Transpoas Approach to Lumbar Corpectomy Shows High Rate of Patient Satisfaction and Functional Outcomes
Commentary by Murat Pekmezci, MD and Dana E. Adkins, MD
Patients with unstable burst fractures treated with anterior lumbar corpectomy and cage placement using a transpsoas approach and short-segment posterior instrumentation showed high rates of satisfaction with outcomes, minimal disability, and excellent physical and mental health outcomes after surgery, researchers reported in the January issue of the Journal of Neurosurgery: Spine.
“It has been previously shown that the classic anterior approaches to the thoracolumbar spine have been associated with significant residual pain and cosmetic concerns related to the incision,” said senior author Murat Pekmezci, MD, Associate Professor of Orthopedic Surgery, Department of Orthopedic Surgery, University of California San Francisco. “The transpsoas approach has decreased these concerns and has been successfully utilized over the past decade for a variety of degenerative pathologies and recently extended into the spine trauma setting. Posterior percutaneous instrumentation and/or fusion also have been shown to deliver similar results to the open techniques with decreased morbidity to the patients.”
“This study demonstrated that these outstanding results can be translated into the trauma setting, not only with the radiographic outcomes and safety profile, but also with the patient-reported outcomes from the perspective of incisional pain and cosmetic appearance, which is what patients are left with after they heal from their injuries,” Dr. Pekmezci told EndocrineWeb.
“This study provides solid clinical evidence that the extreme lateral transpsoas minimally invasive approach to corpectomy can provide good clinical outcomes,” commented Dana E. Adkins, MD, neurosurgeon at Sentara Neurosurgery Specialists. While previous studies have shown that this approach is safe and effective compared to the standard open, anterior approach, “this study uses validated questionnaires to demonstrate adequate patient outcomes, and reports complication rates, patient satisfaction scores, and radiographic evidence of maintenance of lordosis,” Dr. Adkins said.
Retrospective Study Design
The study authors retrospectively examined postoperative outcomes in 12 patients (7 men, 5 women; average age, 42 years) who underwent minimally invasive vertebral body corpectomy and cage placement via a mini-open, extreme lateral, transpsoas approach and posterior short-segment instrumentation for lumbar burst fractures between June 2009 and July 2013. The average clinical follow-up was 38 months, and average radiographic follow-up was 37 months.
I think that the main take home message from this article is that they are using validated patient questionnaires to gather evidence with this technique. Not only is it feasible, but it is at least equivalent to current gold standards of care. And in the future, may be deemed superior, due to the theoretical advantages of minimally invasive surgery (ie, less tissue disruption, less tissue dissection, less post operative pain, early mobilization time).
Radiographic data showed that focal and average lumber lordosis improved from -12° and 39° preoperatively to 10° and 54°, respectively (P<0.05 for both).
Overall, patients were satisfied with their outcomes, had minimal/moderate disability, and had good physical and mental health outcomes after surgery (Table). Five patients (42%) reported that their scar limited their ability to do things around the house, and 91% said that their chest/torso area looked the same (n=2), better (n=6), or much better (n=2) postsurgery.
While the majority of patients (89%) reported that they would have the same treatment again given their current results, 75% said that they would prefer an all-posterior approach if they could have their surgery performed again.
“I think the former result is simply related to the fact that the patients are recovered well from their injuries and happy with their outcomes, therefore would have the same surgical treatment again,” Dr. Pekmezci said. “While the latter result may seem to contradict the former, it is probably related to the patient’s perception about the posterior surgery. The majority of the patients had a posterior approach that was minimally invasive, performed through small incisions with minimal muscle dissection. Therefore, they are probably thinking that this is how they would have felt if everything was done through an all-posterior approach. However, if we were to attempt performing the same procedure (which is a vertebral column resection) using an all-posterior approach, we would have had to make a much bigger incision, with more extensive muscle dissection, bony resection, and fused a longer segment.”
“Their satisfaction with this more extensive posterior approach would not be as high as the one they had with the minimal invasive posterior approach,” Dr. Pekmezci said. “I think this is the main reason why they have these seemingly contradictory results.”
Three patients experienced an intraoperative complication attributable to the anterior approach. The overall postoperative complication rate was 25%, and complications included wound infections (n=1), failure of fixation (n=1), and pulmonary embolism (n=1). The reoperation rate was 17%.
Four of the patients had neurologic deficits prior to surgery, all of which improved after surgery with no new neurological complications reported.
“The biggest limitation of the study, which the authors mention, is the small number of patients,” Dr. Adkins said. “With only 12 patients, it is hard to generate a meaningful comparison to established outcomes and complication rates for more established approaches. It is difficult to compare the findings to data in the literature on expected outcomes and complication rates.”
“However, this study represents excellent progress in demonstrating clinical evidence of outcomes equivalent to, or superior to, more traditional approaches. We start with small single-institution studies and then move on to multicenter efforts to try and capture more patients,” Dr. Adkins noted. “My current preference is to try perform these procedures either using an all posterior or all anterior extreme lateral approach.”
Can an All Anterior Approach Be Used?
Dr. Adkins performs the anterior corpectomy in his practice and noted that there is an option of performing a lateral approach to instrumentation, rather than the posterior approach to instrumentation used in this study.
“Technically, some of the patients could have had all anterior approach,” Dr. Pekmezci said. “However, this technique requires us to split the psoas muscle in order to reach the lateral aspect of the spine. In order to perform the corpectomy, we only split the psoas between two discs and one vertebral body. If we consider placing a plate in addition to the cage, then we would have to expose two additional vertebral bodies, which would increase the extent of iatrogenic injury to the psoas muscle as well as potential injury to lumbar plexus that resides within the psoas muscle. This would also require a bigger skin incision and more dissection.”
“When we combine front and back approach, we actually performed the least invasive options for both approaches and in turn the least possible muscle dissection and insult,” Dr. Pekmezci said. “I think this is one of the main reasons why the patients had such a good clinical and radiographic outcome.”