A limited unilateral transpedicular approach for anterior decompression of the thoracolumbar spinal cord in elderly and high-risk patients

BACKGROUND: Surgical treatment for elderly patients with thoracolumbar (TL) kyphosis and spinal cord (SC) compression presents significant challenges due to compression location, the amount of deformity, and patient's medical status might not permit full correction of the deformity. In this series, we present a surgical approach that provides adequate decompression without the risks associated with a pedicle subtraction osteotomy/posterior vertebral column resection or an anterior corpectomy. METHODS: Three patients presented with TL kyphosis and progressive neurologic symptoms. All had acute weakness; none were ambulatory. SC was compressed over the apex of kyphosis, and for some, there was spinal stenosis at the proximal junction of the TL spine. The surgical technique involved unilateral resection of the pars, pedicles, the posterior one-third of the lateral wall of the vertebral body, decancellation of the impinging kyphus, and finally resection of the posterior vertebral body wall compressing the SC followed by instrumentation and fusion two levels above and below the fused segments. RESULTS: All patients survived the procedure and left the hospital after 10–22 days. Estimated blood loss was 653 ml. No deep infections occurred. One patient developed acute tubular necrosis but recovered fully. The other two showed improvement of one Frankel grade and were independent in the final follow-up. One patient developed acute tubular necrosis but recovered fully yet his neurologic status was unchaged. The other two showed improvement of one Frankel grade and were independent in the final follow-up. CONCLUSION: The procedure described presents a compromise that fits the more elderly patient that might not be able to tolerate major deformity correction and at the same time provides similar results in the short and medium term to more extensive procedures.