Prevention of Perisurgical Complications in Anterior Instrumentation of the Thoracolumbar Spine

A number of new spinal instruments have become available for treatment of the anterior thoraco-lumbar spine. The purpose of this paper is to investigate the incidence and prevention of complications in thoraco-lumbar anterior instrumentation. The mean age of the 36 patients examined was 45.4 y.o. They included 10 fractures, 7 cases of inflammation, 8 malignant tumors, 5 cases of scoliosis and 5 cases of disc disease. Surgery was performed at the thoracic level in 10 patients, the thoracolumbar junction in 11, the lumbar region in 9, the lumbosacral level in one, and extensive thoraco-lumbar lesion in 3 patients. The incidence and counter measures for perisurgical complications in the vascular, respiratory, lymphatic, nervous and genitourinary systems as well as instrumentation failure were analyzed. After anterior decompression procedures, grafted bone fragments injured the lung in one and an anteriorly placed instrument obstructed pulmonary expansion in one patient. Bony and instrumental prominence should be covered by parietal pleura or teflon-patch to prevent lung trauma. Serial stay sutures applied to the whole margin of the separated diaphragm were effective, especially in aged patients whose diaphragm was thin. The extrapleural approach was also recommended to prevent pulmonary complications. CSF leakage into the thoracic cage occurred in one case and was treated conservatively. Extensive exposure of the anterior spinal column induced retropleural chylous pooling which required surgical repair. In one case, the segmental artery was insufficiently ligated and needed reexposure of the wound. Severe osteoporosis induced postoperative local kyphosis in two cases. Preservation of bony endplates, use of the largest available vertebral body spacer (with 30×20mm2), and encircling strut bone grafting yielded good postoperative fusion without loss of correction. Anterior instrumentation surgery yielded the advantages of simultaneous direct decompression and stabilization, however, once complications such as those described here occurred, treatment was difficult. Comprehenseive anatomical knowledge is necessary to prevent such complications.