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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 101-109

Diaphragm sparing mini open thoracotomy with standalone expandable cage: Observational study of a safe novel approach for stabilising thoracolumbar fractures

1 Department of Neurosurgery, NSCB (Government) Medical College, Superspeciality Hospital, Jabalpur, Madhya Pradesh, India
2 Department of Neurosurgery, Shanti Ved Institute of Medical Sciences, Agra, Uttar Pradesh, India

Date of Submission25-Dec-2021
Date of Acceptance02-Feb-2022
Date of Web Publication31-May-2022

Correspondence Address:
Neeraj Basantani
C-303, Kalyani Heights, 100 Feet Road, Dayalbagh, Agra - 282 005, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joss.joss_39_21

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Objective: An ideal surgical procedure to any vertebral fracture with cord compression produces maximum decompression, without producing additional deficits, achieve fixation by fusion of minimum number of motion segments and maintain the corrected kyphosis without any long-term deterioration. Although conventional posterior approach provides three column fixation, it invariably devitalizes the strong paraspinal muscles and posterior ligamentous complex of the involved vertebra and the adjacent segments necessary for maintaining erect posture. The lateral approach too, damages the strongest portion of the vertebra, the pedicle and sometimes the diaphragm has to be cut open and re-sutured. Conventional anterior approaches are mainly used either as a part of combined approach where in, there is extensive destruction of anterior longitudinal ligament and crus of the diaphragm and have the limitation that they cannot address the T11 and T12 fractures without cutting open the diaphragm. The anterior approach is not usually attempted as it is not a familiar approach to the neurosurgeon and literature reports increased morbidity. The main aim of this study is to encourage the reader to employ a new anterior approach toward thoracolumbar fracture management.
Materials and Methods: The chief author has devised a novel, safe, mini open, diaphragm sparing approach to address all these issues, exploring a corridor between medial margin of psoas and left crus of the diaphragm which is sufficient enough for good decompression of the cord and that even a standalone broad foot plated expandable cage for stabilization is effective in correction of kyphosis without posterior supplementation or potential respiratory complications.
Results: All 37 operated patients recovered well and their kyphotic angles were maintained on follow up. All patients improved neurologically without any respiratory complications potentially associated with thoracotomy.
Conclusion: This prospective study proved that kyphotic corrections were better, no subsidence rates observed, and were maintained at 1 year follow-up with this novel approach.

Keywords: Anterior approach, diaphragm sparing, expandable cages, mini open thoracotomy, thoracolumbar fractures

How to cite this article:
Swamy N, Basantani N. Diaphragm sparing mini open thoracotomy with standalone expandable cage: Observational study of a safe novel approach for stabilising thoracolumbar fractures. J Spinal Surg 2022;9:101-9

How to cite this URL:
Swamy N, Basantani N. Diaphragm sparing mini open thoracotomy with standalone expandable cage: Observational study of a safe novel approach for stabilising thoracolumbar fractures. J Spinal Surg [serial online] 2022 [cited 2022 Jul 7];9:101-9. Available from: http://www.jossworld.org/text.asp?2022/9/2/101/346364

  Introduction Top

Biomechanical weakness of thoracolumbar region predisposes it to be most common site (90%) for spine fractures both traumatic and pathological.[1] Various thoracolumbar injury classifications have tried to assess fracture patterns and prognosis objectively. Among these, Denis and Arbeitsgemeinschaft für Osteosynthesefragen classifications were the most commonly used. However, the classification systems are complex and have limited utility in treatment. Vaccaro et al. proposed a new classification, Thoracolumbar Injury Classification and Severity (TLICS) Score which includes the neurologic status in addition to the integrity of the posterior ligamentous complex (PLC). The disrupted PLC has got poor healing ability and generally requires surgical intervention. TLICS helps surgeons in the decision-making process, compared to cumbersome classifications.[2] The literature review suggested that TLICS classification is safe in management strategy given the goals of decompression, mechanical stabilization of fracture, prevention of late deterioration, early mobilization, and rehabilitation.

Conventional posterior and conservative approach have showed late development of instability and implant failure.[1] Anterior approaches is more advantageous as it allows not only adequate decompression but also better correction of sagittal and coronal deformity. However, the presence of diaphragm and the lower rib cage is a serious hindrance. Many anterolateral approaches have been developed to overcome this drawback.

The authors report here an observational study of 37 patients of thoracolumbar junction fractures. All patients were operated by the chief author demonstrating a novel technique “Mini open diaphragm sparing thoracotomy with standalone cage fixation.” This study highlights the advantages of this novel technique over other anterior approaches. Furthermore, the reader will appreciate the minimal morbidity and long-term efficacy of this operation proved in this study.

  Materials and Methods Top

A prospective observational study was conducted on 37 consecutive patients between May 2013 and March 2019. Scores of TLICS of 5 and above were selected for surgical correction. The aim of our study was to determine the effectiveness of author's innovative mini-open diaphragm sparing thoracotomy approach as an alternative to conventional posterior only/lateral only or combined anterior with posterior approaches in spinal cord decompression as well as stabilizing the thoracolumbar fractures without injuring any stabilizing ligament and intervening diaphragm. Institutional ethics committee approval was taken for the study protocol prior to the study. Inclusion criteria were fresh cases of single level traumatic burst fractures of thoracolumbar junction (T11, T12, and L1) and patients who were not willing for surgery initially, who later developed instability subsequently up to 1 year. Exclusion criteria were, pathological fractures, concomitant fractures of the vertebral column, long standing fractures with pseudarthrosis, isolated transverse/spinous process fractures, disabling comorbidities like lung pathology which would interfere with postop assessment of pulmonary function tests. Written informed consent was obtained from all eligible patients who were willing to participate in this prospective study. Detailed history and thorough neurological examination were performed at admission. Impairment assessment was done as per the American Spinal Injury Association (ASIA) score. All the patients were investigated by digital radiograph, Computed Tomography (CT) to characterize the fracture morphology and Magnetic Resonance (MR) imaging to look for status of PLC.

Only patients with a TLICS of 5 or more points underwent surgical treatment. One of the patients with TLICS score of 5 had refused surgery, but subsequently agreed after his kyphotic angle increased from 14° to 21°.

All patients underwent diaphragm sparing mini open-thoracotomy, corpectomy, in right lateral decubitus position. Stabilization was done using wide end plated expandable titanium cage (Globus screw jack expandable cage) and screw rod construct. Patients were mobilized on the same postop evening as per their neurological status. Bedside portable X-ray was done in the postop evening to confirm implants position. Chest physiotherapy using incentive spirometer was started as early as possible. Intravenous antibiotics were administered till drains were removed. Chest tube was removed first, as per the standard guidelines. Peri-construct drain was removed later once output became <20 ml/day. Visual analog scale (VAS) score for postoperative pain assessment was documented from postoperative day (POD) to 10 days. Intravenous analgesics were given till VAS score became 5 or less and then switched over to oral analgesics which were stopped when VAS score became 2 or less. Bed side assessment of pulmonary function test was done on 3rd POD using a portable spirometer. Diaphragmatic movement was assessed by Ultrasonography (USG) on 7th POD. Mechanical spirometric study was done on 12th POD in the pulmonary laboratory and fluoroscopic assessment was done to measure the movements of domes of diaphragm. Patients were subjected to CT scan a day before discharge and patients were discharged on 14th postoperative day.

The first follow-up was done after 15th day of discharge. Then monthly for next 3 months, quarterly for a year, half yearly for 2 years, and yearly thereafter. Parameters of instability, subsidence status of the instrumentation were measured on all occasions by digital X-ray/CT.

Details of operative technique

The patient was placed in right lateral decubitus position. Localization of fractured vertebra along with adjacent vertebrae (both caudal and rostral) was done by C arm [Figure 1]a. After localizing the anterior, posterior, and superoinferior margin of fractured vertebra with caudal and cranial adjacent vertebrae, diagonal was drawn on the skin from the posterosuperior end of the rectangle formed between the posterior superior margins of rostral vertebra to anteroinferior margin of the caudal vertebra as depicted [Figure 1]b, roughly measuring between 5 and 7 cm [Figure 1]c and [Figure 1]d. Fibers of external oblique aponeurosis were cut along the line of incision (when required).
Figure 1: (a) Lateral view of fractured vertebra on fluoroscopy intraoperatively. (b) First K-wire is placed along anterior border of normal vertebral bodies adjacent to fractured vertebra . Second and Third K-wires are placed along the superior and inferior endplates of normal adjacent vertebrae. Fourth K-wire is placed parallel to the first K-wire to complete the rectangle as shown. (c) Marking of skin incision form the antero -inferior point to the postero-superior point of the rectangle formed by the K-wires. (d) Mini thoracotomy incision measuring approximately 7 cm

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Underlying rib and the rib above were excised subperiosteally with generous nibbling on the posterior aspect of rib, so that good amount of rib is available for placing the bone fragments over the screw rod construct. Retropleural space was opened up by cutting, both 11th rib and 12th rib after separating the pleura from the lateral end of ribs. The costal attachment of diaphragm to the rib along with lateral margin of pleural cavity was pushed anteriorly. The retroperitoneal fat in the inferior aspect of operating field along with Gerota's fascia was pushed anteriorly to clearly visualize the Psoas muscle. Retraction maintained by long bladed modified Kelly's retractor [Figure 2]. Upper and lower end of the fractured vertebra were reconfirmed by C-arm. The left crus of the diaphragm were identified as a distinct band anterior to the Psoas blending with anterior longitudinal ligament (ALL). A plane was developed between left crus of the diaphragm and medial margin of psoas. The bone was chiseled in this space. The attachment of psoas to lateral aspect of the vertebral body was dissected out with cautery and pushed posteriorly. A bony trough was created in fractured vertebra keeping a thin rim of bone adjacent to ALL and decompression of the spinal cord was performed in this corridor, till dura is bare [Figure 3]. Trough was created in the bone retaining the thin anterior margin with attachments of left crus of the diaphragm along with ALL. Surgical anatomy diagram is shown in [Figure 4].
Figure 2: Modified Kelly's retractor (long bladed)

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Figure 3: Bony trough created between anterior longitudinal ligament and left crux of diaphragm

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Figure 4: Schematic diagram of expandable CAGE in the safe corridor between left crus of diaphragm and psoas (lateral view)

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Wide footed expandable cage filled with meshed bone [Figure 5] was placed in the bony trough and anterior column was reconstructed. After inserting double hole bone staplers on the lateral side of vertebrae, the screws and rod construct was made between upper and lower vertebra so as to prevent the displacement of cage. Crushed cancellous ribs along with the bone obtained from the corpectomy were used to fill all the space around the cage and construct. If the pleura was found breached, it was stitched back and a chest drain was inserted. A peri-construct drain was also placed at the lower end of the construct in all cases.
Figure 5: Expandable cage with wide footed endplate having lordotic angle (screw jack mechanism made by Globus)

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Fracture T11 was entirely approached by thoracotomy only and posterior parietal pleura was incised at the rib head region and corpectomy was performed in the similar fashion described sparing the pedicle. Three patients had small sharp piece of the bone penetrating the dura. The penetrating bone fragment was removed and dura was covered with surgicel.

  Results Top

Totally 37 patients were included in the study. Twenty-nine patients were male and 8 were female. Youngest patient was a female of 14 years and oldest male of 67 years. Majority of the cases were below 50 years [Table 1].
Table 1: Mean values of key parameters

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The mean follow-up period was 4.8 years. All the parameters like VAS score, requirement of analgesics, antibiotics, correction of kyphosis, spirometer readings, and diaphragmatic movement were charted on excel sheet. T11 (n = 7) was operated via trans-pleural approach. Rest fractures (n = 30) were operated by retro-celomic and retro-pleural approach. The mean operative time was 178 min. Operation time varied because of variabilities in C-arm functioning and imaging quality and each time the Fenochietto's self-retaining retractors had to be removed and re adjusted. Mean operative blood loss was 377 ml [Table 1].

Eleven cases were in ASIA E, 14 cases in ASIA, 7 in ASIA C and 5 in ASIA B. All 14 patients who were in ASIA E were able to walk on the postoperative evening with support and patients who were in ASIA D and C were could be mobilized on the wheel chair. The X-ray done on the POD showed no displacement of the construct in any case [Table 2].
Table 2: Case distribution based on level of injury and ASIA score

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The VAS score recorded on 3, 5, 10th [Table 3] was taken into consideration, though it was recorded every-day on the bed side chart.
Table 3: VAS score profile in the post-operative period

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A Wilcoxon signed-rank test was run comparing the VAS scores on 3rd and 7th POD. The median VAS score on day 3 was 7 and median VAS score on day 10 was 2, thus indicating that there was statistically significant reduction in the postoperative pain, proving the minimal morbidity of this novel procedure [Table 4].
Table 4: Visual Analogue Scale score

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Mean values of the bedside spirometry done on 3rd POD were 80.49%–86.23% and mechanical spirometry was done on 12th day [Table 5].
Table 5: Mechanical spirometry values (>80% is normal)

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The Forced expiratory volume (FEV) 1/Forced Vital Capacity (FVC) values obtained Preop, at POD 3 and at POD 14 are shown as in [Table 6]. Analysis of variance (ANOVA) test applied on these values showed that there was no statistically significant difference in the preoperative or postoperative FEV1/FVC values, thus proving minimal respiratory system morbidity from this procedure [Figure 6].
Table 6: Forced expiratory volume in 1 s/forced vital capacity

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Figure 6: Analysis of Variance test on Forced expiratory volume 1/Forced Vital Capacity values showing no significant change in preop and postop values

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The mean value of diaphragmatic movements on USG was 5.95 cm, range being (3–9 cm) [Table 1]. Mean preoperative Cobb's angle was 23.19° ± 5.86°. Immediate postoperative was 8.57 ± 2.48, at 6 months was 9.14 ± 2.59 and at 1 year was 9.51 ± 2.78. ANOVA test proved that there was a statistically significant decrease in Cobb's angle at immediate period compared to preoperative (P < 0.001). Furthermore, there was no significant deterioration in mean Cobb's angle at 6 months and 1 year compared to previous visit value after the initial settlement as shown by the Bonferroni's post hoc test. No subsidence was found in any case [Table 7], [Table 8] and [Figure 7].
Table 7: Cobb's angle

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Table 8: Post hoc test (Bonferroni*)

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Figure 7: Analysis of Variance test on Cobb's Angle showing statistically significant corrections in postop values

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The degree of bony decompression of cord was 100% on CT at all three levels. A typical example of a patient with LV1 fracture in which kyphosis was corrected with spinal cord clearance is shown [Figure 8].
Figure 8: Preop and postop images of kyphosis correction in LV1 vertebra of the same patient

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In 5 cases, optimal correction of kyphotic angle less than or equal to 11 degrees could not obtained because of the technical difficulties. In 3 cases, the cage (screw jack mechanism) stopped expanding after certain rotations and in 2 cases shaft of the rotating jack was not getting engaged in the serrations of the screw jack and further rotation could not be obtained. Second limitation was that the C-arm was unable to give panoramic view of two or three vertebra above and below the construct so as to correctly judge the centering and correction of kyphotic angle and C-arm did not have the inbuilt parameters to measure the cobb's angle.

All the patients underwent Clean Intermittent Catheterization and patients in ASIA E and D had recovered by 6 months and postvoid residual volume was <20 ml. Patients in ASIA C and B took longer time but by the end of 2 years were able to void satisfactorily with adoptive measures. Erectile impotency was not assessed in the study [Table 9].
Table 9: Improvement of neurological functions

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  Discussion Top

Thoracolumbar region is more prone for injuries being a transition zone where curvature of thorax changes from kyphosis to lordosis, and it is a junction of mobile segment with immobile spine. The cord is bulkier in this region thus prone for damage.

Lots of controversies exist about the ideal approach for decompression of the cord and spinal column stabilization. Both anterior and posterior approaches have merits and demerits. Lateral approaches also pose additional anatomical dilemma by the presence of lower rib cage and the diaphragm.

The goal of surgical management in thoracolumbar fracture is, optimal decompression of the spinal canal as well as neural elements to facilitate neurologic recovery, restore and maintain the vertebral body height for optimal coronal and sagittal alignments, generate a rigid construction to allow pain free early ambulation and rehabilitation while limiting the number of motion segments fused.[3]

Thoracolumbar fracture has mainly been dealt with the traditional posterior approach along with short-segment transpedicular instrumentation so as to obtain stable fixation with the least instrumented centrums but it falls short in achieving the objectives of complete decompression. Even long segment fixation obviates the principles of fracture treatment as it immobilizes two or more healthy motion segments on either end of the fracture. Substantial cord handling does occur as posterior surface of the vertebral body is often fused with the anterior dura. It also fails to maintain the sagittal plane correction.[4],[5],[6] Though the conventional posterior approach can correct the kyphotic angle and restore the alignment, there is great amount of difficulty in achieving complete removal of the in-driven bony fragments especially when it is a butterfly/large penetrating bony fragment, without significant handling of the cord. Posterior fixation usually requires longer segment fixation of adjacent motion segments. The exiting roots and pedicle are at stake when cage is introduced form behind. In addition, long term results of pedicle fixation have shown high rate of implant failure and loss of kyphotic correction in the postoperative period.

Disadvantages of posterior only approach includes instrumentation failure, pseudarthrosis, infection, risks of Spinal Cord Injury, inadequate neurological decompression, inability to remove the penetrating bone fragment, insufficient correction of kyphosis and occasionally need for late instrumentation removal.[7] High rate of failure associated with posterior approach cannot be decreased by additional transpedicular intracorporeal grafting.[8],[9]

As compression is from anterior side, logically it would call for decompression of the cord by an anterior approach and correction of kyphosis by a strut bone graft/cage instead of pivoting it from posterior approach. Conventional anterior approaches are usually not performed because of fear of morbidity, and unfamiliarity of the procedure as well as difficulty in negotiating the intervening diaphragm. Even in a combined approach, where corpectomy is done by lateral approach and is supplemented with posterior fixation long-time failures are reported with the disadvantages of two incisions either in same sitting or in subsequent sittings. Combined approaches are more likely at risk of dislodgement of graft/implant as implant is placed by lateral approach then patient is turned and pedicle screws are placed in a prone position which are then pivoted to get ideal kyphotic correction and lordosis.

Since the main goal of surgery is decompression of the spinal cord, anterior approach should be the technique of choice and as it provides direct decompression of the neural structures with appropriate reconstruction of the anterior column. Supplementation of vertebral body with a device which can bear the load sharing with rigid stabilization should often be the method of choice. Anterior surgery is considered to be the most effective way of achieving all these goals.[9]

Anterior approach is not routinely practiced because of excessive blood loss, damage to the abdominal wall musculature, permanent injuries in diaphragm, possible injuries to peritoneum and vascular structures and incisional pain.[10]

To circumvent disadvantages of posterior approaches and to incorporate the advantages of anterior approaches, mini-open approaches have been performed and have been found to be safe and effective in the treatment of several spinal conditions including vertebral fractures, with minimum blood loss, muscle splitting, and pain.[11],[12],[13],[14],[15] Many types of mini-open anterior approaches for lumbar corpectomy supplemented with percutaneous pedicle screws for dorsal stabilization have been reported for the treatment of an acute lumbar burst fracture, like true lateral Extreme lateral interbody fusion, Anterior Lumbar Interbody Fusion, Lateral Lumbar Interbody Fusion (open/endoscopic).[14],[15],[16],[17],[18],[19],[20],[21]

The chief author adopted the mini open, diaphragm sparing thoracotomy approach to achieve all these goals as well as to overcome disadvantages of conventional/combined approaches. This study was an observational study on 37 consecutive homogeneous cohorts. It revealed that all the desired goals could be achieved as a one stage procedure with least damage to supporting elements. This approach does not alter the functions of diaphragm as the procedure adopted by author did not compromise the moorings of diaphragm or the anterior abdominal wall muscles as it was most often muscle splitting except cutting the posterior superior portion of the external oblique where it intersects with peripheral attachment of diaphragm. Effective postoperative physiotherapy could be employed right from the first POD.

Operative time has varied from 2.5 to 5.5 h. Blood loss without primary posterior stabilization surgery, has been in the ranges from 0.6 to 2.5 L (but can exceed 5 L). The accident-to-surgery interval impacts bleeding, in very early surgery (before 24–48 h) fracture bleeding is hard to control, then when surgery is performed at a later interval.[22]

Clearance of spinal canal is maximum in anterior approaches. Even though the spinal canal remodeling is known to occur regardless of operative or nonoperative treatment, the “surgical clearance” can improve the neurological outcome partially when there is obvious compression over the cord.[23],[24] Several studies have found that the restoration of normal canal dimensions may be associated with the recovery of neurological function for patients with partial deficits. In other words, reduction of deformity and retro-pulsed bone fragment in the canal may play an important role in obtaining optimal surgical outcome.[25]

The spinal canal imaging for clearance following corpectomy have shown that CT assessed it at around (100) % and the results of MR imaging are not in comparison with CT as MR imaging does shows the remnants of ligaments and other soft tissue. Mean preoperative canal stenosis was close to 50% in almost all series.[25],[26] Goutallier studied compression by myelography at 10 days postoperatively and demonstrated that CT considerably underestimates residual compression, which he estimated at a mean 32%. The persistence of discal and ligamentous fragments and intracanal hematoma logically accounts for these differences.[25],[26]

Deformity consolidation rates range from 85% to 100% (Braidwell grade 5), with a mean 10°–20° reduction in initial kyphosis. Secondary correction loss has been found to be <5°.[26],[27],[28] Secondary correction loss prevention after the kyphotic correction has not been satisfactory after using nonexpandable cages. Lumbar plexus is at risk of injury while performing the trans-psoas mini-open approach as it is subperiosteally elevated from transverse process and lateral surface of the body of lumbar vertebra.[29] The incidence of better reconstruction of anterior column and minimal incidence of secondary kyphosis has been well documented in many studies. Studies have also found 0%–13% incidence of subsidence after using expandable cage with wide foot plate. Rectangular end plated cages have fared better than the circular end plates and wide foot print endplates have definite advantage over circular narrow expandable cages.[27],[28],[30],[31],[32]

The prevention of injury to endplate and use of a large end plated expandable cage has definite role in preventing subsidence of the cage as revealed in other studies. Wide end plated expandable with inbuilt kyphotic angle cage had distinct advantage in reconstructing the anterior column, and in restoration of required lordosis, both in sagittal and coronal plane. In this project too, the care was taken not to injure the end plates during operation and incidence of subsidence was nil in this study.

Pulmonary complications (atelectasis, pneumothorax, hemothorax, or pneumopathy) occur in 5%–15% of cases. Their frequency and severity should be reduced by meticulous closure and lung re-expansion. Effective pulmonary drainage in case of a trans-pleural approach or of leakage during infra-diaphragmatic approach does reduce pulmonary complications to a great extent. Video-assisted techniques seem to be effective in limiting hemorrhage, but do not remove the risk of pulmonary atelectasis.[33],[34],[35] Inadvertent breach of pleural cavity did not per SE contribute or add to the morbidity in this study, as reported in the literature. It was noted that the pulmonary function tests done were near normal compared to the peer group.

Bladder impairment may recover completely or partially depending on the severity of injury, timing of surgery and post op rehabilitation.[36],[37]

The procedure was safe in itself as the screws could be inserted bi-cortical without the risk of damaging any structure as the screws occupy the lateral portion of the vertebral body (anterior to spinal cord posterior to great vessels). The incidence of peritoneal injury or injury to vascular structures was not noticed in the study though they were carefully dissected off, considering the possibilities mentioned in the literature, with careful mobilization of Gerota's fascia and retroperitoneal organs along with peritoneum. No other complications mentioned in the literature were observed in the study.

Alexander et al. reported satisfactory response in terms of physical mental outcomes in mini open thoracotomy, as they had minimal pain and aesthetically accepting the scar after anterior approach compared to posterior and with the use of wide end plated expandable cage for treatment of single thoracolumbar segment vertebral fracture anterior report results have been found to be comparable with combined approaches.[26],[38]

However, the follow-up period is 4–8 years and a long term follow-up over a period of 10 years would throw more light upon whether this procedure can be an effective standard alternative procedure to the already established procedures. Furthermore, double-blinded randomized control trials are required to establish this novel technique as a one stop solution to majority of thoracolumbar junction fractures. More prospective studies are required to establish this as a standard approach in cases of burst fracture.

  Conclusion Top

The decompression of the cord is maximum by anterior approach as anterior corpectomy is a direct approach. Expandable cage restores the pathology to near-normal anatomy, with effective neuromeningeal decompression. The use of diaphragm sparing technique and safe window between the crux of the diaphragm minimizes all the disadvantages of traditional anterior or posterior/combined approach. Wide footed expandable endplates with an inbuilt kyphotic angle helps in restoration of correction of kyphosis and alignment without posterior supplementation. Loss of correction in the postoperative period is negligible hence biomechanically it is more stable than other cage fixations. Hence, the author's novel technique can effectively be used as standalone procedure without posterior supplementation. However, the study cohort is small and a larger study for a longer period is required to state that this new technique is better than the prevailing techniques.


All patients included in this study signed a consent form which was well informed to them in their own language.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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

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


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