Is It Worth the Sacrifice? Complications of Sacrificing the Neurovascular Bundle During Posterior-Only Transpedicular Thoracolumbar Corpectomies

Introduction: Posterior-only thoracolumbar corpectomy allows for the placement of expandable cages to reconstruct the spinal column following vertebral body resection. This approach often requires neurectomies of thoracic and upper lumbar levels to increase working area, resulting in mild sensory deficits. Despite its use, data on its complications are scarce, particularly concerning risks like spinal cord infarction due to injury to the artery of Adamkiewicz (T7 to L4). This study evaluates the complication profile of neurovascular bundle sacrifices, focusing on neurectomies in posterior-only thoracolumbar corpectomies.

Methods: Retrospective review of 35 patients who underwent posterior-only thoracolumbar corpectomies with expandable cage insertion between October 2021 and August 2024. Data on cerebrospinal fluid (CSF) leaks, muscle strength, sensitive deficits, and abdominal wall paresis was collected. Manual muscle testing (MMT) was used to calculate the strength delta. Postoperative MRIs were reviewed to detect T2-weighted signal intensity changes in the spinal cord. Descriptive statistics and chi-square tests were calculated in SPSS.

Results: 35 patients with 57 corpectomies were included. 54 neurectomies were performed from T3 to L2. 87% (n=47) thoracic, 13% (n=7) lumbar. 37 nerve on the left and 17 on the right. No patients developed abdominal wall paresis or clinically significant dysesthesias. Transient motor deficits were noted in 8 patients (23%), all fully recovered to their preoperative strength or better by the end of follow-up (Mean 121 days). Chi-square analysis revealed no statistically significant correlation between the level of neurectomy and the transient deficits between thoracic or lumbar (p=0.847).
Similarly, the number of neurectomies did not significantly correlate with transient motor deficits (p=0.944). We found a trend toward an association between side of neurectomy and side of transient weakness, which was not significant (p=0.165). Ten postoperative MRIs showed no spinal cord signal changes.

Conclusion : While avoiding neural structure sacrifice is ideal, thoracic and upper lumbar neurectomies (above L3) appear generally safe in this approach, which can cause permanent dermatomal numbness but no weakness. Surgeons should balance the risks and benefits of neurectomy, performing it only when necessary to optimize surgical outcomes. The absence of significant complications in this series supports the selective use of neurectomy in this procedure.