Overview and Indications
Anterior lumbar corpectomy and fusion is a special type of spinal decompression and fusion procedure that utilizes an anterolateral (flank or side of the body incision – through the abdominal region) approach to remove bone and tissue that is causing compression of the spinal cord and nerves. However, in order to do so generally involves removing nearly the entire vertebral body and disc, which must be replaced with a piece of bone graft and mended (fused) together to maintain stability. A small metal plate with screws may also be used to add additional stability.
This type of surgery is most often performed for patients with a spinal fracture, tumor, or infection that is causing compression of the spinal nerves. Anterior corpectomy and fusion can also be performed in the thoracic (chest) region or thoracolumbar (lower chest/mid-back) region, depending on where the neurologic compression is located. The primary advantage of performing an anterolateral approach over a posterior surgery (through a back incision) is that there is a much wider exposure of the bone, disc, and lesion causing neurologic compression, which can be removed without retraction of the spinal cord and neurologic structures (and therefore, a decreased risk of neurologic injury and increased chance of improvement).
Patients with a severe spinal problem or instability may also require a posterior spinal fusion with metal instrumentation in addition to an anterior corpectomy and fusion. If necessary, the second surgery is typically performed in a staged fashion 1-4 days after the first anterior surgery.
The surgery is performed utilizing general anesthesia. A breathing tube (endotracheal tube) is placed and the patient breathes with the assistance of a ventilator during the surgery. Preoperative intravenous antibiotics are given. Patients are positioned in the lateral (lying on the side) position, generally using a special, flexible operating table. The surgical region (chest and/or abdominal area) is cleansed with a special cleaning solution. Sterile drapes are placed, and the surgical team wears sterile surgical attire such as gowns and gloves to maintain a bacteria-free environment.
A 5-10 inch (depending on the number of spinal levels to be fused) oblique incision is made over the involved spinal levels. The intestine sac and large blood vessels are identified, and carefully moved to the side and protected throughout the surgery. The involved vertebral levels are confirmed using an x-ray, and the bone, disc, and/or compressive lesion(s) are removed using special biting and grasping instruments (such as a pituitary rongeur, kerrison rongeur, and curettes). Special distractor instruments are used to restore the normal height of the open space, as well as to determine the appropriate size spacer to be placed. A bone spacer (metal or plastic spacers may also be used) is then carefully placed in the space. Regular or fluoroscopic x-rays are taken to confirm that the spacer is in the correct position. Metal screws, plates, and/or rods are often placed to add stability to the spine and improve the rate of bone healing (fusion).
If the thoracic or thoracolumbar spine (chest area or mid-back) is involved, a portion of rib is often removed to be used as bone graft as well as increase the opening for the surgery. The lung is deflated temporarily while the bone, disc, and compressive lesion(s) are removed. Afterwards, the lung is re-inflated and a special tube (chest tube) is placed in the lung and kept there a few days so that the lung stays fully inflated and excess fluid does not accumulate.
After the surgery is completed, the wound area is usually washed out with sterile water containing antibiotics. The deep fascial layer and subcutaneous layers are closed with strong sutures. The skin can usually be closed using special surgical glue or small sutures, leaving a thin scar. A small bandage is usually placed, and is changed every day or two after the surgery.
The total surgery time is approximately 3 to 4 hours, depending on the severity of the spinal problem and number of spinal levels involved.
Most patients are usually able to go home 4-7 days after surgery. Patients will typically stay longer, approximately 6-10 days, if a posterior spinal surgery is also performed. Before patients go home, physical therapists and occupational therapists work with patients and instruct them on proper techniques of getting in and out of bed and walking independently. Patients are instructed to avoid bending at the waist, lifting (more than five pounds), and twisting in the early postoperative period (first 2-4 weeks) to avoid a strain injury. Patients can gradually begin to bend, twist, and lift after 4-6 weeks as the pain subsides and the back muscles get stronger.
Patients are generally not required to wear a back brace after surgery. Occasionally, some patients may be issued a soft or rigid lumbar corset that can provide additional thoracic and/or lumbar support in the postoperative period, if necessary.
The wound area should remain covered with a gauze bandage secured in place with tape. The area should be kept clean and dry. The bandage should generally be changed every 1-2 days, especially after showering.
Patients can shower immediately after surgery, but should keep the incision area covered with a bandage and tape, and try to avoid the water from water hitting directly over the surgical area. After the shower, patients should change the bandage, and dry off the surgical area. The dressing should otherwise be changed every 2-3 days when at home. Patients should not take a bath until the wound has completely healed, which is usually around 2 weeks after surgery.
Patients may begin driving when the pain has decreased to a mild level, which usually is between 2-6 weeks after surgery. Patients should not drive while taking pain medicines (narcotics). When driving for the first time after surgery, patients should make it a short drive only and have someone come with them, in case the pain flares up and they need help driving back home. After patients feel comfortable with a short drive, they can begin driving longer distances alone.
Return to Work and Sports
Patients may return to light work duties as early as 6 weeks after surgery, depending on when the surgical pain has subsided. Patients may return to moderate level work and light recreational sports as early as 3-4 months after surgery, if the bone has healed, the surgical pain has subsided, and the back strength has returned appropriately with physical therapy. Patients who have undergone an anterior thoracic or lumbar corpectomy and fusion generally should not be permitted to return to heavy lifting and sports activities.
Doctor’s Visits and Follow-Up
Patients will return for a follow-up visit to see the doctor approximately 12-14 days after surgery. The incision will be inspected. There may or may not be sutures to be removed. Medications will be refilled if necessary. Patients will usually return to see Dr. Spoonamore every 4-6 weeks thereafter, and an x-ray will be taken to confirm the fusion area is stable and healing appropriately. If necessary, home physical therapy may be prescribed to improve a patient’s walking ability. At 8-12 weeks after surgery, patients will be given a prescription to begin physical therapy for gentle back exercises.
Results and Outcome Studies
The results of anterior thoracic/lumbar corpectomy and fusion surgery are generally good and successful. However, the risks are higher than many other types of spinal surgery because patients who require this type of surgery often have a severe spinal condition (tumor, infection, etc.). In addition, patients are frequently older and have other significant medical problems. A number of research studies in medical journals demonstrate greater than 70% good or excellent results from anterior thoracic/lumbar corpectomy and fusion surgery for various spinal conditions. Most patients are noted to have significant improvement of their back pain and ability to walk and function after surgical intervention. Patients with a preoperative spinal cord injury or neurologic deficit may not improve following surgery, however, a thorough anterior decompression and stabilization generally provides the best chance at neurologic recovery (if there is a large anterior compressive lesion) as opposed to posterior surgery or nonoperative treatment.
An HS, Lim TH, You JW, et al. Biomechanical evaluation of anterior thoracolumbar spinal instrumentation. Spine 1995;20:1979-83.
Been HD. Anterior decompression and stabilization of thoracolumbar burst fractures by the use of the Slot-Zielke device. Spine 1991;16:70-7.
Bohlman HH, Freehafer A, Dejak J. Late anterior decompression of spinal cord injuries. J Bone Joint Surg Am 1975;57A:1025.
Bradford DS, McBride GG. Surgical management of thoracolumbar spine fractures with incomplete neurologic deficits. Clin Orthop 1987;218:201-16.
Dimar JR II, Wilde PH, Glassman SD, et al. Thoracolumbar burst fractures treated with combined anterior and posterior surgery. Am J Orthop 1996;25:159-65.
Dunn HK. Anterior stabilization of thoracolumbar injuries. Clin Orthop 1984;189:116-24.
Emery SE, Chan DP, Woodward HR. Treatment of hematogenous pyogenic vertebral osteomyelitis with anterior debridement and primary bone grafting. Spine. 1989;14:284-291.
Harrington KD. Anterior decompression and stabilization of the spine as a treatment for vertebral collapse and spinal cord compression from metastatic malignancy. Clin Orthop. 1988;233:177-97.
Harrington KD. Anterior cord decompression and spinal stabilization for patients with metastatic lesions of the spine. J Neurosurg. 1984;61:107-17.
Hodgson AR, Stock FE. Anterior spinal fusion. A preliminary communication on the radical treatment of Pott’s disease and Pott’s paraplegia. Clin Orthop. 1994;300:16-23.
Kaneda K, Abumi K, Fujiya M. Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation. Spine 1984;9:788-95.
Kaneda K, Taneichi H, Abumi K, et al. Anterior decompression and stabilization with the kaneda device for thoracolumbar burst fractures associated with neurologic deficits. J Bone Joint Surg Am 1997;79:69-83.
Kostuik JP. Anterior fixation for burst fractures of the thoracic and lumbar spine with or without neurological involvement. Spine 1988;13:286-93.
Krodel A, Kruger A, Lohscheidt K, Pfahler M, Refior HJ. Anterior debridement, fusion, and extrafocal stabilization in the treatment of osteomyelitis of the spine. J Spinal Disord. 1999;12:17-26
Lewandrowski KU, Hecht, AC, et al. Anterior Spinal Arthrodesis With Structural Cortical Allografts and Instrumentation for Spine Tumor Surgery. Spine 2004;29(10):1150-58.
McAfee PC, Bohlman HH, Yuan HA. Anterior decompression of traumatic thoracolumbar fractures with incomplete neurological deficit using a retroperitoneal approach. J Bone Joint Surg Am 1985;67:89-104.
Meding JB, Stambough JL. Critical analysis of strut grafts in anterior spinal fusions. J Spinal Disord. 1993;6:166-74.
Molinari RW, Bridwell KH, Klepps SJ, et al. Minimum 5-year follow-up of anterior column structural allografts in the thoracic and lumbar spine. Spine. 1999;24:967-72.
Osenbach RK, Hitchon PW, Menezes AH. Diagnosis and management of pyogenic vertebral osteomyelitis in adults. Surg Neurol. 1990;33:266-75.
Safran O, Rand N, Kaplan L, Sagiv S, Floman Y. Sequential or simultaneous, same-day anterior decompression and posterior stabilization in the management of vertebral osteomyelitis of the lumbar spine. Spine. 1998;23:1885-90.
Schnee CL, Ansell V. Selection criteria and outcome of operative approaches for thoracolumbar burst fractures with and without neurological deficit. J Neurosurg 1997;86:48-55.
Shufflebarger HL, Grimm JO, Bui V, Thomson JD. Anterior and posterior spinal fusion. Staged versus same-day surgery. Spine. 1991;16:930-933
Tomita K, Kawahara N, Kobayashi T, et al. Surgical strategy for spinal metastases. Spine. 2001;26:298-306.
Turkmen CS, Ziyal IM, Dalbayrak S. Reconstruction of the thoracal spine with an anterior interbody fixator and methylmethacrylate. Technical note and case report. J Neurosurg. 2002;97:403-4.
Weigel B, Maghsudi M, Neumann C, Kretschmer R, Muller FJ, Nerlich M. Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life. Spine. 1999;24:2240-46.