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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 3  |  Issue : 2  |  Page : 258-264

Technological advancements that can be adopted for performing a safe vertebral column resection


Division of Spine, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Jalan Tan Tock Seng, Singapore

Date of Submission07-Mar-2019
Date of Decision10-Apr-2019
Date of Acceptance23-Oct-2019
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Jacob Yoong-Leong Oh
Division of Spine, Department of Orthopaedic surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng.
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/isj.isj_17_19

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  Abstract 

Recent technological advancements have reduced the risks involved in vertebral column resection (VCR) with a wide range of tools that can be adopted. We intend to highlight the importance of these tools for performing a safe VCR. The patient, a 35-year-old man, presented with hyperkyphotic thoracic spine and symptomatic thoracic myelopathy. Radiological evaluation showed anterior wedging and fused T6-T7 vertebra, resulting in a gibbus deformity causing significant canal stenosis. Hence, T3-T10 posterior stabilization, T5-T8 decompression, and T6-T7 VCR and anterior column reconstruction were planned. We used recent technological advancements such as: (1) three-dimensional printed spine model for preoperative planning, (2) multimodal intraoperative neuromonitoring, (3) ultrasonic bone debulking, and (4) computed tomography–based image-guided spinal navigation. These advancements have made spine surgery relatively safer, predictable, and precise. Moreover, the field is constantly evolving. Hence, adapting to these advancements and utilizing it in complex scenarios are highly beneficial.

Keywords: Assistive technology, computer-assisted surgery, neuronavigation, three-dimensional printing, vertebral column resection


How to cite this article:
Kaliya-Perumal AK, Oh JY. Technological advancements that can be adopted for performing a safe vertebral column resection. Indian Spine J 2020;3:258-64

How to cite this URL:
Kaliya-Perumal AK, Oh JY. Technological advancements that can be adopted for performing a safe vertebral column resection. Indian Spine J [serial online] 2020 [cited 2020 Oct 25];3:258-64. Available from: https://www.isjonline.com/text.asp?2020/3/2/258/289646




  Introduction Top


Vertebral column resection (VCR) is a challenging procedure that requires meticulous planning and execution. This complex reconstruction procedure reportedly has higher complication rates compared to other spine surgeries.[1] Emerging technological trends have reduced the risks involved in VCR with a wide range of tools that can be opted by the surgeon. The most recent advancement is the incorporation of robotic technology and artificial intelligence (AI) to spine surgery.[2] However, apart from robots, certain other technologies can be used for specific purposes. These include (1) three-dimensional (3D) printing for preoperative planning, (2) intraoperative neuromonitoring for continuous neurological scrutiny, (3) ultrasonic debulking for bone removal, and (4) computed tomography (CT)–based image-guided spinal navigation for pedicle screw application and surface monitoring.[3],[4],[5],[6] Among these technologies, intraoperative neuromonitoring is relatively established and cost-effective; however, the importance and cost-effectiveness of 3D printing, ultrasonic debulking, and spinal navigation needs to be explored. We intend to highlight the surgical pearls of these modalities by reporting a case where thoracic T6-T7 VCR with anterior column reconstruction was performed.


  Case Report Top


Brief history and examination findings

A 35-year-old man presented with unsteady gait and bilateral lower limb weakness for six months. He reported a history of thoracic spine surgery performed elsewhere when he was 11 years old; however, no other details were available. On inspection, thoracic hyperkyphosis was noticed along with a healed posterior midline scar. Neurological examination revealed normal power, altered sensation, and exaggerated deep tendon reflexes in both lower limbs.

Radiological evaluation

X-ray and CT evaluation showed anterior wedging and fusion of T6, T7 vertebra resulting in a 50degrees gibbus deformity [Figure 1]. Sagittal T4-T9 Cobbs angle was 74degrees. Magnetic resonance imaging showed significant central canal narrowing at T6-T7 region along with extensive syrinx from T4-T9 [Figure 2].
Figure 1: X-ray and three-dimensional (3D) reconstructed computed tomography (CT) images showing anterior wedging and fusion of T6 and T7 vertebra. (A) Whole spine lateral view X-ray image. (B) Sagittal view 3D CT image. (C) Posterior view 3D CT image

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Figure 2: (A) Midsagittal magnetic resonance imaging (MRI) showing the apex of deformity (T6-T7) causing indentation of the cord along with extensive syrinx from T4-T9. (B–E) Axial cut MRI images at T5, T6, T7, and T8 levels showing the syrinx

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Diagnosis

Considering our clinico-radiological assessment, a diagnosis of thoracic myelopathy, due to stenosis caused by the kyphotic deformity, exacerbated by the extensive syrinx, was made.

Preoperative planning

For precise preoperative planning, the patient’s thoracic spine model was 3D printed; using which, the bony anatomy was studied in detail. The surgery was then strategized step by step using the 3D model. The exact extent of laminectomy required for adequate posterior decompression and the planned osteotomy was highlighted [Figure 3]. Ultimately, T3-T10 posterior stabilization, T5-T8 decompression, and T6-T7 VCR and anterior column reconstruction were planned.
Figure 3: Three-dimensional printed spine model showing the fused T6 and T7 vertebra causing the deformity. (A) Arrows highlighting the planned laminectomy levels. (B) Lines representing the planned osteotomy

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We believe that the syrinx was secondary to the obstruction of cerebrospinal fluid (CSF) flow caused by the progressive stenosis. The presence of syrinx along with spinal canal stenosis doubled the compressive effect on the cord. Therefore, we planned to address the canal stenosis and deformity first. Given that syrinx caused due to obstruction in CSF flow can resolve following decompression, and also considering the risks involved in draining the syrinx, we chose to conservatively manage it.

Procedure

Following anesthesia, electrodes were placed for intraoperative neuromonitoring (somatosensory-evoked potential and motor-evoked potential). The patient was then positioned prone on a Jackson table, prepared, and draped. The thoracic spine was exposed via standard posterior approach.

First, pedicle screws were applied three segments above and below the planned VCR under O-arm navigation guidance [Figure 4]. Then, T5-T8 laminectomy was performed in a piecemeal manner. Bilateral costotransversectomy of T6 and T7 vertebra was performed to visualize the pedicles. After removing the pedicles, T6 and T7 nerve roots were removed to allow access to the anterior column. Spoon retractors were placed bilaterally to expose paravertebral corridors. Temporary rod was fixed on one side and corpectomy was initiated from the other side, and vice versa [Figure 5].
Figure 4: Setup for intraoperative three-dimensional image-guided O-arm spinal navigation

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Figure 5: Intraoperative image showing the fixed temporary rod on one side and corpectomy using ultrasonic burr through the other side

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A combination of diamond head ultrasonic burr and rongeurs were used for bone removal. The exact extent of bone removal was periodically checked using a navigated probe so that a complete VCR could be performed safely without violating any vital anterior structures [Figure 6]. By using the ultrasonic burr, the use of osteotome was limited to avoid gross movements, which may affect the neural elements.
Figure 6: Periodical checking using a navigated probe (blue line) to identify the extent of ultrasonic debulking so that the instruments did not violate the limits of the anterior longitudinal ligament

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Once adequate debulking was carried out, an expandable cage was placed in the anterior column and distracted [Figure 7]. Also, rods were fixed bilaterally, and in situ bending was performed [Figure 8]. Once the required deformity correction was achieved, final tightening was performed to hold the rods in place, and autografting was carried out for posterior fusion above and below the VCR site.
Figure 7: Intraoperative radiograph showing the expandable cage in place after completing the corpectomy

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Figure 8: Performing in situ bending after fixing rods bilaterally

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Postoperative follow-up

The postoperative period was uneventful, and rehabilitation protocols were initiated. The patient recovered well, achieved fusion, and his unsteadiness eventually resolved despite leaving the extensive syrinx unattended [Figure 9]. He was at his best functional state by six months after surgery. Since then, he remains to be under our periodic follow-up and has consented for his case to be reported.
Figure 9: Six months postoperative X-ray showing the implants well in situ

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  Discussion Top


Spine surgery is constantly evolving.[7] Today, the available newer technology offers us to plan on 3D models instead of X-rays, imply intraoperative neuromonitoring instead of wake-up tests, use ultrasonic burrs instead of rongeurs, and optimize screw placements using spinal navigation instead of freehand procedures.[3],[4],[5],[6] With these technological advancements, spine surgery has become relatively safer, predictable, and precise.

The 3D printed spine model can efficiently act as a simulator so that the entire procedure can be practiced on the model.[4] To highlight, the size of the implants, the length/contour of the connecting rod, and the amount of deformity correction needed can precisely be predicted using the model. With increasing popularity and commercial availability of 3D printing technology, this modality could soon become a routine choice for preoperative planning of complex spine surgeries.

It is most important to match this preoperative planning to the patient’s anatomy intraoperatively; for which the image-guided spinal navigation plays a major role. By periodically using a navigated probe, the limits of the surgical working area or bony resection can be verified in the navigation display monitor.[8] This is an extended utility of spinal navigation other than pedicle screw fixation and is highly essential in a procedure, such as thoracic VCR, where the anterior limit cannot be violated during bony resection considering the risk to vascular structures.

Moreover, the onerous process of resecting bone to achieve appropriate decompression or deformity correction can be made easier and safer with the help of an ultrasonic burr.[9] Finally, throughout the procedure, continuous multimodal intraoperative neuromonitoring scrutinizes any unlikely neurological insult and warns the surgeon to take necessary action, then and there.[10] Highlights from the aforementioned literature references regarding 3D printing, intraoperative neuromonitoring, ultrasonic debulking, and spinal navigation were tabulated [Table 1].
Table 1: Highlights from the literature references regarding three-dimensional printing, intraoperative neuromonitoring, ultrasonic debulking, and spinal navigation

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We intend to report this case to highlight the surgical pearls of using these advanced modalities to aid complex procedures such as VCR. Despite the advantages, it should be noted that these modalities are expensive as of today and not all institutions can opt for its use. Considering the short follow-up of six months, we have not commented on the status of fusion, implant failure, or resolution of syrinx in this report, as it would be too early to analyze these parameters. This limits our discussion of the clinical outcome in this case.


  Conclusion Top


Newer technologies have potentially changed the way spine surgery was long performed. They have made spine surgery relatively safer, predictable, and precise. As the field is constantly evolving, adapting to these advancements and utilizing it in complex scenarios are highly beneficial.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lenke LG, Newton PO, Sucato DJ, Shufflebarger HL, Emans JB, Sponseller PD, et al. Complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: A multicenter analysis. Spine (Phila Pa 1976) 2013;38:119-32.  Back to cited text no. 1
    
2.
Theodore N, Arnold PM, Mehta AI. Introduction: The rise of the robots in spinal surgery. Neurosurg Focus 2018;45:Intro.  Back to cited text no. 2
    
3.
Hazer DB, Yaşar B, Rosberg HE, Akbaş A. Technical aspects on the use of ultrasonic bone shaver in spine surgery: Experience in 307 patients. Biomed Res Int 2016;2016:8428530.  Back to cited text no. 3
    
4.
Laratta JL, Ha A, Shillingford JN, Makhni MC, Lombardi JM, Thuet E, et al. Neuromonitoring in spinal deformity surgery: A multimodality approach. Global Spine J 2018;8:68-77.  Back to cited text no. 4
    
5.
Wilcox B, Mobbs RJ, Wu AM, Phan K. Systematic review of 3D printing in spinal surgery: The current state of play. J Spine Surg 2017;3:433-43.  Back to cited text no. 5
    
6.
Overley SC, Cho SK, Mehta AI, Arnold PM. Navigation and robotics in spinal surgery: Where are we now? Neurosurgery 2017;80:86-99.  Back to cited text no. 6
    
7.
Kazemi N, Crew LK, Tredway TL. The future of spine surgery: New horizons in the treatment of spinal disorders. Surg Neurol Int 2013;4:S15-21.  Back to cited text no. 7
    
8.
Shin JH, Yanamadala V, Cha TD. Computer-assisted navigation for real time planning of pedicle subtraction osteotomy in cervico-thoracic deformity correction. Oper Neurosurg (Hagerstown) 2019;16:445-50.  Back to cited text no. 8
    
9.
Chen Y, Chang Z, Yu X, Song R, Huang W. Use of ultrasonic device in cervical and thoracic laminectomy: A retrospective comparative study and technical note. Sci Rep 2018;8:4006.  Back to cited text no. 9
    
10.
Chen B, Chen Y, Yang J, Xie D, Su H, Li F, et al. Comparison of the wake-up test and combined TES-MEP and CSEP monitoring in spinal surgery. J Spinal Disord Tech 2015;28: 335-40.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
 
 
    Tables

  [Table 1]



 

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