Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. Beginning in 2013, we began using the NuVasive MaXcess System (Fig) with a minimal access lateral incision for thoracic and lumbosacral spine exposures. There is some concern that these small-access approaches are not adequate when bleeding and other complications arise. This study sought to determine the feasibility and usefulness of a minimal access retractor during anterolateral spine exposures and its effect on both intraoperative and postoperative complications.Methods: We reviewed patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, levels of exposure, estimated blood loss, intraoperative and postoperative complications were collected. Data for standard exposure versus minimally invasive exposures were compared.Results: We performed 197 anterolateral spine exposure cases during the study period. The mean age was 54.1 years with 52% males and a mean body mass index of 29.4 kg/m 2 . Of the 197 patients, 131 had lateral exposure to access levels T6 to L5. Minimal access approaches using the NuVasive retractor were done in 22 patients (18%). In the standard exposure group, complications occurred in 23 patients (21%) whereas only 2 (9%) complications occurred in the minimal access group (Table). There was one death owing to respiratory failure in the standard exposure group done for spine infection.Conclusions: Historically, anterolateral spine exposures required relatively large incisions with significant soft tissue dissection. Advancements in retractor systems and surgical technique allow for smaller incisions, less dissection, and fewer complications.
Objectives: One of the challenges of spine surgery is the need for adequate exposure of the anterolateral spinal column. Improved retractor systems with integrated lighting minimize the need for large thoracotomy, flank, or abdominal incisions. In 2013, we began using the NuVasive MaXcess® system via a minimal-access lateral incision for thoracic and thoracolumbar spine exposures. These small-access approaches may not offer adequate exposure when bleeding and other complications arise. We sought to determine the feasibility and outcomes of a minimal-access retractor during anterolateral spine exposures. Methods: An institutional-review-board-approved retrospective chart review was performed of all patients who underwent anterolateral thoracic and lumbosacral spine exposure at an academic hospital between December 1999 and April 2017. Cervical and posterior spine exposures were not included. Information regarding patient demographics, comorbid conditions, operative techniques, exposure, estimated blood loss, length of stay, and intraoperative and postoperative complications was collected. Data for standard exposure vs. minimally invasive exposures were compared. Results: Between December 1999 and April 2017, 223 anterolateral spinal exposures were performed at our institution. Of those, 122 (54.7%) patients had true lateral exposures, with 22 (18%) using the minimally invasive retractor. The mean age of our patient population was 57 years (19–89), with 65 (53%) men and a mean body mass index of 29.0 (17.4–58.6). In the standard exposure group, complications occurred in 22 (22%) patients, whereas only two (9%) complications occurred in the minimal-access group. There were no significant differences in overall intraoperative and postoperative complications, except for cardiopulmonary complications, which were reduced in the minimally invasive group (p < 0.019). Patients with minimally invasive exposure had a significantly shorter length of stay than those with standard exposure (7 vs. 13 days, p = 0.001). Conclusions: Minimal-access techniques using advanced retractor systems are both feasible and safe compared to standard techniques allowing for similar lateral spine exposure, but with smaller incisions, fewer cardiopulmonary complications, and shorter lengths of stay.
Objective: We previously analyzed changes in aortic size over the cardiac cycle for patients with aortic valve stenosis but no aortic disease. In this study, we analyzed patients with descending thoracic aortic aneurysm (DTA) and DeBakey type III aortic dissection (AD). Methods: Electrocardiography-gated cardiac computed tomography scans of DTA and AD patients were analyzed. Standardized measurements were made in systole and diastole to determine radial aortic strain and distensibility for 10 anatomic locations along the aortic arch and longitudinal strain for Ishimaru landing zones 0, 1, and 2. Results: Our previous study found age and body mass index to be significant confounding factors on aortic strain, but patients with DTA (n ¼ 10) and AD (n ¼ 19) were not significantly different in terms of age (71 6 8 vs 68 6 11 years; P ¼ .37) or body mass index (29.8 6 3.6 vs 30.8 6 11.4 kg/m 2 ; P ¼ 0.74). Diastolic aortic diameter was greater in patients with DTA vs AD at the sinotubular junction (40.4 6 6.2 mm vs 34.5 6 7.1 mm; P ¼ .03) and in the mid-ascending aorta (46.8 6 5.6 mm vs 37.9 6 4.5 mm; P < .001) but not significantly different at the other locations along the arch. The length of Ishimaru landing zones 0 to 2 was not significantly different for DTA vs AD (Table). There were no significant differences between the two groups at any location. Radial distensibility ranged between 2.3 Â 10 À3 mm Hg À1 and 7.7 Â 10 À3 mm Hg À1 for the different locations along the arch in DTA patients vs 1.6 Â 10 À3 mm Hg À1 and 8.3 Â 10 À3 mm Hg À1 in AD patients, with no significant differences at any location. Conclusions: The aortic arch has similar dimensions in DTA and AD patients, except for the ascending aorta, which is wider in DTA patients. DTA patients and AD patients show limited radial strain and distensibility in the aortic arch. Longitudinal strain is significant only in the ascending aorta for both DTA and AD patients. This may have implications for stent graft sizing, especially for thoracic endovascular aortic repair procedures with proximal landing zone 0.
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