23 Thoracoscopically Assisted Anterior Approach
to Thoracolumbar Fractures
R. Beisse
23.1
Terminology
The term thoracoscopic-assisted anterior approach to thoracolumbar fractures describes an anterior ap- proach to the thoracic (T5 – 10), as well as to the thora- columbar junction (T11-L2) which is performed using a closed endoscopic technique. The synonymous terms used in other scientific publications are video-assisted thoracoscopic surgery (VATS) or thoracoscopic spine surgery.
23.2
Surgical Principle
The goal of thoracoscopic surgery in the treatment of fractures is the restoration of normal curvature and stability of the affected motion segment(s). This is usu- ally achieved in a two-step procedure which includes posterior reduction and stabilization with a pedicle screw system. Anterior decompression of the spinal ca- nal, reconstruction of the fractured vertebra, as well as augmented (anterior plate system) interbody fusion with autogenous bone graft or with a vertebral body re- placement device is performed through a closed thora- coscopic anterior approach, which can be extended in- to the retroperitoneal space down to L3 if necessary.
23.3 History
Attempts at treating unstable fractures of the thoraco- lumbar junction by posterior reduction, decompres- sion, and (transpedicular) bone grafting, result in an average loss of correction of 10° in long-term follow-up studies [15]. Anterolateral stabilization with the use of a plating system and intercorporeal fusion with autoge- nous bone graft offers biomechanical, as well as techni- cal advantages in the reconstruction of the anterior col- umn which has to share 80 % of the axial load on the motion segment [20]. However, the tremendous iatro- genic trauma at the thoracolumbar junction is the ma-
jor disadvantage of this open surgical strategy [7, 8].
Most common discomforts are intercostal neuralgia, as well as post-thoracotomy pain syndromes [13]. More- over, complete dissection of the diaphragmatic inser- tions from the anterior circumference of the thoraco- lumbar spine is often necessary [1, 5].
Mack, Regan, Rosenthal, and colleagues were the first to report the application of thoracoscopic surgical principles to an anterior approach to the thoracic and thoracolumbar spine [16, 22 – 24]. There have been sev- eral attempts to open up the retroperitoneal space [10, 17, 19] and the thoracolumbar transition of the spine for endoscopic surgery [6, 11, 12, 18]. The endoscopic approach technique to the thoracolumbar junction, used at the Berufsgenossenschaftliche Unfallklinik in Germany for 7 years (1996 – 2004), was published first in 1998 [2]. Since 1996 this endoscopic approach has been used in a total of 410 patients to perform partial corpectomy and discectomy followed by the recon- struction of the anterior column with vertebral replace- ment and anterior instrumentation.
23.4 Advantages
The following advantages are associated with a thora- coscopic anterior approach:
Small intercostal surgical approaches without the necessity of rib resection or the use of rib retrac- tors
Excellent intraoperative view to the target area by the use of a high-resolution 30° optical lens system coupled to modern video-imaging equipment Efficient and safe anterior decompression of the spinal canal
Treatment of oligo- and multisegmental pathology without additional surgical approaches
Diminished blood loss
Low peri- and postoperative morbidity due to re-
duced wound pain, early extubation, and accelerat-
ed rehabilitation
23.5
Disadvantages
Increased monitoring of anesthesia and prepara- tion due to double-lumen ventilation
Long learning curve for surgeon and assistant Longer operating times initially.
23.6 Indications
The anterior thoracoscopic approach is indicated in the following situations (usually in combination with pos- terior instrumentation):
Fractures of the thoracic spine located at the thora- columbar junction from T4 to L3.
Fractures classified as A 1.2, A 1.3, A 2, A 3B, and C according to the AO classification [11] with signifi- cant curvature disturbance of 20° and more in the sagittal or frontal plane.
In fractures of types B and C, posterior instrumen- tation is mandatory. In other types it is optional.
Posttraumatic, degenerative, or tumorous narrow- ing of the spinal canal.
Discoligamentous segmental instability.
Posttraumatic deformities.
23.7
Contraindications
A thoracoscopic approach is contraindicated in the fol- lowing situations:
Significant previous cardiopulmonary disease with restricted cardiopulmonary function
Acute posttraumatic lung failure Significant disturbances of hemostasis
23.8
Patient’s Informed Consent
The patient should be informed about the following ap- proach-specific risks and hazards:
Donor site morbidity due to harvesting of the bone graft from the iliac crest (see also Chapters 45, 46) Direct or indirect injuries to the aorta, vena cava, azygos vein or segmental vessels
Blood loss from cancellous bone surface Injury to the heart and/or lungs
Possibility of conversion to a conventional “open”
thoracotomy
Injury to the spinal cord, spinal nerves, and sym- pathetic trunk with neurological deficits (deaffe- rentation syndrome) and sympathetic dystrophy Injury to spleen, liver, kidney, and ureter (thoraco- lumbar junction)
Injury to the thoracic duct
Pseudoarthrosis with loss of correction Implant loosening, implant failure
Infections at the target area, as well as at the donor site
Restricted pulmonary function due to fibrosis, scarring, atelectasis, or pleural effusion Diaphragmatic hernia
Necessity for anti-thrombotic medication Necessity for blood transfusion in emergency operations with risk of immunodepression, ana- phylaxis, as well as infection (HIV, hepatitis B, or cytomegaly virus)
23.9
Surgical Technique
23.9.1
Approach to Thoracolumbar Junction: Diaphragmatic Anatomy
The diaphragm originates from three locations, a ster- nal, a costal and a lumbar part, by means of crura and from arcuate ligaments. The sternal part arises by two fleshy slips from the dorsum of the xiphoid process.
The costal part arises from inner surfaces of cartilages and adjacent portions of the last six ribs on either side.
The right crus arises from the sides of the vertebral bodies of L1-3. The left crus arises from the sides of L1 and L2 vertebral bodies. The medial arcuate ligament covers the upper part of the psoas major muscle, at- taching from the sides of first and second lumbar verte- brae to the tip of the L1 transverse process. The lateral arcuate ligament covers the quadratus lumborum and attaches from the tip of the L1 transverse process to the lower border of the 12th rib. Thus, both the crura and arcuate ligaments of the diaphragm are inserted below the T12-L1 disc space [11, 21].
Lesions located above the T12-L1 disc can be ap- proached thoracoscopically from above without divid- ing the diaphragm as both crura and arcuate ligaments, which form the lumbar part of the diaphragm, are locat- ed below the T12-L1 disc space (Fig. 23.1). However, be- low the T12-L1 disc space, the spine is surrounded by the diaphragmatic crura, psoas muscles, and arcuate ligaments and thus in lesions located in this area require diaphragmatic detachment for adequate exposure.
The entire thoracolumbar junction can be exposed
thoracoscopically with minimal diaphragmatic detach-
ment. This is made possible by an anatomic peculiarity
of the pleural cavity and the diaphragmatic insertion,
Fig. 23.1. Diaphragmatic anatomy at the thoracolumbar junc- tion and the position of the portals
the lowest point of which, the costodiaphragmatic re- cess, is projected onto the spine with a perpendicular projection just above the inferior endplate of the sec- ond lumbar vertebra. Thus, with a diaphragmatic opening of about 4 – 6 cm, the entire L2 vertebral body can be exposed in the same way as with the convention- al open techniques.
23.9.2
Access Technique 23.9.2.1
Instruments
The following instruments are necessary to perform thoracoscopic-assisted anterior approaches to the tho- racic and lumbar spine:
Routine surgical set for skin incision and prepara- tion of the intercostal space
Instruments for removal of bone graft from the ili- ac crest (e.g., oscillating saw, sharp dissector, chis- els, mini-fragment set to reconstruct the iliac crest) Video-endoscopy: three-chip camera, 30°-angled rigid endoscope, xenon-light source, two monitors on opposite sides with the possibility of reversing the endoscopic picture, video recorder and printer, irrigation/suction unit, speculum (Aesculap, Tutt- lingen, Germany)
Instruments for the thoracoscopic dissection of the prevertebral anatomic structures, as well as for re- section of bone and ligaments, osteotomes, hooks for dissection, hook probes, sharp and blunt ron- geurs, Kerrison rongeurs, curettes, graft holder, reamers, mono- and bipolar probe (Aesculap) Instruments for implant placement, e.g., awl, screwdriver, plate set (MACS TL; Aesculap) Disposable instruments, lung retractor, clip appli- cator
23.9.2.2 Anesthesia
The procedure is performed with the patient under general anesthesia. Selected intubation with single- lung ventilation facilitates intrathoracic preparation.
The positioning of the double-lumen tube is controlled by a bronchoscopic technique. A Foley catheter and a central venous line(s) are placed, as well as an arterial line for continuous blood pressure measurement.
23.9.2.3 Positioning
The patient is placed in a stable lateral position on the right side and fixed with a four-point support at the symphysis, sacrum, and scapula, as well as with arm rests (Fig. 23.2).
For the treatment of fractures from T4 to T8, a left- sided position is preferred, whereas for the approach to the thoracolumbar junction (T9-L3), right-sided posi- tioning is preferred. We have moved away from pre- scribing fixed reference vertebrae for approaching from right or left. The decision on which side to choose for access is taken in each individual case based on the preoperative CT scans of the spinal section and the vas- cular situation of the aorta and the vena cava they show.
When positioning the patient, care has to be taken that the upper arm is abducted and elevated in order not to disturb the placement and manipulation of the endo- scope.
23.9.2.4 Localization
The target area (e.g., L1 fracture) is projected onto the skin level under fluoroscopic control and the borders of the fractured vertebra are marked on the skin (Fig. 23.3).
The working channel is centered over the target vertebra
Fig. 23.2. Positioning the patient
Fig. 23.3. Localization of the target area and the skin incisions
(10 mm). The optical channel (10 mm) is placed be- tween two and three intercostal spaces cranial to the target vertebra in the spinal axis. For fractures of the middle and upper thoracic spine, the optical channel is placed caudal to the target vertebra. The approach for suction/irrigation (10 mm) and retractor (10 mm) is placed approximately 5 – 10 cm anterior to the working and optical channel.
Before the operation starts, the position and free tilt of the C-arm has to be checked. Sterile draping extends from the middle of the sternum anterior to the spinous processes posterior as well as from the axilla down to about 8 cm caudal to the iliac crest.
Fig. 23.4. Intraoperative setup of the operation team and equipment
Both monitors are placed at the lower end of the op- erating table on opposite sides in order to enable free vision for the surgeon, as well as for the assistant. The surgeon and cameraman stand behind the patient. The C-arm approach is between the surgeon and the cam- eraman. The assistant, as well as the C-arm monitor are placed on the opposite side (Fig. 23.4).
23.9.2.5
Approach and Placement of Portals
The operation is started with the most cranial approach (optical channel). Through a 1.5-cm skin incision above the intercostal space, small Langenbeck hooks are inserted. The muscles of the thoracic wall are crossed using a blunt, muscle-splitting technique and the intercostal space is opened by blunt dissection. The pleura is exposed, an opening into the thoracic cavity is created, the 10-mm trocar is inserted, and single-lung ventilation is started.
The 30° endoscope is inserted at a flat angle in the di- rection of the second trocar. Perforation of the thoracic wall to insert the second, third, and fourth trocars is performed under visual control through the endo- scope, as shown in Fig. 23.5.
23.9.2.6
Prevertebral Dissection
The target area can now be exposed with the help of a
fan retractor inserted through the anterior port. The
Fig. 23.5. Placement of the endoscope and placement of retrac- tor, suction/irrigation, as well as working channel under endo- scopic control
Fig. 23.6. Intraoperative view of the thoracolumbar junction.
The retractor is placed on the diaphragm and a blunt probe is pointing out the anterior border of the spine
a Fig. 23.7. Case example I.
a Fracture of the T12 verte- bra type B 1.2 (AO classifica- tion)
retractor holds down the diaphragm and exposes the in- sertion of the diaphragm on the spine. The anterior cir- cumference of the motion segment, as well as the course of the aorta are palpated with a blunt probe (Fig. 23.6).
The line of dissection for the diaphragm is “marked”
with monopolar cauterization. The diaphragm is then incised using endo-scissors. A rim of 1 cm is left on the spine to facilitate closure of the diaphragm at the end of the procedure. Retroperitoneal fat tissue is now ex- posed and mobilized from the anterior surface of the psoas insertions. The psoas muscle is dissected very carefully from the vertebral bodies in order not to dam- age the segmental blood vessels “hidden” underneath.
23.9.3 Case Example I
In the following an endoscopic monosegmental fusion T11 – T12 is described for a fracture of the twelveth tho- racic vertebra type B 1.2 (AO classification) in a 26- year-old woman (Fig. 23.7a, b). Posterior reduction and fixation has been performed initially. We intend to per- form an endoscopic monosegmental anterior recon- struction with lag screw fixation of the split fracture at the lower half of the first lumbar vertebra.
23.9.3.1
Exposure of the Spine
Figure 23.8 demonstrates the intraoperative situation
after endoscopic exposure of the target area. The dia-
phragm is opened to access the retroperitoneal space
(Fig. 23.8). The retractor is now placed into the gap in
the diaphragm. Under fluoroscopic control, the first
screw of the MACS TL plate system (Aesculap) is insert-
ed into the caudal vertebral body (Fig. 23.9a, b).
b
Fig. 23.7. (contin.) b Biseg- mental posterior reduction and fixation using the Universal Spine System
Fig. 23.8. Opening of the diaphragm to expose the retroperito- neal space
a b
Fig. 23.9. Insertion of the first screw. a Three-dimensional model. b Intraoperative view
The cortical surface of the vertebral body is opened with a sharp trephine about 1 – 1.5 cm from the posteri- or border of the vertebral body infra- and supradjacent to the fracture (Fig. 23.10). A self-tapping screw is in- serted under fluoroscopic control in the vertebra supe-
Fig. 23.10. Insertion of the first screw and the polyaxial dump- ing element
rior to the fractured one, as well as in the fractured ver-
tebra. If there is an A 2 or A 3 fracture, it might be advis-
able to place the screw into the vertebra below the frac-
ture. The segmental vessels of the fractured vertebra
are mobilized, closed with vascular clips, and dissected.
23.9.3.2
Partial Corpectomy and Decompression of the Spinal Canal
The extent of the planned partial vertebrectomy is de- fined with an osteotome. The disc spaces are opened to define the borders. After resection of the intervertebral disc(s), the fragmented parts of the vertebra are re- moved carefully with rongeurs. Radical removal of non-fractured parts of the vertebral body should be avoided. If decompression of the spinal canal is neces- sary, the lower border of the pedicle should first be identified with a blunt hook. The base of the pedicle is then resected in a cranial direction with a Kerrison rongeur and the thecal sac can be identified. Now the posterior fragment which occupies the spinal canal can be removed (see Figs. 23.13 and 23.14; case example II).
23.9.4 Bone Grafting
Preparation of the graft bed is then completed and the length, as well as the depth of the bone graft are mea-
a b
Fig. 23.11. Insertion of the bone graft after partial corpectomy and discectomy. a Three-dimensional model. b Intraoperative view
a b
Fig. 23.12. Fixation of the MACS TL plate. a Three-dimensional model. b Intraoperative view
sured with a caliper. A tricortical bone graft is taken from the iliac crest. If the bone graft is longer than 2 cm, the iliac crest is reconstructed as described by Blauth et al. using a titanium plate [5]. The bone graft is prepared for insertion and mounted on a graft holder. The corti- cal bone is perforated with several burr holes to facili- tate vascular in-growth and new bone formation. The working portal is removed and a speculum is inserted.
This allows the insertion of a bone graft up to 1.5 cm in length into the thoracic cavity. If the bone grafts are longer, they are inserted without the use of the specu- lum, but with the help of Langenbeck hooks. In these cases, they are mounted on the graft holder inside the thoracic cavity. The bone graft is inserted by press-fit into the graft bed (Fig. 23.11a, b).
If slight reduction maneuvers are necessary, these can be achieved by manual pressure on the spinous processes of the involved segment thus creating a segmental lordosis. Then the MACS TL plate is insert- ed and mounted onto the screws. The stable-angled ventral screws are inserted using a target device (Fig.
23.12a, b).
23.9.5 Closure
The retractor is rearranged and the gap in the dia- phragm is closed with staples using an endoscopic technique (Fig. 23.13). The thoracic cavity is irrigated, blood clots are removed, and a chest tube is inserted with the end placed in the costodiaphragmatic recess.
The portals are closed with sutures after removals of the trocars. Postoperative X-rays as well as CT scans show a perfect reduction (Fig. 23.14).
23.9.6
Case Example II
Figures 23.15 and 23.16 demonstrate a case of an unsta- ble complete compression burst fracture of the first lumbar vertebra with severe spinal canal compromise.
After primary dorsal reduction and fixation, endoscop-
Fig. 23.13. Endoscopically-assisted suturing of the diaphragm
Fig. 23.14. Endoscopic mono- segmental anterior recon- struction T11 – T12 with bone graft and MACS TL system
ic anterior decompression was performed followed by anterior reconstruction using a distractible vertebral body replacement device (Synex) and an anterior fixa- tion plate (MACS TL system).
23.10
Postoperative Care
Postoperative AP and lateral X-rays of the target area are taken. The patient is extubated immediate- ly after the operation. In patients with chronic ob- structive pulmonary disease, old patients, as well as in patients with cardiovascular disease, artificial ventilation might be necessary for the first 24 h after the operation.
Low-dose low molecular weight heparin is given for thromboembolic prophylaxis.
The patient stays in the intensive care unit for 24 h.
The chest tubes can usually be removed on the first postoperative day.
On the second postoperative day physiotherapy is started (1 h/day).
From the third postoperative week, physiotherapy is intensified to 2 – 3 h daily.
X-ray controls are performed on the second post- operative day, after 9 weeks, as well as after 6 and 12 months.
The patient is allowed to return to work after
12 – 16 weeks.
Fig. 23.15. Case example II. Compression fracture type A 3.3 with spinal canal compromise
Fig. 23.16. Case example II. Primary dorsal reduction and fixation followed by endoscopic anterior decom- pression and reconstruction using Synex and MACS TL systems for bisegmental fusion
23.11
Complications, Hazards, and Pitfalls
23.11.1
Potential Intraoperative Complications
Incorrect positioning of the patient, as well as in- correct positioning of the C-arm might result in malpositioning of the screws.
Insufficient preparation of the segmental vessels can result in accidental injury, bleeding, and loss of visual control of the target area.
Risk of damage to the nerve roots by uncontrolled monopolar coagulation.
Risk of injury to the aorta and vena cava due to forceful use of sharp instruments.
Accidental injury to the heart, lung, and vessels which may require open thoracotomy.
Local injury to the lung parenchyma which may require suture or stapling.
Opening of the peritoneum which requires an endoscopic suture.
Dural tearing.
Insufficient preparation of the graft bed which might lead to forceful impaction with risk of indi- rect injury to the dura and spinal nerves due to displacement of bone or disc fragment into the spinal canal or foramen.
Insufficient reduction of the fractured vertebra.
23.11.2
Potential Postoperative Complications
Intrathoracic hemorrhage requiring thoracoscopic revision procedure or thoracotomy
Deep wound infection requiring open revision, debridement, removal of implant, and reosteosyn- thesis
Recurrent pleural effusions
Intrathoracic adhesions
Implant failure
0 0.2 0.4 0.6 0.8 Strategy
Fusion Decompression
Diaphr agm Split
35% 65%
15%
46%49%
5%
49%
0 10 20 30 40 T4
T6
T8
T10
T12
L2 23.11.3
Own Complications
The following major intraoperative complications oc- curred: loosening of one locking nut, and one uncon- trollable bleeding from cancellous bone. Both compli- cations occurred during the first interventions and ne- cessitated a change to an open approach. Another con- version to open thoracotomy was necessary in a patient with a lesion to the aortic wall which required sutures to control the bleeding. Thus, the overall conversion rate actually is 0.8 %.
An iatrogenic transient lesion of the L1 nerve root with sensory deficit and a transient compression of the thoracodorsalis nerve on the opposite side due to faulty positioning occurred. One deep wound infection at the approach site at L2 and one infected hematoma at the site of bone graft harvesting were seen. The overall rate of complications due to infections, pseudoarthrosis, and implant failure was 4.3 %, and 1.1 % due to the prepara- tion and implantation of screws and implant. Complica- tions due to the endoscopic approach, such as encapsu- lated pleural effusion, pneumothorax, and neuralgia of the intercostal nerve, occurred in 5.4 % of cases.
23.12
Conclusion and Critical Evaluations
Between May 1996 and May 2001, 371 patients with traumatic injuries of the thoracic and thoracolumbar spine underwent a minimally invasive thoracoscopic reconstruction, interpositional bone graft or cage, and anterior plate fixation (Fig. 23.17) [14]. The mean fol- low-up for our study group is 2.3 years, with at least 1- year X-ray follow-up in more than 85 % of patients.
When the AO classification scheme is used, 61 % of the fractures were type A variants, 22 % were type B vari- ants, and 17 % were highly unstable type C variants. As expected from the traumatic nature of the patients’ in- juries the majority (73 %) of the fractures were located within the region of the thoracolumbar junction (T11- L2) (Fig. 23.18). With stratification of our patients’ mo- tor and sensory function according to the classification scheme of Frankel et al. [9], 59 % of our patients were Frankel class E with no focal motor or sensory findings.
Of the 41 % of patients who had deficits, 14 % were class D, with preservation of useful function distal to the injury; 4 % were class C, with no useful motor func- tion distally; 4 % were class B, with no useful distal mo- tor function but some sparing of sensory function; and 19 % were Frankel class A, with complete neurological injury. Overall, 15 % of patients demonstrated evidence of significant neurological compression at the time of admission as well as a neurological deficit, thus requir- ing anterior endoscopic decompression.
Fig. 23.17. Types of procedures performed (n = 371)
Fig. 23.18. Thoracoscopic operations on the thoracic and thora- columbar spine (n = 371)
In 52 % of the surgical procedures for thoracolumbar pathologies, the diaphragm was incised and closed with staples or sutured under endoscopic control. No postoperative complications such as hernias or paresis of the diaphragm were recorded.
The duration of surgery became shorter over time.
At the beginning it took 6 h, but the average operation time is now 2 – 3 h. Included in this time are all proce- dures such as monosegmental grafting, resection of the posterior fragment for decompression of the spinal ca- nal, multisegmental surgery, as well as those performed at different levels. The shortest time for a monoseg- mental fusion T11/T12 was 70 min. Partial incision at the attachment and suture of the diaphragm increases the surgical time by 30 min and resection of the poste- rior rim by 60 – 90 min.
Based on our up-to-date experience with approxi- mately 840 endoscopic procedures, the advantages of a minimally invasive procedure are as follows. There is marked reduction in postoperative pain and a prompt return to function and mobility of the patient. Our goal to reduce the morbidity associated with the approach could be reached. Routine experience with “open”
spine and thoracic surgery is required to shorten the learning curve and to handle potential complications.
We are confident that the development of implants and
instruments adapted to the endoscopic procedure will
reduce the rate of complications and the duration of the operation even further.
The endoscopic approach has replaced open thora- cotomy in the group of patients described. The impres- sion that postoperative morbidity, as well as rehabilita- tion time, could be shortened by using to the endoscop- ic approach was proved in a clinical study comparing the results of 30 patients each following either open or endoscopic treatment. In the endoscopic group, the du- ration of application of analgesics was decreased by 31 % and the overall dosage of applied analgesics was decreased by 42 %. These results are supported by com- paring our own results with those published by Facis- zewski et al. [8]. In this multicenter study the complica- tion rate of a total of 1,223 open anterior approaches to the thoracic and lumbar spine were reported. The post- operative rate of pleural effusion, intercostal neuralgia, and pneumothorax was 14 % as compared to 5.4 % in our own series. The infection rate in the study was 0.57 % as compared to 0.53 % in ours. Injury to major blood vessels was reported to be 0.08 % which is less than in our study (one of 371 patients). However, we did not have any significant postoperative neurological deficits or lethal complications in the first 5 years, which were reported to be around 0.5 % in Faciszewski et al.’s series. A deadly complication occurred due to the appliance of high frequency burr and, as a conse- quence, we no longer use rotating devices for endo- scopic procedures. The goal to decrease intraoperative and postoperative morbidity has been achieved by the use of thoracoscopic techniques. However, complica- tions such as pseudoarthrosis, donor site morbidity, or loosening of implants could not be influenced.
The biological and biomechanical drawbacks of ver- tebral body replacement with autogenous bone grafts have not yet been solved. Some of the complications al- so resulted from insufficient angular stability of the im- plants primarily used; since November 1999 improve- ments have been made using an anterior fixation sys- tem providing angular stability [4].
The level of safety of endoscopic surgery is reflected in lower complication rates and operation times which are at least comparable with the open procedure. The basic intention in introducing endoscopic techniques – to reduce access morbidity – could be fully realized.
The complications are the expression of the dangers and limits of the procedure, the indication setting, and the high-risk environment of spinal surgery, which even the use of endoscopy cannot alter [3].
Acknowledgements.
The author is indebted to Mr.
Axel Stahlhut-Klipp, Fa. Framedivision, (www.frame- division.de) Herner Strasse 299, Geb 11/4, 44809 Bo- chum, for Figs. 23.1, 23.9a, 23.11a, and 23.12a.
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