Thoracoscopic discectomy and fusion in an animal model: safe and effective when segmental blood vessels are spared.
METHODS
Disc-endplate excision and spine fusion were compared in animals randomly assigned to segmental vessel-spared and segmental vessel-ligated groups in an in vivo goat model of anterior spine discectomy and fusion using thoracoscopic techniques.


OBJECTIVE
To compare safety and completeness of disc and endplate excision, and to perform a histologic and biomechanical comparison between fusion masses when the segmental vessels are spared and when they are ligated using thoracoscopic techniques. SUMMARY OFF BACKGROUND DATA: Because thoracoscopy is relatively new and technically demanding, many surgeons ligate the segmental blood vessels to enhance spine exposure and limit the risk of injury during discectomy and fusion. Although rare, spinal cord compromise secondary to segmental vessel ligation has been reported.


METHODS
This study was divided into two phases. In Phase 1, 10 mature goats were randomly assigned to either the segmental vessel-ligated or the segmental vessel-spared group. Disc and endplate excision was performed at six consecutive thoracic levels in each animal (30 levels per group). The animals were killed, and the depth of disc excision was measured in the transverse and sagittal planes. The vertebral bodies then were separated through the disc space; photographic images of the endplates were digitized, and the area of endplate excision was calculated. In Phase 2, 12 mature goats were randomly assigned to the segmental vessel-ligated or vessel-spared group, and five noncontiguous thoracic segments were fused using autologous iliac crest graft. At 4 months the animals were killed, and the spines were harvested. At each disc level, the three-dimensional rotational and translational motions were analyzed and histomorphometric analysis was performed.


RESULTS
Phase 1: Each animal survived the operative procedure, and no surgical complications occurred. No difference was found between vessel-ligated and vessel-spared groups in operative time (21.8 vs 22.7 minutes per disc), blood loss (97 vs 159 mL), or transverse (81% vs 74%) or sagittal (85% vs 85%) disc excision. The total area of endplate excision was 70% in the vessel-ligated group and 67% in the vessel-spared group (P > 0.1). Phase 2: Biomechanical testing demonstrated no difference in stiffness of the fused segments between the two groups in flexion-extension or axial rotation. However, greater flexibility in lateral bending was found in the specimens whose vessels were ligated (P < 0.05). The percentage of trabecular bone volume was similar between the two groups.


CONCLUSIONS
The segmental vessels in the thoracic spine can be effectively spared without injury during disc excision and fusion. Although slightly more disc area was excised with ligation of the vessels, this was not statistically significant, and the fusion mass was similar between the two groups. Sparing the segmental vessels may provide blood supply that aids fusion mass, and the result may be greater spine stiffness in the coronal plane. Sparing the segmental vessels during thoracoscopic anterior disc excision and fusion can be safe. It should be considered in patients with a high risk for neurologic injury because of decreased spinal cord perfusion in revision surgery, severe kyphosis, congenital anomalies. Because the neurologic risk of vessel ligation has not been clearly established for idiopathic scoliosis, the surgeon will have to consider the risk-benefit ratio of adopting these methods when deciding not to ligate vessels in these patients.
Sucato
Daniel J
DJ
Texas Scottish Rite Hospital, Dallas, Texas, USA. dsucato@tsrh.org
Welch
Robert D
RD
Pierce
Bill
B
Zhang
Hong
H
Haideri
Nessie
N
Bronson
Dwight
D
D000818:Animals; D001696:Biomechanical Phenomena; D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D001808:Blood Vessels; D017586:Diskectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D006041:Goats; D008026:Ligation; D023421:Models, Animal; D018583:Pliability; D016059:Range of Motion, Articular; D012306:Risk; D020760:Spinal Cord Ischemia / Q000517:prevention & control; D013123:Spinal Fusion / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D013131:Spine / Q000098:blood supply* / Q000473:pathology / Q000601:surgery*; D013906:Thoracoscopy / Q000009:adverse effects / Q000379:methods* / Q000706:statistics & numerical data; D013997:Time Factors; D016896:Treatment Outcome