Prone Lateral Minimally Invasive Retropleural Corpectomy Using a Rotatable Radiolucent Jackson Table

Summary

Here, we present a single-position prone lateral retropleural corpectomy with a rotatable Jackson table. This technique is feasible for diverse etiologies, including deformity, infection, traumas, and tumors.

Abstract

Prone lateral single-position spinal surgery allows simultaneous manipulation of the anterior and posterior columns, avoiding re-draping and improving lordotic alignment. A minimally invasive retropleural approach avoids potential complications associated with one-lung ventilation and diaphragmatic takedown.

Using a rotatable radiolucent Jackson table, we perform minimally invasive retropleural corpectomy for lesions from T7 to L1. After securing the patient in the prone position with tape and contralateral positioners, the table is rotated 30° away from the surgical side. True anteroposterior (AP) and lateral views are obtained using intraoperative C-arm fluoroscopy. A 5-6 cm incision is made between the anterior and posterior borders of the targeted vertebra. The nearest rib beneath the incision is resected for approximately 8-9 cm, facilitating access. Careful dissection of the retropleural space is performed without penetrating the parietal pleura, extending along the ventral side of the rib to the rib head of the targeted vertebra. The rib head is excised, and the segmental vessel is ligated. Adjacent disc levels and the anterior vertebral body are exposed. The above and below discs are prepared, and corpectomy is performed using appropriate instruments. The pedicle can be removed to expose the posterior vertebral wall for direct decompression of the ventral dura if needed. Simultaneous percutaneous pedicle screw insertion can be performed during the lateral approach or after rotating the table back to the horizontal position if an osteotomy is needed. An air leak test is conducted before wound closure; a chest tube can be inserted if the pleura is violated.

This prone lateral minimally invasive retropleural corpectomy technique allows simultaneous lateral and posterior approaches without re-draping. It is particularly useful for minimally invasive approaches to anterior lesions without sacrificing the posterior ligamentous complex.

Introduction

Approaches to thoracic pathology remain challenging. Lesions can be accessed by either a posterior-based approach (transpedicular, costotransversectomy, or lateral extracavitary approaches) or a lateral-based approach (thoracotomy or thoracoscopic approaches)¹.

Among the anterolateral approaches, thoracotomy can be performed via transpleural (TP) or retropleural (RP) approaches. The primary difference between TP and RP lies in approach-related complications. The TP approach requires one-lung ventilation and pleural violation, leading to a higher rate of approach-related complications, particularly pulmonary complications and intercostal neuralgia, which range from 16.7% to 50%^2,3,4,5. The RP approach minimizes tissue invasion and avoids one-lung ventilation, thereby reducing pulmonary complications. As demonstrated in a direct comparison by Soda et al., the RP approach was associated with a significantly lower rate of pleural effusion with pneumonia compared to the TP approach (5.2% vs. 20%)⁶. Additionally, if needed, RP approach can be combined with the retroperitoneal approach in the thoracolumbar region without the need for diaphragm takedown^7,8.

Recently, the single-position dual approach has gained attention because of its ability to improve operation room efficacy. As evidenced, shorter operative times and hospital stays were reported in single-position patients when compared to flip patients in a meta-analysis including 1196 patients.However, in the single-position group, pedicle screw placement complications were more frequently observed in the decubitus single position compared to the prone single position. This indicates that surgeons may be more comfortable performing the posterior approach in the prone position^9,10.

A prone lateral retropleural approach utilizing a rotatable Jackson Table offers three significant benefits. First, minimal pleural invasion: The RP approach reduces pleural violation, thereby decreasing the risk of postoperative pulmonary complications. Second, familiarity with posterior procedures in the horizontal prone position for the surgeon: Performing posterior procedures in the decubitus position is less familiar to the surgeon, increasing the risk of screw placement complications. Third, enhanced operation room efficiency: The use of a rotatable Jackson Table allows for a rapid transition from the rotated prone to the horizontal prone position without the need for re-draping and repositioning.

The purpose of this study is to evaluate the feasibility of the prone lateral RP approach and report outcomes in a consecutive series of patients with varying etiologies. Additionally, the study aims to compare pulmonary complications and surgical outcomes between the prone lateral RP approach and the conventional two-stage decubitus TP approach corpectomy combined with a horizontal prone posterior approach.

Protocol

This study was approved by the institutional review board of Chang Gung Medical Foundation (IRB No. 202400604B0). Informed consents were obtained from the patients involved in this study.

1. Preoperative positional preparation

1. Preoperative communication
   1. Performing preoperative communication between the spine surgeon and anesthesiologist is essential for prone lateral surgery. For this, position the patient intraoperatively at a 30°-40° rotation for a specified duration.
2. Approach side decision making
   1. For thoracic segments (T8-T11), use a right-sided approach to avoid mobilization of the aorta. Conversely, for thoracolumbar segments (T11-L2), use a left-sided approach due to its potential connection to the left retroperitoneal antepsoas approach.
      NOTE: However, the choice of approach side may vary based on the laterality of the lesion.
3. Pad placement of Jackson table
   1. There are no specific pad position regulations for the retropleural approach. Ensure not to obstruct the surgical field (Figure 1).
      NOTE: If a combined retroperitoneal approach is needed, ensure the hip pad on the approach side is downward to the upper thigh, providing full exposure from the ribs to the iliac crest when in the prone position.
4. Patient positioning
   1. Utilize the Mizuho Jackson Modular Table System for all prone lateral surgeries. Following the induction of general anesthesia, position the patient prone on the rotatable radiolucent Jackson table.
5. Lateral positioner placement
   1. Place two radiolucent lateral positioners on the contralateral side, supporting the ribs and femoral trochanteric area during rotation and serving as a backstop during graft placement.
   2. If using non-radiolucent positioners, ensure that they do not obstruct the intraoperative fluoroscopic view, such as the teardrop of the obturator oblique view for the placement of the S2-alar-iliac (S2AI) screw.
      NOTE: There is no body weight limitation for patients currently in the institute where these surgeries are performed. The most obese patient in the case series weighed 108.7 kg. Surgeons may add a fat pad cushion between the patient and the positioners to prevent skin pressure sore or abrasions.
6. Taping for stabilization
   1. To further stabilize the patient, apply tape to the legs, arms, and head. Tape the head to the table carefully to avoid excessive tension and remain supported within the positioning cushions during table rotation (Figure 2).
7. Manual rotation of the patient
   1. Once the patient is securely positioned, manually rotate the patient 30°-40° away from the approach side. For thoracic or thoracolumbar spine procedures, manually rotate approximately 30° (Figure 3).
      NOTE: If a combined retroperitoneal approach is planned, a rotation of about 40° optimizes access to the antepsoas corridor for lower lumbar levels (L3-L5).
8. Marking surgical levels
   1. Mark the lateral and posterior surgical levels under true lateral and AP view under the C-arm.
   2. For thoracic or thoracolumbar segments, center the skin incision over the nearest rib to the targeted level, which will subsequently be harvested as an autograft. A 4-5 cm incision is typically adequate for a one- or two-level discectomy (Figure 4).
      NOTE: A true lateral view is characterized by the endplates and pedicles being parallel, while a true AP view is defined by the spinous process bisecting the pedicles symmetrically.
9. C-arm positioning
   1. After marking, sterilize and drape the patient to expose the lateral and posterior surgical corridor. Position the C-arm in a true AP view and secure it in place (Figure 5). If needed, achieve a true lateral view by rotating the C-arm.
   2. To facilitate repositioning true AP and lateral views in rotated prone patients, document the specific C-arm rotation angles.

2. Surgical techniques

1. Workflow
   1. For prone lateral surgery, begin with a retropleural approach for interbody fusion in a rotated prone position, followed by pedicle screw placement in a horizontal position.
2. Surgeon's ergonomics
   1. Operate on the ventral side of the patient.
      NOTE: The surgeon stands during the surgical corridor exposure and can sit for the remainder of the lateral procedure.
3. Rib dissection
   1. In approximately a 30° rotated prone position, incise the skin. Then, perform a circumferential subperiosteal dissection of the rib as dorsal as possible.
   2. Utilize a rib cutter and rongeur for partial rib resection after detaching the rib from the subcostal neurovascular bundle and parietal pleura.
4. Retropleural development
   1. As described by Uribe et al.¹¹, develop the retropleural space carefully between the endothoracic fascia and parietal pleura.
   2. To minimize the risk of incidental parietal pleura tears during the subsequent procedure, perform a generous retropleural blunt dissection above and below the targeted disc.
5. Rib head removal and retractor docking
   1. After the development of retropleural space, dock a table-mounted oblique lateral interbody fusion (OLIF) retractor to retract the parietal pleura ventrally. Then, remove the rib head near the targeted disc and the pedicle to expose the operative field if needed (Figure 6).
6. Disc preparation
   1. After fully exposing the surgical corridor, prepare the discs above and below the targeted vertebral body through annulotomy with a knife and discectomy with a disc shaver and rongeur.
7. Corpectomy and cage placement
   1. After disc preparation, carefully remove the vertebral body with osteotome, rongeur, and high-speed burr. If direct decompression is indicated, remove the ipsilateral pedicle to allow direct visualization of the posterior longitudinal ligament (PLL) and ventral dura.
   2. Perform direct decompression under a surgical microscope. Cut the anterior longitudinal ligament (ALL) when significant angle realignment is required.
      NOTE: If the ALL is released, ensure that the cage is not placed too anteriorly, while if the PLL is released, ensure that the cage is not placed too posteriorly.
8. Air leak test
   1. After completing the retropleural procedure in a 30° rotated prone position, test the integrity of the pleura by filling the wound with sterile water using a syringe.
   2. Once the wound is filled, begin Ambu bagging. If the visceral pleura is violated, air bubbles appear on the water's surface, necessitating the placement of a chest tube.
9. Posterior approach
   1. After the air leak test, rotate the table to a horizontal position without re-draping.
      NOTE: This position is more familiar to surgeons for performing posterior-based procedures such as pedicle screw insertion (open or percutaneous), decompression, osteotomy, cement augmentation, and endoscopic surgery.

Results

Cohort demography
From April 2022 to January 2025, 27 consecutive patients underwent single-position prone-lateral retropleural (RP) corpectomy. This cohort was compared to 54 patients who underwent a conventional two-stage transpleural (TP) approach corpectomy in the decubitus position combined with a posterior approach in the prone position. In the RP group, the mean age was 62.3 years, with males accounting for 63% of the cohort. The mean body mass index (BMI) was 26, and the Charlson Comorbidity ...

Discussion

This study presents a detailed protocol for a single-position, prone lateral retropleural corpectomy. During the surgery, particular attention should be given to disc preparation, as the balance between disc removal and bony endplate preservation is crucial for achieving union and preventing cage subsidence¹². Furthermore, if an accidental pleural violation is noted during the air leak test, a chest tube, which has a larger diameter and greater negative pressure, should be placed instead of a Hemo...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Femoral strut allograft and rib autograft	N/A	N/A
Humerus strut and cancellous allograft	N/A	N/A
Obelisc Vertebral Body Replacement	Ulrich	CS 2920-17	expandable cage
Obelisc Vertebral Body Replacement	Ulrich	CS 2920-20	expandable cage
Obelisc Vertebral Body Replacement	Ulrich	CS 2920-23	expandable cage
T2 STRATOSPHERE	Medtronic	436013D	expandable cage
Tibia cancellous allograft, rib autograft and tibia strut allograft	N/A	N/A
Tibia strut allograft and cancellous tibia allograft	N/A	N/A
Tibia strut allograft and rib autograft	N/A	N/A
Tibia strut allograft, femoral head cancellous allograft and rib autograft	N/A	N/A
Tibia strut and cancellous allograft	N/A	N/A
Ulnar strut allograft and local bone autograft	N/A	N/A