration, splenic injury and fracture of the sacral bone on the right side. The progressive intracranial pressure was released by trepanation and bifrontal craniectomy. The abdominal injuries were treated conservatively. After stabilization of the intracranial situation, dorsal spondylodesis from T2 to T4 was performed employing the cannulated NEON system (Ulrich(®)) with CT-controlled positioning of guide wires. One year on, the implants have been removed and the patient has good function, with only a small atactic dysfunction as residuum. To our knowledge, this is the first report of a pediatric Chance fracture located in the upper thoracic spine following a fall from great height that describes how this treatment approach led to a very favorable outcome.