What is the indication and management for corpectomy (surgical removal of a vertebral body)?

Corpectomy: Indications and Management

Primary Indications

Corpectomy is indicated for anterior spinal cord decompression when neural elements are compressed by anterior pathology (disc, bone, tumor, infection) causing myelopathy or radiculopathy, and for removal of destructive vertebral body lesions from trauma, tumor, or infection. 1

Specific Clinical Scenarios Requiring Corpectomy:

Degenerative/Compressive Disease:

• Severe cervical spondylotic myelopathy (modified Japanese Orthopaedic Association score ≤12) with anterior compression should be treated with surgical decompression, with benefits maintained 5-15 years postoperatively 2
• Ossification of posterior longitudinal ligament causing cord compression 1
• Postoperative kyphosis correction requiring anterior reconstruction 1

Metastatic/Pathologic Disease:

• Pathologic vertebral compression fracture with frank spinal instability and/or neurologic deficits—surgery is the standard of care 2
• Metastatic spinal cord compression, particularly from osseous compression, where surgery is more likely to allow neurological recovery compared to radiation therapy alone 2
• Patients should have predicted survival ≥3 months, age <65 years, single level compression, and neurologic deficits present <48 hours for optimal benefit 2
• Spinal Instability Neoplastic Score (SINS) should guide surgical referral: unstable or potentially unstable spines warrant surgical consultation 2

Trauma:

• Vertebral body fractures with retropulsed bone fragments causing spinal cord compression 1
• Traumatic vertebral body destruction requiring anterior column reconstruction 3

Infection:

• Coccidioidal or other spinal infections confined to disc space or vertebral body requiring aggressive debridement 2
• Complete corpectomy may be required even if entire vertebral body is involved 2

Surgical Approach Selection

The surgical approach must be determined by the specific spinal segment involved, structures affected, and extent of pathology:

Anterior Approach:

• Appropriate when infection or pathology is confined to disc space or vertebral body 2
• Familiar to most spine surgeons with less muscle manipulation and better wound healing 2
• Entire disc and surrounding bone should be removed, even requiring complete corpectomy 2
• Patients tolerate anterior cervical surgery and retroperitoneal lumbar surgery extremely well 2

Lateral Approach:

• Access to T3-L3 vertebral column via traditional thoracotomy or video-assisted thoracoscopic surgery (VATS) 2
• Lateral retroperitoneal approach for L1-L4 2
• Complete corpectomy should expose ventral epidural space and thecal sac if complete vertebral destruction present 2

Posterior Approach:

• Can be used for any spinal segment, typically for epidural abscess decompression 2
• Caution required when decompressing ventral epidural abscess via posterior approach alone in cervical/thoracic spine 2
• More painful due to muscle dissection 2

Reconstruction Techniques

Vertebral body reconstruction following corpectomy requires achieving solid fusion for durable support and pain reduction:

Graft Material Options:

Autologous Bone (Preferred):

• Iliac crest or rib harvest provides best option when possible 2
• Used successfully in 141/185 cases with 98.8% fusion rate 1
• Patient's medical condition affects bone quality and fusion maturation 2

Allograft:

• Cadaveric allograft acceptable substitute, devoid of living cells 2
• Fibular allograft used in 44/185 cases 1
• Premanufactured implants available in various shapes/dimensions 2
• May be more likely to subside due to rigidity 2

Synthetic Options:

• Titanium mesh filled with removed vertebral bone used in 69/71 cases 4
• Telescopic cages used in select cases 4

Instrumentation:

• Anterior plate-screw fixation system used in 179/185 cases (96.8%) 1
• Locking plates for stabilization 4
• Dunn device utilized with autografts in 19/37 cases 3
• Posterior stabilization may be added in select cases (5/37 patients) 3

Extent of Corpectomy

Single-level corpectomy:

• Performed in 87/185 cervical cases, with 45 requiring additional discectomy at different level 1
• Single-level in 46/71 spondylotic cases 4
• 83/124 metastatic cases 5

Two-level corpectomy:

• 70/185 cervical cases, with 27 requiring additional discectomy 1
• 25/71 spondylotic cases 4

Three-level corpectomy:

• 28/185 cervical cases 1
• Three or more level corpectomy associated with high morbidity rate and should be avoided 4

Multi-level corpectomy:

• 41/124 metastatic cases 5

Expected Outcomes

Neurological Improvement:

• No permanent neurological deterioration in 185 cervical corpectomy cases; 160 patients (86.5%) improved 1
• Radiculopathy always improved; myelopathy reversed in most patients 1
• In metastatic disease, 21/34 patients with pareses improved neurologically 5
• Best results in Nurick grades 0-1: 95% became cured; grades 2-4 showed 50%, 31%, and 28% improvement respectively 4

Pain Relief:

• Average VAS pain score decreased from 7.2 to 3.8 in metastatic disease 5
• Performance improved from Karnofsky score 50.26 to 68.65 5

Fusion Rates:

• 98.8% fusion rate in cervical corpectomy series 1
• 25/27 patients (92.6%) achieved solid fusion at minimum 1-year follow-up 3

Complications and Management

Intraoperative Complications:

• Vertebral artery injury occurred in 4/185 cases (2.2%); preserved in 2 with no neurological sequelae 1
• Average blood loss: 580ml for lumbar, less for cervical (67 min operative time) and thoracic (123 min) 5
• 62% required blood transfusion postoperatively 5

Postoperative Complications:

Hardware-Related (Most Common):

• Hardware failure in 7/71 cases (9.9%) 4
• Subsidence in 5 cases (7%), with only 1 requiring intervention 4
• Endplate damage adjacent to prosthesis in 11% of metastatic cases 5
• Incorrect screw placement in 2 cases, 1 requiring revision 4

Neurological:

• Transient deterioration in 6/185 patients, all improved 1
• Postsurgical worsening in 3/71 cases: 2 improved, 1 remained grade 4 4
• Complete irreversible paralysis in 2/124 metastatic cases 5

Other:

• Permanent dysphagia in 4/71 cases (5.6%) 4
• Permanent dysphonia in 1/71 cases 4
• Prevertebral hematoma requiring urgent evacuation 4
• One death from respiratory disturbances 4

Mini-Open vs. Open Approach for Thoracic Metastases:

• Mini-open transpedicular corpectomy associated with significantly less blood loss (917.7ml vs. 1697.3ml, p=0.019) and shorter hospital stay (7.4 vs. 11.4 days, p=0.001) 6
• Trend toward lower infection rate (9.5% vs. 17.9%) and complication rate (9.5% vs. 21.4%), though not statistically significant 6
• No difference in operative time (452.4 vs. 413.6 minutes) 6

Postoperative Management

Early Mobilization:

• All patients began walking or sitting within 2 weeks of surgery 3
• Average hospitalization 14 days (range 7-24 days) for metastatic disease 5

Monitoring Requirements:

• Close neurological status monitoring for spinal cord compression 7
• Pain management often requiring intravenous medications initially 7
• Immediate access to medical intervention for complications 7

Long-term Surveillance:

• Conservative management of subsidence successful in majority since rarely symptomatic 4

• 90% one-year survival rate in metastatic cases indicates effective treatment and appropriate patient selection 5

Critical Patient Selection Factors

Contraindications to Corpectomy in Metastatic Disease:

• Life expectancy <3 months 2
• Poor performance status 2
• Widespread visceral metastatic disease 2
• Insufficient cardiopulmonary health to tolerate anesthesia 2

Optimal Candidates:

• Overall good health with good survival prognosis 5
• Predicted survival ≥3 months 2
• Single level compression 2
• Neurologic deficits present <48 hours 2