Single-stage posterior midline approach for dumbbell tumors of the thoracic spine, with intraoperative CT guidance

BACKGROUND: Several different procedures have been advocated for thoracic spine dumbbell tumor resection, combining thoracic and neurosurgical approaches, in single and multiple stages, using various incisions and positions. These have led to controversies in the ideal management. The authors report their analysis of a series of 11 patients successfully treated through a one-step midline approach for complete resection and instrumentation when indicated under intraoperative CT (ICT) guidance. METHODS: The patients’ clinical presentations, imaging results, operative findings and follow-up were reviewed in 11 patients (age ranged from 11 to 62 years), over the period from August 2007 to May 2010. A single-stage, posterior midline incision approach with laminectomy, facetectomy, costotransversectomy, for complete resection of intraspinal and paraspinal components of tumor was used. Spinal instrumentation under ICT guidance was also carried out in relevant (six) cases with tumors involving junctional spinal regions such the cervico-thoracic or thoraco-lumbar region. RESULTS: The initial clinical presenting symptom was pain in eight patients and paresthesia in one, while two patients were detected incidentally on routine chest X-rays. Total excision was achieved in 10 patients (9 schwanommas, 1 neurofibroma) with the exception of one patient who had a recurrent malignant peripheral nerve sheath tumor adherent to the vertebral artery. No significant postoperative complications occurred and an early mobilization/discharge was achieved in all patients with an average hospital stay of 5 days. CONCLUSIONS: A one-step approach through a posterior midline incision is feasible, safe and efficient for complete excision of thoracic dumbbell tumors. This approach facilitates laminectomy, facetectomy, costotransversectomy and instrumentation under ICT guidance, while limiting muscle damage, blood loss, operative time, postoperative pain, thus enabling early mobilization with a reduced hospital stay.