Transcostovertebral kyphoplasty of the mid and high thoracic spine

Abstract

While Kyphoplasty is increasingly becoming a recognised minimally invasive treatment option for osteoporotic vertebral fractures and neoplastic vertebral collapse, the experience in the treatment of vertebrae of the mid (T5-8)- and high (T1-4) thoracic levels is limited. The slender pedicle morphology restricts the transpedicular approach at these levels, necessitating extrapedicular placement techniques. Fifty five vertebrae of 32 consecutive patients were treated with kyphoplasty at levels ranging from T2-T8 for vertebral fractures (27 patients) or osteolytic collapse (5 patients). All procedures were performed through the transcostovertebral approach under fluoroscopic guidance. The radioanatomical landmarks of this minimally invasive approach were consistently identified and strictly adhered to. One fracture required open instrumentation due to posterior column injury in addition to kyphoplasty. Identification of specific radioanatomical landmarks allowed precise tool introduction in all cases without intraspinal or paravertebral malplacement. Average operating time for patients with osteoporotic fractures was 30 min per level (range 13-60 min) and 52 min per level (range 35-95 min) in neoplastic cases. Biopsy yield in patients with known or suspected malignancies was 100%. Epidural cement leakage was detected in one patient with pedicular osteolysis. Perforation of the lateral vertebral cortex during balloon inflation occurred in another patient. Both intraoperative complications were without clinical significance. Kyphoplasty in mid- to -high thoracic levels is possible via the transcostovertebral route under fluoroscopic guidance. Strict adherence to a stepwise protocol of tool introduction following defined radioanatomical landmarks is mandatory for the safe completion of this minimally invasive technique.

3D Reconstructions of Spinal Segmental Arteries Using CT Angiography: Applications in Minimally Invasive Spinal Procedures

“…[7][8][9][10] This procedure uses a cannula with a relatively large diameter, compatible with low pressure and a high-viscosity filler material, which may decrease complications related to filler leakage. 9 Despite these advantages, the extrapedicular approach may injure the segmental artery.…”

Percutaneous approach to the upper thoracic spine: optimal patient positioning

“…We favour the trans-costovertebral approach using fluoroscopic guidance, as described by Boszczyk et al [2]. This allows safe use of large cannulas or biopsy needles with a potentially larger diameter than the upper thoracic pedicles, thus avoiding spinal canal intrusion.…”

“…Boszczyk et al [2] have advocated fluoroscopically guided kyphoplasty cranial to T5. They have shown the transcostovertebral approach to the high thoracic spine can be successfully used for kyphoplasty, vertebroplasty and biopsy.…”

The Michel Benoist and Robert Mulholland yearly European Spine Journal review

“…The paper by Boszczyk [7] describing a transcostovertebral approach of the mid-and high-thoracic spine remedies this, as they achieved 100% success. Your reviewer has always used this approach for biopsy, and with a 2 mm needle achieved a similarly high rate of successful biopsy (Fyfe [11]).…”