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Corpectomy
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| Corpectomy | |
|---|---|
 | |
| Other names | Vertebrectomy |
| Specialty | Neurosurgery |
| ICD-9-CM | 80.99 |
A corpectomy or vertebrectomy is a surgical procedure that involves removing all or part of the vertebral body (Latin: corpus vertebrae, hence the name corpectomy), usually as a way to decompress the spinal cord and nerves. Corpectomy is often performed in association with some form of discectomy.[1]
When the vertebral body has been removed, the surgeon performs a vertebral fusion. Because a space in the column remains from the surgery, it must be filled using a block of bone taken from the pelvis or one of the leg bones or with a manufactured component such as a cage. This bone graft holds the remaining vertebrae apart. As it heals, the vertebrae grow together and fuse.[1]
References
[edit]- ^ a b "Cervical Corpectomy". UMM.edu. University of Maryland Medical Center. 17 June 2013. Retrieved 13 February 2013.
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Corpectomy
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A corpectomy is a surgical procedure involving the partial or complete removal of a vertebral body, typically along with adjacent intervertebral discs, to decompress the spinal cord and nerve roots compressed by conditions such as degenerative disease, trauma, tumors, or infections.[1][2][3] This approach is most commonly anterior, accessing the spine from the front of the neck or torso, and is particularly prevalent in the cervical spine to address myelopathy or radiculopathy.[1][2]
Indications for corpectomy include severe spinal stenosis from bone spurs, herniated discs, ossification of the posterior longitudinal ligament (OPLL), vertebral fractures, or neoplastic lesions, often after conservative treatments like medications or physical therapy have failed.[1][2][3] The procedure is indicated when structural instability or multilevel pathology necessitates direct access to the vertebral corpus for adequate decompression, with a minimum channel width of 16-18 mm required for effective spinal cord relief.[3] Historically, anterior corpectomy techniques evolved from the 1950s, building on the Smith-Robinson method introduced in 1955, which emphasized safe anterior access and has become the standard for over 90% of such surgeries by the early 2000s due to improved recovery and reduced morbidity.[2]
During the operation, performed under general anesthesia, the surgeon makes an incision to expose the affected vertebra, removes the damaged bone and disc material, and reconstructs the spine using a bone graft, cage implant (such as titanium mesh or nano-hydroxyapatite/polyamide composites), or strut from sources like the iliac crest or fibula, often followed by instrumentation for stability.[1][2][3] Variations include oblique corpectomy for asymmetric compression without fusion or minimally invasive central corpectomy (MICC) to minimize tissue trauma.[2][3] Outcomes are generally favorable, with over 82% of patients discharged within three days, though complications such as dysphagia (5.2%), adjacent segment disease (8.6%), or hardware failure (up to 70% in multilevel cases) can occur, underscoring the need for careful patient selection.[2]
Definition and Anatomy
Definition
A corpectomy is a surgical procedure involving the removal of all or part of a vertebral body, known as the corpus vertebrae, to decompress the spinal cord or nerve roots from compression caused by the bone itself.[1][4] This approach targets structural issues within the vertebra, providing more extensive decompression compared to procedures like discectomy, which primarily address intervertebral disc material or associated bone spurs without excising the vertebral body.[1][5] The term "corpectomy" derives from the Latin word corpus, meaning "body," referring to the vertebral body, and the Greek ektomē, meaning "excision" or "removal."[6] Corpectomies can be classified as partial, involving only a portion of the vertebral body, or total, entailing complete removal of the body along with adjacent disc spaces.[7] They may also be performed at a single level or multiple levels, depending on the extent of compression.[2] Spinal fusion is often performed concurrently with corpectomy to restore stability following the bone removal.[4]Relevant Spinal Anatomy
The vertebral column, or spine, consists of a series of 33 vertebrae divided into cervical, thoracic, lumbar, sacral, and coccygeal regions, providing structural support, protecting the spinal cord, and facilitating movement.[8] A typical vertebra features a robust anterior vertebral body, which serves as the primary weight-bearing component, connected posteriorly to the vertebral arch formed by two short pedicles that project backward from the body, two flat laminae that complete the arch, a midline spinous process for muscle and ligament attachment, and paired transverse processes extending laterally for additional muscular and ligamentous connections.[9] The vertebral body is cylindrical and kidney-shaped in cross-section, covered by hyaline cartilage superiorly and inferiorly to articulate with intervertebral discs, while the arch encloses the spinal canal housing neural elements.[10] Regional variations in vertebral structure adapt to functional demands across the spine. Cervical vertebrae (C1–C7) have smaller, more mobile bodies with uncinate processes forming uncovertebral joints for lateral stability, large triangular vertebral foramina to accommodate the cervical spinal cord, and transverse foramina for vertebral artery passage; notably, C1 (atlas) lacks a body, and C2 (axis) features a dens for rotation.[8] Thoracic vertebrae (T1–T12) exhibit progressively larger heart-shaped bodies with costal facets on the transverse processes and demifacets on the body for rib articulation, supporting the rib cage and limiting excessive flexion.[9] Lumbar vertebrae (L1–L5) possess the largest, thickest bodies and robust pedicles to bear substantial axial loads, with short, sturdy spinous processes oriented horizontally for powerful paraspinal muscle attachments.[10] Adjacent to the vertebrae are critical structures integral to spinal function and stability. Intervertebral discs, fibrocartilaginous cushions between vertebral bodies (except C1–C2 and below S2), consist of a central gel-like nucleus pulposus surrounded by the fibrous annulus fibrosus, absorbing shock and permitting limited motion.[8] The spinal cord, a continuation of the brainstem, resides within the vertebral canal formed by the stacked vertebral arches, extending from the foramen magnum to the conus medullaris at L1–L2 in adults, where it tapers into the cauda equina.[9] Paired spinal nerve roots emerge from the cord via the intervertebral foramina, bounded by pedicles of adjacent vertebrae, to innervate the periphery.[10] The anterior longitudinal ligament spans the anterior vertebral bodies to resist hyperextension, while the posterior longitudinal ligament lines the posterior aspect of the bodies and discs within the canal to prevent hyperflexion and contain disc herniations.[8] Pathophysiological damage to the vertebral body, such as from tumor invasion or fracture, can significantly impair these structures by encroaching on the spinal canal. Metastatic tumors often originate in the richly vascular red marrow of the vertebral body, spreading via Batson's venous plexus and activating osteoclasts to erode bone, leading to pathological collapse that compresses the spinal cord or nerve roots and causes neurological deficits like pain, weakness, or paralysis.[11] Similarly, traumatic or osteoporotic fractures destabilize the body, displacing fragments into the canal and directly impinging on neural elements, exacerbating compression and potentially necessitating decompression procedures like corpectomy to restore space.[12]Indications and Diagnosis
Common Indications
Corpectomy is commonly indicated for degenerative conditions such as multilevel degenerative disc disease (DDD) or spondylosis, particularly when there is significant involvement of the vertebral body and intervertebral discs leading to spinal stenosis, myelopathy, or radiculopathy.[2][13] In these cases, the procedure allows for direct decompression by removing the affected vertebral body, which is essential when the pathology extends beyond the disc space into the bone, causing anterior cord compression.[14] These conditions often involve ossification or osteophyte formation that narrows the spinal canal, and corpectomy is preferred over discectomy alone for multilevel involvement or when kyphotic deformity contributes to neural compromise.[13] Traumatic injuries, including vertebral burst fractures and associated instability, represent another primary indication for corpectomy, where removal of the fractured body facilitates decompression and restoration of spinal alignment.[15][14] Such fractures typically result from high-energy impacts and involve retropulsion of bone fragments into the spinal canal, necessitating corpectomy to achieve neural element decompression when conservative management fails or neurological deficits are present.[16] Severe kyphosis following trauma may also warrant the procedure to correct deformity and prevent further progression.[17] Neoplastic diseases, both primary tumors and metastatic lesions invading the vertebral body, frequently require corpectomy for tumor resection and spinal stabilization, especially in cases of spinal metastases from cancers such as breast or lung.[2][15] The surgery is indicated when the tumor causes significant bone destruction, cord compression, or instability, often after failure of radiotherapy or chemotherapy to control local growth.[2] For instance, metastatic infiltration exceeding 50% of the vertebral body height typically necessitates body removal to achieve separation surgery goals and enable adjuvant therapies.[18] Infectious processes like vertebral osteomyelitis or discitis, often accompanied by abscess formation that erodes the vertebral body, are common indications for corpectomy to enable thorough debridement and drainage.[15] These infections, frequently bacterial in origin, lead to bone destruction and instability, requiring aggressive surgical intervention when antibiotics alone are insufficient.[15] Other indications include ossification of the posterior longitudinal ligament (OPLL), where corpectomy provides multilevel decompression for hill-shaped or extensive ossifications causing myelopathy.[2][13] Additionally, corpectomy may be performed for failed prior surgeries, such as pseudoarthrosis after fusion, or in severe kyphosis unresponsive to less invasive corrections.[19][20] Overall, corpectomy is rationally selected when pathology involves more than 50% of the vertebral body or spans multiple levels, as these scenarios demand comprehensive resection for effective decompression and reconstruction beyond what discectomy or laminectomy can achieve.[2][18] Diagnosis of these conditions typically relies on imaging modalities such as MRI or CT to assess the extent of involvement.[2]Diagnostic Methods
Diagnosis of corpectomy candidacy begins with a comprehensive clinical evaluation, focusing on neurological assessment for myelopathy and associated symptoms. Patients typically undergo a detailed history review, including any prior trauma or malignancy, alongside pain assessment in the neck, shoulders, or extremities. The neurological exam evaluates for signs of upper motor neuron involvement, such as hyperreflexia in the biceps, triceps, patellar, and Achilles reflexes, as well as pathologic reflexes like the Hoffmann sign (finger flexion upon flicking the middle finger) and Babinski response, which indicate corticospinal tract dysfunction.[21] Gait disturbances, often presenting as an ataxic or spastic wide-based walk, are common and can be assessed via tandem gait testing, occurring in approximately 72% of myelopathy cases.[21] Imaging modalities are essential for visualizing the extent of spinal cord compression and structural abnormalities that may necessitate corpectomy, particularly in conditions like degenerative disease, trauma, or tumors. Magnetic resonance imaging (MRI) is the primary tool, providing detailed soft tissue evaluation of cord compression, signal changes indicative of myelopathy, and tumor extent, with high sensitivity for intradural and extradural pathology.[2] Computed tomography (CT) scans excel in assessing bony anatomy, including vertebral fractures, ossification of the posterior longitudinal ligament, and alignment deformities.[2] Plain X-rays, including lateral views, are routinely used to evaluate overall spinal alignment, instability, and initial screening for degenerative changes or fractures.[2] Advanced diagnostic tests are employed when standard imaging is inconclusive or contraindicated, or to confirm specific etiologies. Myelography, often combined with CT (CT myelogram), is utilized if MRI is not feasible due to contraindications like pacemakers, offering visualization of spinal cord and nerve root compression via contrast injection into the thecal sac.[2] Electromyography (EMG) and nerve conduction studies assess for radiculopathy by measuring electrical activity in muscles and nerves, identifying denervation patterns in affected roots, particularly useful in distinguishing radicular pain from myelopathy.[22] For suspected tumors or infections, biopsy—typically percutaneous CT-guided or open—is performed to obtain tissue samples for histopathological analysis, confirming malignancy or infectious agents prior to resection.[2] Preoperative planning integrates these diagnostics to determine the surgical extent and approach for corpectomy. Sagittal reconstructions from MRI or CT scans are critical for assessing the number of vertebral levels requiring resection and evaluating kyphotic deformity or cord involvement.[2] Instability is graded using dynamic X-rays with flexion-extension views, which detect abnormal motion (e.g., >3.5 mm translation or >11 degrees angulation in the cervical spine), though supine comparisons may enhance sensitivity for subtle subluxations.[23]Surgical Techniques
Preoperative Evaluation
Preoperative evaluation for corpectomy involves a multidisciplinary assessment to optimize patient outcomes and minimize perioperative risks, including thorough medical history review, physical examination, and targeted testing tailored to the patient's comorbidities and the spinal level involved.[24] This process ensures the patient is suitable for surgery after conservative treatments have failed, confirming indications such as severe spinal cord compression or instability.[25] Medical optimization is a cornerstone, beginning with cardiac and pulmonary clearance to identify and mitigate risks of perioperative adverse events. For cardiac evaluation, guidelines recommend a focused history, physical exam, and risk stratification using tools like the Revised Cardiac Risk Index, with further testing such as echocardiography indicated for patients with active cardiac conditions or poor functional capacity undergoing intermediate- to high-risk procedures like corpectomy.[26] Pulmonary assessment includes screening for obstructive or restrictive lung disease via history, spirometry if indicated, and optimization of conditions like chronic obstructive pulmonary disease to reduce postoperative respiratory complications.[27] Nutritional status is evaluated through serum albumin levels, as hypoalbuminemia (<3.25 g/dL) is associated with increased perioperative adverse events, longer hospital length of stay, and higher 30-day reoperation rates following vertebral corpectomy for metastatic disease.[28] Smoking cessation is strongly advised at least 4-8 weeks preoperatively, as continued smoking independently elevates risks of pseudarthrosis, infection, and reoperation in spine fusion procedures accompanying corpectomy.[29] Neurological assessment establishes a baseline for postoperative comparison, documenting motor strength, sensory function, reflexes, gait, and bowel/bladder status to quantify deficits from myelopathy or radiculopathy.[30] This includes standardized scales like the modified Japanese Orthopaedic Association score for cervical myelopathy, helping to correlate symptoms with imaging findings and guide expectations for neurological recovery.[25] Imaging review is critical for surgical planning, utilizing MRI to assess spinal cord compression and soft tissue pathology, CT to evaluate bony anatomy and confirm the vertebral level(s) for resection, and flexion-extension X-rays to detect instability influencing fusion extent.[25] These studies enable precise determination of the corpectomy levels and adjacent segments requiring instrumentation, reducing intraoperative surprises.[30] Patient counseling encompasses informed consent discussions on procedure-specific risks such as infection (approximately 1-2%), transient dysphagia (5-25% in multilevel cervical cases, resolving in most by 6-12 months), neurological worsening, and hardware failure, alongside alternatives like decompressive laminectomy and realistic outcomes including pain relief and functional improvement in most cases.[25][31] This shared decision-making process addresses patient concerns and aligns expectations with evidence-based prognosis. Anesthesia considerations are planned collaboratively, with special attention to airway management in cervical corpectomy due to potential difficult intubation from neck pathology or positioning; fiberoptic techniques may be prepared.[32] For all corpectomies, general anesthesia is standard, and venous thromboembolism (VTE) prophylaxis is strategized preoperatively, often combining mechanical methods (e.g., intermittent pneumatic compression) with pharmacologic agents like low-molecular-weight heparin for high-risk patients to prevent deep vein thrombosis rates of 1-10% in spine surgery.[33]Operative Procedure
The operative procedure for corpectomy primarily involves an anterior approach to access the vertebral body for decompression, though posterior or lateral approaches are utilized in select cases where anterior access is contraindicated, such as in patients with prior anterior surgery or certain thoracolumbar pathologies.[34][35] Intraoperative imaging, such as fluoroscopy, guides level confirmation to ensure precise localization.[30] In the cervical region, the anterior approach follows the Smith-Robinson technique, with the patient positioned supine and the neck extended. A transverse incision is made along a skin crease in the anterior neck, typically at the level of the pathology, followed by dissection through the platysma and retraction of the sternocleidomastoid and carotid sheath laterally while protecting the recurrent laryngeal nerve medially.[30][36] Exposure of the vertebral bodies is achieved by mobilizing the esophagus and trachea medially, with longus colli muscles elevated to reveal the anterior spine; adjacent intervertebral discs are removed using pituitary rongeurs and curettes to define the resection margins.[30] The targeted vertebral body is then resected subtotal or totally using a high-speed burr to thin the posterior cortex to an eggshell thickness, followed by removal with Leksell rongeurs, osteotomes, and curettes, limited laterally by the uncinate processes to avoid the vertebral artery. Endoscopic variants, such as endoscopic anterior cervical corpectomy and fusion (E-ACCF), are emerging for select cases like infections, offering reduced tissue trauma. Robotic assistance is also being explored for precision in multi-level resections.[30][37] Decompression proceeds by excising the posterior longitudinal ligament if necessary and clearing retropulsed fragments with Kerrison punches under direct visualization of the dural sac, achieving spinal cord relief while maintaining hemostasis via bipolar cautery and cottonoid patties.[30] For thoracic corpectomies, an anterior transthoracic approach is most common, with the patient in a lateral decubitus position and single-lung ventilation to deflate the ipsilateral lung. A posterolateral thoracotomy incision is made over the rib corresponding to the pathology level, with rib resection if needed for exposure, followed by entry into the pleural cavity and mobilization of the lung anteriorly.[38][39] Thoracoscopic variants use multiple small ports for minimally invasive access. Adjacent discs are excised with rongeurs and curettes, and the vertebral body is removed pedicle-to-pedicle using a high-speed drill, ultrasonic aspirator, or curettes, preserving the anterior longitudinal ligament where possible.[38] Decompression involves resecting the posterior vertebral wall and posterior longitudinal ligament to visualize and clear the dural sac of compressive elements, with hemostasis controlled by bipolar cautery and hemostatic agents.[38] In multi-level cases, subtotal spondylectomy may be performed to minimize morbidity, particularly above T11 where aortic or vascular structures influence side selection.[38] Lumbar corpectomies employ a retroperitoneal anterior approach, positioning the patient supine or laterally with a transverse or oblique incision in the flank to access the psoas muscle and peritoneum. The retroperitoneal space is developed by blunt dissection, retracting the peritoneum medially and mobilizing the great vessels (aorta/IVC) as needed for left- or right-sided exposure.[40][41] Adjacent discs are removed with rongeurs, followed by vertebral body resection using a burr and curettes to achieve complete corpectomy, often in a piecemeal fashion for metastatic or traumatic lesions at L2-L4.[40] Decompression targets the cauda equina by excising the posterior elements and ligament, ensuring direct dural visualization, with bipolar cautery for epidural bleeding control.[40] Minimally invasive variants use tubular retractors to limit muscle disruption.[40] Posterior approaches are reserved for select thoracolumbar cases, such as L5 corpectomy in fractures or infections, with the patient prone and a midline incision exposing the lamina. Laminectomy is performed to access the canal, followed by pedicle removal and transpedicular corpectomy using curettes and rongeurs, achieving up to 75-80% decompression unilaterally or fully bilaterally.[35][34] The posterior longitudinal ligament is incised for dural exposure, with nerve root ligation if required for ventral access, and hemostasis maintained via cautery.[35] Lateral extrapleural or transpedicular extensions may enhance reach in complex anatomies.[38]Instrumentation and Fusion
Following corpectomy, instrumentation and fusion are essential to reconstruct the anterior spinal column, restore vertebral height, and achieve long-term stability by promoting bony union across the defect. This reconstruction typically involves placing a graft or interbody device within the corpectomy site, secured by anterior plating systems, with supplemental posterior fixation in select multi-level or unstable cases.[2][42] Graft options for filling the corpectomy defect include autografts harvested from the iliac crest or local vertebral bone, which provide osteogenic potential but carry donor site morbidity risks. Allografts, such as fibular struts, offer structural support without donor site issues but may have lower fusion rates compared to autografts. Synthetic alternatives, including polyetheretherketone (PEEK) cages packed with bone graft material, are increasingly favored for their biocompatibility, radiolucency, and reduced subsidence risk.[43][42][2] Fusion techniques primarily employ anterior cervical plate and screw systems to immobilize the construct, achieving immediate load-sharing and promoting fusion in 90-100% of cases for single- or multi-level procedures. In multi-level corpectomies or those with significant instability, posterior pedicle screw fixation provides supplemental support, enhancing overall construct rigidity and reducing anterior graft stress. Skip corpectomy techniques, where an intervening vertebra is preserved, further improve biomechanical stability by distributing loads across intact bone.[42][44][2] Interbody devices such as expandable titanium cages or titanium mesh cages (TMCs) are used to restore disc height and maintain anterior column integrity, often filled with autograft or demineralized bone matrix for osteoinduction. TMCs, introduced in the 1980s, offer high structural strength for larger defects but can lead to subsidence in up to 40% of cases without plating; alternatives like nano-hydroxyapatite/polyamide 66 cages show lower subsidence rates (around 12%) due to better osseointegration.[44][43][2] Biomechanically, these methods prioritize anterior column support to counteract axial loads, prevent graft subsidence, and minimize pseudarthrosis by achieving 80-90% load-sharing through rigid fixation. Bicortical screw purchase in plates increases pull-out resistance by 15-20%, while device designs that match vertebral endplate curvature enhance contact area and fusion success.[42][44][43] Intraoperative fluoroscopy is routinely employed to verify device placement, endplate parallelism, and screw trajectory, ensuring alignment and reducing malposition risks during reconstruction.[42][2]Postoperative Management
Immediate Postoperative Care
Following anterior or posterior corpectomy, patients are typically admitted to the intensive care unit (ICU) or a high-dependency unit for close monitoring in the immediate postoperative period to assess neurological stability and detect early complications such as hematoma or airway issues.[45] Neurological examinations, including motor strength, sensation, and reflexes, are performed every 1-2 hours initially, with vital signs monitored continuously for signs of bleeding, hypotension, or respiratory distress.[46] This vigilant oversight helps prevent neurological deterioration, as transient changes can occur in up to 3% of cases and require prompt intervention.[47] Pain management employs a multimodal approach to control incisional and neuropathic discomfort while minimizing sedation that could obscure neurological assessments. Opioids such as oxycodone are administered intravenously or orally for breakthrough pain, combined with nonsteroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids to reduce opioid requirements and inflammation.[48] Patient-controlled analgesia may be used in the first 24-48 hours, transitioning to oral regimens as tolerated, with pain scores assessed regularly using scales like the Visual Analog Scale.[46] Early mobilization begins on postoperative day 1 to promote circulation and prevent secondary complications, with patients encouraged to ambulate short distances while wearing a rigid brace such as a cervical collar for spinal stability.[49] Venous thromboembolism (VTE) prophylaxis is initiated immediately postoperatively using low-molecular-weight heparin or unfractionated heparin, alongside mechanical measures like compression stockings, given the elevated risk in immobilized spine surgery patients.[50] Wound care involves monitoring the incision site for erythema, drainage, or dehiscence, with surgical drains (if placed) emptied and measured every 4-8 hours until output is minimal, typically removed within 48 hours.[51] Perioperative antibiotics, such as cefazolin, are typically continued for 24 hours postoperatively to help prevent surgical site infection, after which the wound is kept clean and dry without submerging.[52] Postoperative imaging, including plain radiographs or computed tomography, is obtained within the first 24-72 hours to verify hardware position, graft alignment, and spinal stability.[53]Recovery and Rehabilitation
Following a corpectomy, patients typically remain in the hospital for 3-7 days to ensure initial stability and manage pain before discharge.[54] Full recovery generally spans 3-6 months, though this varies by spinal level, patient health, and fusion success, with some requiring up to 6 months or more for complete return to baseline function.[49][55] Physical therapy is essential for restoring mobility and strength, often beginning with gentle activities like walking shortly after discharge to promote circulation and prevent complications.[56] Formal therapy typically starts 4-6 weeks postoperatively, incorporating isometric exercises to engage core and paraspinal muscles without straining the surgical site.[57] Over subsequent weeks, programs progress to strengthening for the core and paraspinals, including light resistance bands or weights under supervision, with sessions 2-3 times per week for 6-8 weeks to build endurance and balance.[55][58] Bracing supports spinal alignment during early healing, with duration tailored to the affected levels and surgical approach; for cervical corpectomy, a rigid collar is worn continuously for 6 weeks.[55] Thoracic and lumbar cases may require a thoracolumbar orthosis for 6-12 weeks, depending on stability.[59] Weaning protocols involve gradual reduction in wear time, guided by surgeon assessment to avoid instability.[60] Activity restrictions protect the fusion site, prohibiting heavy lifting over 10-20 pounds for at least 3 months to prevent hardware stress or nonunion.[61][55] Driving may resume 2-6 weeks postoperatively once pain is controlled, the patient is off narcotics, and with surgeon clearance.[62] Follow-up appointments include serial imaging, such as X-rays or CT scans at 6 weeks, 3 months, 6 months, and 1 year to evaluate fusion progress and hardware integrity.[30] These assessments guide adjustments to therapy and restrictions, ensuring optimal long-term outcomes.[63]Risks and Complications
Intraoperative Risks
During corpectomy, vascular injury represents a critical intraoperative hazard, particularly in anterior approaches where instrumentation or decompression may damage adjacent major vessels. In cervical corpectomy, the vertebral artery is at risk during lateral exposure or osteophyte removal, with an incidence of 0.3%–0.5%, potentially leading to massive hemorrhage, cerebral ischemia, or death if not promptly controlled. In thoracic or lumbar corpectomy, injury to the aorta or iliac vessels can occur from retractors or drill penetration, with reported incidences ranging from 0.01% to 1%, often resulting in life-threatening bleeding that requires immediate vascular repair.[64][65][66] Neurological damage is another primary intraoperative concern, arising from direct trauma to the spinal cord or nerve roots during retraction, drilling, or graft placement. Isolated nerve root injury is the most common iatrogenic event in cervical corpectomy, detectable via somatosensory evoked potential monitoring, with risks heightened by prolonged retraction or improper instrumentation alignment. Spinal cord injury may occur from excessive manipulation or vascular compromise to the cord's blood supply, emphasizing the need for real-time neuromonitoring to mitigate permanent deficits.[67][68][64] Airway complications in anterior cervical corpectomy can manifest intraoperatively due to soft-tissue edema, hematoma formation, or direct tracheal injury from retractors or surgical trauma. Such events may lead to acute obstruction or respiratory compromise, with multilevel procedures increasing the risk through greater tissue dissection; intraoperative vigilance, including readiness for intubation adjustments, is essential to prevent escalation.[69][45] Hardware malposition during corpectomy instrumentation poses risks of breaching the spinal canal or adjacent structures, such as with screw placement or cage subsidence in multilevel cases. In cervical corpectomy, graft migration occurs in up to 33%–70% of multilevel constructs, potentially causing neural compression or instability that necessitates immediate revision. Thoracic or lumbar screw malposition can similarly impinge on vascular or neural elements, with risks amplified by anatomical variations identified preoperatively.[25][64] Anesthetic risks are predominantly linked to intraoperative blood loss, which averages 500–1,000 mL in corpectomy procedures depending on the spinal level and extent of resection, potentially inducing hypotension and spinal cord hypoperfusion. Controlled hypotension techniques may be employed to minimize bleeding, but careful hemodynamic monitoring is required to avoid ischemic complications, particularly in patients with preoperative vascular risk factors.[70][71][64]Postoperative Complications
Postoperative complications following corpectomy can arise due to the procedure's complexity, involving vertebral body removal and spinal reconstruction, and may include infections, fusion failures, swallowing difficulties, hardware issues, and systemic events. These complications vary by spinal level (cervical, thoracic, or lumbar), patient comorbidities, and surgical extent, with overall rates reported between 10% and 20% in large cohorts.[72][73] Early detection through clinical monitoring and imaging is essential to mitigate long-term morbidity. Surgical site infections occur in approximately 1-5% of cases, often presenting as superficial wound issues or deeper discitis/osteomyelitis, particularly in anterior cervical approaches. Risk factors include multilevel procedures and prolonged operative time. Management typically involves targeted antibiotic therapy for at least 6 weeks, with surgical debridement for persistent or deep infections to achieve resolution and prevent recurrence.[72][74][75] Non-union or pseudarthrosis, representing fusion failure, affects 10-20% of multilevel corpectomies, more commonly with allograft use or in smokers, leading to persistent pain or instability. In single-level cases, rates are lower at around 7%. Prevention strategies include autograft preference and rigid anterior plating; management options encompass revision surgery for hardware augmentation or non-invasive bone growth stimulators to promote healing.[76][77][78] Dysphagia and hoarseness are prevalent in cervical corpectomies, occurring in up to 50% of patients transiently due to esophageal or recurrent laryngeal nerve irritation from retraction. These symptoms usually resolve within weeks to months with conservative measures such as dietary modification, speech therapy, and anti-inflammatory medications, though persistent cases may require endoscopic evaluation.[79][80][81] Implant failure, including cage subsidence or migration, is monitored via serial radiographs and occurs in 5-16% of cases, higher in multilevel or osteoporotic patients. Subsidence greater than 3 mm can compromise alignment but often stabilizes without intervention; symptomatic failures necessitate revision to prevent neurological compromise.[73][82][83] Systemic complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE) arise from immobility, with rates of 3.8% for DVT and 1.7% for PE in thoracolumbar corpectomies; pneumonia may also develop secondary to reduced mobility or intubation effects. Prophylaxis with intermittent pneumatic compression and early mobilization is standard, alongside anticoagulation for high-risk patients to reduce incidence.[84][85]Outcomes and Prognosis
Success Rates
Corpectomy procedures demonstrate high rates of successful decompression for cervical myelopathy, with studies reporting significant neurological improvement in 80-97% of patients, often evidenced by gains in Japanese Orthopaedic Association (JOA) scores of 3-5 points postoperatively.[86][87] For instance, one cohort analysis showed mean JOA score increases from 11.3 to 14.2, corresponding to recovery rates of approximately 60-70%.[88] Recent meta-analyses as of 2024 confirm similar JOA and Neck Disability Index (NDI) improvements for anterior cervical corpectomy and fusion (ACCF) compared to anterior cervical discectomy and fusion (ACDF), though ACCF may involve higher operative risks.[89] These outcomes reflect effective relief of spinal cord compression, particularly in degenerative cases, though variability exists based on preoperative severity and patient factors.[90] In degenerative conditions, corpectomy provides substantial pain relief, with visual analog scale (VAS) scores typically reducing by 40-60% at one-year follow-up, as seen in cases transitioning from median preoperative VAS of 7 to 4 postoperatively.[91] This improvement correlates with enhanced neck disability index (NDI) scores, indicating meaningful functional gains in daily activities.[92] Fusion rates following corpectomy are robust when instrumentation is utilized, ranging from 85-95% in single- and multi-level procedures, as confirmed by radiographic assessments in multiple cohorts.[93][94] Without instrumentation, rates drop to around 70%, highlighting the role of plating or cages in promoting bony union and stability.[25] For neoplastic indications, corpectomy combined with adjuvant therapy achieves effective tumor control in spinal metastases cases.[95] Meta-analyses indicate superior outcomes for single-level corpectomy versus multi-level approaches, attributed to lower complication profiles and higher fusion success.[25][96]Long-term Effects
Long-term functional recovery after corpectomy is generally favorable, with approximately 60-80% of patients achieving sufficient improvement to return to work or regular activities within 6 months, particularly those with preoperative myelopathy or radiculopathy. However, persistent motor weakness affects 10-20% of individuals, often linked to the extent of preoperative neurological deficit and the level of spinal involvement. Younger patients and those presenting with better baseline function tend to experience more sustained gains in mobility and daily functioning over time.[97][98][99] Adjacent segment disease represents a notable long-term concern, with degeneration occurring in 14% of patients at adjacent levels by 10 years post-procedure, potentially necessitating further intervention due to accelerated wear from altered biomechanics at the fusion site. This risk is higher in multilevel corpectomies and correlates with factors such as preoperative alignment and fusion extent.[100][101] In patients with metastatic spinal tumors, corpectomy contributes to oncologic survival benefits in selected cases with good performance status, allowing for improved symptom control and adjuvant therapies, with 1-year survival rates ranging from 30-92%. Patient-reported outcomes, as measured by the SF-36 questionnaire, demonstrate significant enhancements in physical and mental health domains postoperatively, with average score improvements across multiple subscales reflecting better quality of life. Durability of these gains is moderated by patient age, comorbidities, and tumor histology.[102][103] Reoperation rates following corpectomy are driven primarily by disease progression, implant failure, or adjacent segment pathology rather than initial surgical issues. These rates underscore the importance of patient selection and postoperative monitoring to optimize long-term prognosis.[104][105]History and Evolution
Early Developments
The origins of corpectomy trace back to early efforts in spinal decompression during the late 19th century, when posterior approaches like laminectomy were pioneered to address neural compression from various pathologies, including trauma and infection. In 1894, French surgeon Antony Chipault performed one of the first documented laminectomies for spinal cord injury and paraplegia associated with tuberculosis (Pott's disease), marking a foundational step in surgical intervention for spinal stability and decompression, though limited to posterior access without vertebral body removal.[106] These early procedures highlighted the need for more direct anterior access to the vertebral column, as posterior methods often failed to adequately address anterior compression from disc or bony pathology.[107] By the early 20th century, advancements in spinal fusion techniques provided essential groundwork for post-resection stability, influencing the eventual development of corpectomy. In 1911, American surgeons Russell Hibbs and Fred Albee independently introduced autologous bone grafting for spinal arthrodesis, primarily to treat scoliosis and tuberculous spondylitis, using spinous processes or tibial grafts to promote fusion and prevent deformity progression after decompression.[108] Their methods, refined through the 1910s and 1920s, emphasized biological fusion to maintain spinal integrity, setting the stage for combining decompression with reconstruction in anterior approaches during the mid-20th century.[109] A pivotal milestone occurred in 1958, when Robert Robinson and George Smith described the anterior cervical discectomy and interbody fusion technique, initially for degenerative disc disease and spondylosis, which evolved into corpectomy by extending resection to the vertebral body for more comprehensive decompression.[110] This anterior approach revolutionized access to the cervical spine, reducing risks compared to posterior methods and enabling direct visualization of pathology.[111] Initial corpectomy applications in the 1960s were primarily limited to severe trauma and infections like Pott's disease, where vertebral body excision was necessary for radical debridement. Arthur Hodgson and colleagues, through the "Hong Kong procedure" reported in 1956 and formalized in 1960, performed anterior vertebral body resections with rib strut grafting for tuberculous spondylitis, achieving improved neurological outcomes in endemic regions by addressing abscesses and instability.[112] Similarly, early reports of corpectomy for cervical fractures emerged in the 1960s, with multilevel body excisions combined with autologous grafts, as detailed by Boni and Denaro in 1969, focusing on trauma-induced compression.[113] These cases underscored corpectomy's role in high-stakes scenarios, paving the way for broader adoption.Modern Advances
During the 1980s and 1990s, advancements in instrumentation enhanced the stability and safety of corpectomy procedures; notably, Caspar plates were introduced in the early 1980s as a rigid anterior cervical plating system to provide immediate stabilization following decompression and fusion.[114] Concurrently, endoscopic and minimally invasive variants emerged, with retropleural approaches for thoracic corpectomy described in the early 1990s to reduce morbidity compared to traditional open thoracotomy.[70] From the 2000s onward, expandable cages revolutionized reconstruction after corpectomy by allowing intraoperative height adjustment to restore disc height and lordosis while minimizing endplate damage; these devices, first commercialized in the early 2000s, demonstrated superior subsidence resistance in biomechanical studies.[115] Navigation systems, such as O-arm integration, further improved precision in corpectomy by providing real-time 3D imaging for accurate decompression and implant placement, particularly in complex cervical cases involving ossification of the posterior longitudinal ligament.[116] Additionally, biologics like recombinant human bone morphogenetic protein-2 (rhBMP-2) were incorporated to enhance fusion rates post-corpectomy, with clinical evidence supporting its efficacy in promoting solid arthrodesis without increased complication risks in anterior cervical applications.[117] Corpectomy indications expanded in oncologic applications through en bloc spondylectomy guided by the Enneking classification, which categorizes tumor margins to achieve wide or radical resections for primary spinal tumors, improving local control while preserving neurological function.[118] Robotic assistance, exemplified by the Mazor system introduced in the 2010s, facilitated more accurate pedicle screw placement and trajectory planning in corpectomy-adjacent fusions, reducing radiation exposure and operative time in spine tumor resections.[119] Recent developments up to 2025 have focused on personalized implants, with 3D-printed titanium corpectomy cages showing improved biomechanical stability and clinical outcomes, including reduced subsidence and enhanced fusion in cervical reconstructions.[120] Studies have also demonstrated the feasibility of outpatient multilevel corpectomy procedures using minimally invasive techniques, achieving comparable 2-year neurological improvements to inpatient two-level corpectomies with lower resource utilization during the COVID-19 era.[121][122]References
- https://wikianesthesia.org/wiki/Anterior_cervical_spine_surgery