Minimally Invasive Treatment of the Thoracic Spine Disease: Completely Percutaneous and Hybrid Approaches

The aim of the study was to evaluate the feasibility of a limited invasive approach for the treatment of upper thoracic spine disease. Seven patients with type-A thoracic fractures and three with tumors underwent long thoracic stabilization through a minimally invasive approach. Four patients underwent a completely percutaneous approach while the other three underwent a modified hybrid technique, a combination of percutaneous and open approach. The hybrid constructs were realized using a percutaneous approach to the spine distally to the spinal lesion and by open approach proximally. In two patients, the stabilization was extended proximally up to the cervical spine. Clinical and radiographic assessment was performed during the first year after the operation at 3, 6, and 12 months. No technically related complications were seen. The postoperative recovery was rapid even in the tumor patients with neurologic impairment. Blood loss was irrelevant. At one-year follow-up there was no loosening or breakage of the screws or failure of the implants. When technically feasible a completely percutaneous approach has to be taken in consideration; otherwise, a combined open-percutaneous approach could be planned to minimize the invasivity of a completely open approach to the thoracic spine. 1. Introduction Although widely used in the lumbar and lower thoracic spine, the minimally invasive approach is still limited in the treatment of the upper thoracic spine disease. The principal issue regarding treatment of thoracic spinal disorders through a minimally invasive approach is the potential for resulting neurologic injuries. The high risk of devastating complications is probably the primary roadblock to a wider use of the percutaneous approach to the thoracic spine. Anatomic peculiarities and difficult clear visualization under fluoroscopy of the pedicles of the upper thoracic spine make percutaneous screw fixation a demanding procedure especially when multilevel thoracic fixation is required. In order to limit the invasiveness of completely open surgery and to verify the feasibility of this demanding procedure, we began using a minimally invasive approach to the thoracic spine according to the following strategy. A completely percutaneous approach was carried out in well-selected cases in which the fluoroscopic visualization of the pedicles was optimal, while in cases where a completely percutaneous procedure was unfeasible, a combined, open-percutaneous approach to the thoracic spine was then performed. The surgical strategy we developed consists in percutaneous