Spondylectomy is a complex surgical procedure involving the complete removal of a vertebral body, a single bone segment of the spinal column. This is a significant undertaking due to the intricate nature of the spinal column and its proximity to delicate neural structures like the spinal cord. It is reserved for severe spinal conditions that cannot be addressed by less extensive surgical interventions.
What is Spondylectomy?
Spondylectomy involves the complete removal of a vertebral body, the main cylindrical bone in the spine that bears weight. This procedure may also include the removal of adjacent structures, such as intervertebral discs above and below the affected vertebra, or even portions of neighboring vertebrae, depending on the extent of the disease. The primary objective is to alleviate pressure on the spinal cord or nerve roots and to restore stability to the spinal column.
This surgery is indicated for serious spinal conditions. Spinal tumors, whether primary (originating in the spine) or metastatic (spreading from other parts of the body), are a common reason for performing a spondylectomy. This extensive removal aims to achieve clear margins and prevent recurrence for tumors like giant cell tumors, chordoma, chondrosarcoma, and osteosarcoma.
Severe spinal infections, like osteomyelitis or discitis, which are unresponsive to prolonged antibiotic treatment, can also lead to significant destruction of vertebral bone, making spondylectomy a necessary intervention. In such cases, removing the infected bone helps to eradicate the infection and prevent its spread, while also decompressing any affected neural elements.
Complex spinal deformities or severe trauma where the vertebral body is significantly compromised, leading to instability or neurological impingement, may also require spondylectomy. When simpler procedures are insufficient to correct the deformity or address the neurological symptoms, this more extensive removal allows for substantial correction and subsequent reconstruction.
Surgical Approaches and Techniques
Spondylectomy can be performed using various surgical approaches, chosen based on the location of the affected vertebra, the nature of the condition, and the surgeon’s preference.
Anterior Approach
The anterior approach involves accessing the spine from the front of the body, often through the chest or abdomen. It is commonly used for tumors or conditions in the thoracic (mid-back) or lumbar (lower back) spine. This approach allows for direct visualization of the vertebral body, facilitating the removal of the affected segment.
Posterior Approach
The posterior approach involves accessing the spine from the back, through an incision along the midline of the back. This method is frequently utilized for conditions affecting the cervical (neck) spine and certain thoracic or lumbar segments. A posterior-only approach can achieve complete tumor excision and circumferential spinal reconstruction in a single surgical setting.
Combined Approach
In more complex cases, a combined approach, involving both anterior and posterior access, may be necessary. This two-stage procedure allows for comprehensive removal of the vertebral body and reconstruction, particularly when the pathology extends significantly or requires extensive stabilization. For example, a combined posterior-anterior approach is often employed for lower lumbar spine tumors.
The extent of vertebral body removal also varies, leading to different types of spondylectomy. A total spondylectomy involves the complete removal of the entire vertebral body, along with its associated elements. Subtotal spondylectomy refers to the removal of most of the vertebral body, while leaving a portion intact. Partial spondylectomy, the least extensive, involves removing only a segment of the vertebral body. Following the removal of the vertebral body, spinal reconstruction and stabilization are performed using various implants like cages, rods, and screws to maintain spinal alignment and support the column.
Recovery and Rehabilitation
The recovery following a spondylectomy is a prolonged process, reflecting the extensive nature of the surgery. Patients remain in the hospital for several days to over a week, depending on the complexity of the procedure and their overall health. During this immediate post-operative period, pain management is a primary focus, often involving intravenous medications and later transitioning to oral pain relievers.
Early mobilization is encouraged, usually beginning with assisted walking within a day or two after surgery, to prevent complications such as blood clots and to promote circulation. Physical therapists work with patients to teach safe movement techniques, including getting in and out of bed and walking, while minimizing stress on the healing spine. The use of a brace or external support, such as a soft cervical collar or a more rigid neck brace, may be recommended to provide stability and support to the spine during the initial healing phase, often for several weeks or months.
Rehabilitation is a cornerstone of recovery, aimed at regaining strength, flexibility, and overall mobility. This involves a structured physical therapy program that progresses from gentle exercises to more challenging ones as healing advances. The expected timeline for full recovery can range from several months to a year, with significant improvements often seen within the first six months. Return to daily activities and work varies greatly; individuals with sedentary jobs might return within a few weeks, while those with physically demanding occupations may require three to six months or more before resuming full duties.
Potential Risks and Complications
Spondylectomy carries inherent risks. General surgical risks include bleeding, which can be substantial given the vascularity of the spine, and infection at the surgical site. Adverse reactions to anesthesia, though rare, are also a possibility.
Spine-specific complications are a concern due to the close proximity of delicate neural structures. Nerve damage, which can manifest as weakness, numbness, or even paralysis, is a potential risk. Spinal cord injury, though infrequent, can have severe and lasting consequences. Cerebrospinal fluid (CSF) leaks, resulting from a tear in the dura mater (the membrane surrounding the spinal cord), can occur during or after surgery, potentially leading to headaches, meningitis, or other neurological issues. If a CSF leak is detected during surgery, it is typically repaired immediately, but some may develop later and require further intervention.
Other potential complications include non-union, where the bones fail to fuse properly after reconstruction, or hardware failure, where the implanted rods, screws, or cages loosen, fracture, or dislodge. These issues may necessitate additional surgery. Deep vein thrombosis (DVT), the formation of blood clots in the legs, and pulmonary embolism (PE), where a clot travels to the lungs, are also risks associated with prolonged immobility after major surgery. A long-term complication observed in some spinal fusion cases is adjacent segment disease, where increased stress on the vertebrae next to the fused segment leads to degeneration over time.