Three-dimensional thoracoscopic vertebral body replacement at the thoracolumbar junction.

OBJECTIVE: The aim is to stabilize the thoracolumbar spine with a thoracoscopically implanted vertebral body replacement (VBR). To improve intraoperative depth perception and orientation, implantation is performed under three-dimensional (3D) thoracoscopic vision. INDICATIONS: Vertebral burst fractures at the thoracolumbar junction (A4 AOSpine classification), pseudarthrosis, and posttraumatic instability with increasing kyphosis. CONTRAINDICATIONS: Severe pulmonary dysfunctions, pulmonary or thoracic infections, previous thoracic surgery, and pulmonary adhesions. SURGICAL TECHNIQUE: The patient is lying in a right lateral decubitus position. Localization of the fractured vertebra. Minimally invasive transthoracic approach. Perform single lung ventilation and insert the 3D thoracoscope two intercostal spaces above the working portal. Utilization of special binocular glasses for 3D vision of the operation field and secure resection of the fractured vertebra. Measurement of the bony defect and insertion of the expandable cage. Control of correct cage position under fluoroscopy. Insertion of a chest tube and inflate the left lung. POSTOPERATIVE MANAGEMENT: Chest × ray Remove chest tube when output is <500 ml/24 h Early mobilization on the ward 6 weeks no weight-bearing >5 kg
RESULTS: Between 2012 and 2017, 12 patients received a VBR under 3D thoracoscopic vision. After a mean follow up of 26 months, no cage dislocation was noticed and all patients recovered from the initial back pain. Complications were notable in two cases (17%) with a small pneumothorax after removal of the chest tube and postoperative pneumonia in one patient (8%). All responded to conservative treatment. Revision surgery was not necessary.