Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations

Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis

BACKGROUND AND OBJECTIVES

Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH.

METHODS

PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term "thoracic disc herniation" up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy.

RESULTS

We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23).

CONCLUSION

The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.

Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR)

Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10-11 level, two patients Th 7-8, one patient Th 9-10, one patient Th 11-12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions.

Transdural Ventral Sling Technique for Calcified Thoracic Disk Herniations

BACKGROUND

Surgery for thoracic disc herniations remains an ongoing challenge, with numerous surgical approaches, all with their own inherent risks. Discectomy via a posterior laminectomy was historically the treatment of choice; however, it was deemed very high risk with elevated rates of neurologic injury. The posterior transdural approach is an alternative surgical option for soft and calcified thoracic disc herniations.

METHODS

A 56-year-old female with many years of numbness/tingling in her hands and difficulty with fine motor tasks presented with progressive weakness and loss of balance in her legs. Imaging revealed a prominent focal central calcified disc herniation at the T5-T6 level causing severe effacement and distortion of the spinal cord. A posterior transdural approach for direct visualization of a large calcified disc herniation was performed, removing the calcified disc without the need for extensive exposure or entry into the thoracic cavity. A ventral sling of the dura was created to allow rotation of the spinal cord while removing the disc.

RESULTS

Intraoperative ultrasound confirmed complete disc resection, restoring cerebral spinal fluid flow circumferentially without residual impingement or cerebrospinal fluid leaks. At six months postsurgery, the patient's gait imbalance had resolved, and she had full lower extremity strength (5/5). Radiographic evaluation indicated stable implants without subsidence, pullout, fracture, or alignment loss.

CONCLUSIONS

The transdural approach is less invasive in nature, minimizes surgical exposure, patient morbidity, and provides better intraoperative control of the spinal cord. This constitutes an effective alternative surgical approach to both soft and calcified central thoracic disc herniations.

Posterior video-assisted trans pedicular surgery for calcified midline thoracic disc herniation

BACKGROUND

In the treatment of patients with calcified midline thoracic disc herniation (CMTDH), the posterior video-assisted transpedicular surgery (VATPS) technique is employed. Both anterior and posterior surgical approaches for treating CMTDH carry a significant risk of surgical complications and potential morbidity. This technical note introduces a surgical procedure that avoids the drawbacks associated with these approaches.

METHODS

The VATPS technique presents a comprehensive approach for treating thoracic disc herniation, combining both microscopic and endoscopic stages. The microscopic phase entails a small thoracoscopic incision, muscle release, hemilaminotomy, facet joint resection, and vertebra removal, culminating in creating a corpectomy cavity for endoscope access. Careful separation of adhesions between the dura and ligaments marks this stage. Transitioning to the endoscopic phase, an endoscope is inserted into the cavity, allowing for precise visualization and separation of residual adhesions, removal of calcified disc fragments using specialized instruments, and ensuring complete discectomy.

RESULTS

Fourteen patients underwent VATPS for CMTDH. During the procedure, evoked responses were reduced in one patient. However, no postoperative neurological deficits were observed. We also noted significant improvements in the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) scores when comparing the preoperative and postoperative assessments.

CONCLUSION

VATPS, a minimally invasive technique, offers excellent anterior visibility comparable to that of the anterolateral approach, all while avoiding the adverse effects associated with thoracotomies and the complications resulting from spinal cord encroachment often seen in the posterolateral approach. Moreover, it is a safer alternative to conventional endoscopic posterior thoracic surgery. The cavity formed within the vertebral corpus provides ample working space for the use of an endoscope.

Giant calcified thoracic disk herniations: ossification of PLL or autonomous entity?

BACKGROUND

Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of ossified posterior longitudinal ligament (OPLL) with a possible common pathophysiology consisting in the dural violation.

METHODS

Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital, Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed.

RESULTS

There was no mortality, whereas permanent morbidity consisted of 1 case of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL.

CONCLUSIONS

GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.

Transdural circumferential decompression for thoracic spinal stenosis caused by beak-type ossification of the posterior longitudinal ligament: a technical note

PURPOSE

Thoracic myelopathy caused by ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine is usually progressive and responds poorly to conservative therapy, making surgery the only effective treatment option. A variety of surgical procedures have been developed to treat thoracic OPLL. However, the optimal surgical approach for removal of thoracic OPLL remains unclear. In the present study, we described a newly modified posterior approach for the removal of OPLL: circular decompression via dural approach, and complete removal of OPLL can be achieved under direct vision and without neurological deficit.

MATERIALS AND METHODS

Three patients with beak-type thoracic OPLL presented with progressive thoracic myelopathy and leg weakness. Magnetic resonance imaging showed the spinal cord severely compressed. The surgical management of the three patients involved the 'cave-in' circular decompression and transdural resection of OPLL.

RESULTS

Transdural circumferential decompression was successfully performed in all three patients. Clinical outcome measures, including pre- and postoperative radiographic parameters, were assessed. All of the patients were followed up for an average of 12 months (ranging from 10 to 15 months), and no surgery-related complications occurred. Weakness relief and neural function recovery were satisfactorily achieved in all patients by the final follow-up.

CONCLUSIONS

Transdural circumferential decompression was an effective method for thoracic spinal stenosis caused by concurrent beak-type OPLL, by which OPLL could be safely removed. It is especially useful when there is a severe adhesion between the dura OPLL.

Comparison of Anterior Approach and Posterior Circumspinal Decompression in the Treatment of Giant Thoracic Discs

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

The treatment of giant thoracic disc herniation (gTDH)remains challenging for surgeons worldwide because of its large volume and calcified or ossified nature and the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness. We aim to compare the anterior decompression and spinal fusion (ASF) and posterior circumspinal decompression and spinal fusion (PCDF) for patients with myelopathy due to gTDH in the largest study to date by sample size.

METHODS

Preoperative and postoperative functional status, surgical details, and complication rates were compared between the 2 groups.

RESULTS

A total of 186 patients were included: 63 (33.9%) ASF and 123(66.1%) PCDF. The PCDF group had significantly shorter operation duration (163.06 ± 53.49 min vs. 180.78 ± 52.06 min, P = 0.032) and a significant decrease in intraoperative blood loss(716.83 mL vs. 947.94 mL, P = 0.045), and also a shorter hospital length of stay (LOS) and postoperative LOS (6 vs. 7, P = 0.011). The perioperative complication rate (13.8% vs. 28.6%, P = 0.015) and surgery-associated complication rate(13.0% vs. 27.0%, P = 0.018) were significantly higher in the ASF group. A higher rate of complete decompression was achieved in the PCDF group. There were no observed significant differences in changes in functional status between the 2 groups.

CONCLUSION

PCDF for central or paracentral gTDHs is a highly effective and reliable technique. It can be performed safely with a low complication rate. If either procedure can adequately excise a central or paracentral gTDH, a PCDF approach may be a better option.

Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts

Thoracic herniated disks are relatively rare. They account for approximately 2% of all intervertebral herniated disks in large series. Traditional surgery via laminectomy has frequently yielded disappointing results, although the recent literature reports that anterior calcified thoracic herniation was successfully treated with this approach. This issue has encouraged a search for alternatives, such as anterolateral, lateral, and posterolateral approaches to the thoracic spine. From January 2009 to December 2019, we selected 66 patients harboring a symptomatic median-paramedian herniated disk at the level of the thoracic spine, treated at the authors' institutions. The present experience would give further support to the use of costotrasversectomy, along with its "mini-invasive" modifications, as a suitable and safe approach for thoracic disk disease. Although we must admit that endoscopy is likely to become the gold standard of surgical method in the future and that the anterior approach with mini-toracotomy without rib removal will become popular, the future scenario could certainly reserve an important place for the approach we have used in the surgical management of this challenging spinal pathology, mainly because of the approach's versatility and short learning curve.

Long-term operative outcome of giant calcified thoracic disc herniation – A retrospective analysis of 24 patients

Background:

Thoracic disc herniations (TDHs) are rare (0.15–4%) and often cause significant myelopathy (70–95%). They are defined as “Giant” if they occupy >40% of the spinal canal. Further, they are ossified/calcified in 42% of cases, with a 70% incidence of intradural extension. Here, we reviewed our experience resecting 24 giant thoracic discs utilizing a posterolateral surgical approach.

Methods:

Over a 2-year period, we evaluated the outcomes for 24 patients averaging 40 years of age undergoing posterolateral resections of giant ossified/calcified TDH. We evaluated multiple clinical and radiographic parameters; demographics, Frankel grades, surgical time, perioperative complications, and number of levels involved. In addition, utilizing magnetic resonance/computed tomography studies, we documented that the most commonly involved level was T11–T12, and the average canal occupancy ratio (i.e., degree of canal encroachment) was 58.2 ± 7.72%.

Results:

Neurological improvement was seen in 22 of the 24 patients; none experienced neurological deterioration over the average 2-year post-operative period. Six complications occurred; three dural tears and three suture site infections.

Conclusion:

The posterolateral approach proved to be safe and effectively for resecting 24 giant ossified/calcified TDH with minimum complications.

Minimally invasive dorsal approach in the surgery of giant thoracic disc herniation: technical note and clinical case report

Giant thoracic disc herniations are calcified hernias that fill more than 40% of the spinal canal and result in myelopathy with associated neurological symptoms. This is a fairly rare abnormality that requires surgical treatment. Currently, there is no unambiguous opinion about the surgical approach to the treatment this pathology. It is believed that the most effective method is the anterior approach (mini-thoracotomy or thoracoscopic approach), which reduces the risks of spinal cord injury, but is associated with the risks of damage to the lungs, pleura and major vessels. It is also quite large. We describe the case of a 60-year-old female patient with a giant thoracic disc herniation. Complete removal of the hernia through a minimally invasive dorsal approach was performed, followed by stabilization. No complications have been registered after the surgery. In this case, surgery resulted in a curative treatment outcome for the patient.

[Surgical treatment of herniated thoracic discs using transthoracic extrapleural approach]

OBJECTIVE

To analyze the results of herniated thoracic disc resection via transthoracic extrapleural approach.

MATERIAL AND METHODS

The study included 16 patients with 18 symptomatic herniated thoracic discs wo underwent transthoracic extrapleural surgery. In 11 cases, clinical pattern of disease was represented by myelopathy with radicular or axial pain syndrome. Five patients had radiculopathy alone. Median localization of hernias was observed in 8 (44.4%) cases, paramedian hernias - in 10 (55.6%) cases. There were 10 (55.6%) ossified hernias, 5 (27.7%) giant, 10 (55.5%) large and 3 (16.6%) medium hernias.

RESULTS

In most patients, VAS score of pain syndrome decreased by 2-6 points (mean 3.6). In 4 patients, this value remained the same. Among 11 patients with myelopathy, regression of conduction disorders in 1 year after surgery was achieved in 9 (82%) cases including complete recovery in 6 (55%) patients (Frankel E, Nurick - 0-I). In 2 patients, neurological status was equal to preoperative one. In all cases, the follow-up examination confirmed total removal of compressive substrate and found no signs of spine instability. Surgery time varied from 80 to 210 min (mean 161), blood loss - from 300 to 800 ml (mean 378 ml). Two patients had transient neurological deterioration. There was damage to dura mater in 4 cases. Intercostal neuralgia was observed in 3 patients.

CONCLUSION

While retaining the advantages of open thoracotomy, transthoracic extrapleural approach is less traumatic, allows complete spinal cord decompression, minimizes the risk of iatrogenic spinal cord injury and avoids certain postoperative complications.

Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation.

METHODS

This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described.

RESULTS

Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation.

CONCLUSION

This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series

BACKGROUND

Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches.

OBSERVATIONS

Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness.

LESSONS

In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.

Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases

STUDY DESIGN

Retrospective observational study.

OBJECTIVES

Thoracic disc prolapse (TDP) surgeries have reported complications ranging from paraplegia to approach related complications. This study is to present a series of TDP patients surgically treated with transforaminal thoracic interbody fusion (TTIF). Emphasis on surgical technique and strategies to avoid complications are analyzed.

METHODS

Eighteen patients with TDP were included. Imagings were analyzed for end-plate changes and calcification. Type of disc prolapse (central/para-central) and percentage of canal occupancy were noted. Objective outcome was quantified with Visual Analogue Scale (VAS), modified Nurick's grade, and ASIA (American Spinal Injury Association) score. All complications were noted.

RESULTS

Eighteen patients (average age 43.65 years) having total 22 levels operated, that included double level (n = 2) and missed level (n = 2) are reported. All patients had myelopathy. Calcification of disc (n = 13), central disc prolapses (n = 9), para-central (n = 11) and more than 50% canal occupancy (n = 8) were noted. VAS back pain, modified Nurick's grade and ASIA grade improved significantly in all patients. One patient had postoperative transient deficit. The functional score achieved its maximum at 1 year follow-up and remained static at final follow-up of 65.05 months. Union was achieved in all patients.

CONCLUSIONS

The most important factor for outcome in TDP is the technical aspect of avoiding cord manhandling and avoiding wrong level surgeries. TTIF is not devoid of complications but can give good results to posterior approach trained surgeons.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

PURPOSE

The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches.

METHODS

Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12-79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions.

RESULTS

Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X² 4.13 P:0.042). Severe post-operative neuralgia (VAS 7-10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X² 7.07 p 0.0078).

CONCLUSIONS

MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Clinicopathologic Features of Thoracolumbar Interdural Disc Herniations: A Retrospective Case Series with a Systematic Literature Review

BACKGROUND

Transdural disc herniations represent about 0.3% of all herniated discs. Preoperative imaging rarely demonstrates this condition. Therefore, diagnosis of transdural disc herniation is usually made intraoperatively. We describe the clinicopathologic features of extremely rare cases of thoracic and lumbar interdural disc herniations mimicking spinal intradural en plaque tumors.

METHODS

This is a retrospective case series with a systematic literature review. Clinical presentation, imaging, differential diagnosis, intraoperative microsurgical findings, and possible pathogenesis were reviewed according to published guidelines. All patients underwent a posterior approach for microsurgical excision of disc herniation, but no epidural lesion was found. At intradural exploration, a tumor-like en plaque lesion was discovered. The surface of the lesion was incised, and multiple friable, cartilaginous white-yellow fragments were removed to achieve complete intralesional excision.

RESULTS

The postoperative course was characterized by progressive neurologic improvement in all cases. In peculiar anatomic (adhesions between the anulus fibrosus, posterior longitudinal ligament, and ventral surface of dura mater) and pathologic (calcified giant disc herniation, spinal canal stenosis, previous lumbar spine surgery) conditions, penetration of disc fragment in the thickness of spinal dura mater can occur.

CONCLUSIONS

Interdural disc herniations constitute a rare pathologic condition characterized by the migration of the herniated disc in neither the epidural nor the subdural spinal space, but rather in the thickness of the spinal dura mater. Further advances are necessary in neuroradiologic investigations to achieve a correct preoperative diagnosis, which is essential, as spine surgeons must be aware of these rare pathologies.

Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach

Although symptomatic thoracic disk herniation (TDH) is relatively rare, its treatment is quite difficult. Our aim is to present the outcomes and complications in patients with thoracic disk herniation treated with minimally invasive lateral transthoracic approach (LTTA). Fifty-nine consecutive patients with 69 symptomatic disk herniations that underwent minimally invasive LTTA to treat TDH between 2007 and 2016 were enrolled. Medical records were reviewed retrospectively. The numbers of TDH were as follows: 41 central, 10 paracentral, and 18 both central and paracentral. The number of calcified disk herniations was found to be 32. No patient developed neurological deficit. Postoperative neurological improvement occurred in 39 (90.7%) of 43 patients with myelopathy. Preoperative VAS scores, ODI scores, and SF-36 scores improved at the follow-up, respectively. Mean blood loss, hospitalization period, and follow-up period were found to be 391.2 mL, 4.7 days, and 60 months; respectively. The following complications were observed: dural tear (five patients), intercostal neuralgia (three patients), rib fracture (one patient), pleural effusion requiring chest tube (two patients), hydropneumothorax requiring chest tube (one patient), small pneumothorax (one patient), atelectasis (one patient), pulmonary embolism (one patient), and pneumonia (one patient). Minimally invasive LTTA not only minimizes the manipulation of the thecal sac decreasing the risk for neurological injury compared to traditional posterior methods but also significantly decreases the pulmonary complications associated with traditional open procedures. Based on the authors' experience, anterior approach should be preferred especially in calcified central disk herniations regardless of surgeon's experience.

Surgical treatment of thoracic disc herniation: an overview

BACKGROUND

Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord.

METHODS

Literature review.

RESULTS

Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications.

CONCLUSION

Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Management of Giant Thoracic Disc Herniation by Thoracoscopic Approach: Experience of 53 Cases

BACKGROUND

Giant thoracic disc herniation (gTDH) is a rare condition. It is defined by a herniation that occupies at least 40% of the thoracic spinal canal and is usually calcified. Several surgical techniques have been described to date but this surgery remains a technically difficult procedure.

OBJECTIVE

To report the long-term outcome of 53 patients with myelopathy due to gTDH who were operated on by a thoracoscopic approach. The technical details of the preoperative assessment and the surgical procedure are presented.

METHOD

We present a retrospective study of a database of 53 patients operated for symptomatic gTDH by a thoracoscopic approach. The following clinical parameters were assessed initially and used during follow-up: Frankel grade and JOA score adapted to the thoracic spine (mJOA), pain in the lower limbs and limitation of the walking perimeter to less than 500 meters. The quality of spinal cord decompression was assessed postoperatively by magnet resonance imaging (MRI).

RESULTS

The mean follow-up was 78.1 mo (SD 49.4). At the last follow-up visit, clinical examination showed a mean improvement of 0.91 Frankel grade (P < 0.001) and 2.56 mJOA score respectively (P < 0.001). Lower limb pain and walking perimeter were also improved. Postoperative MRI revealed that the resection was complete in 35 cases, subtotal in 13 cases, and incomplete in 5 cases.

CONCLUSION

gTDH is a condition that often evolves favorably after surgery. The thoracoscopic approach is a feasible alternative technique.

Full-endoscopic uniportal decompression in disc herniations and stenosis of the thoracic spine using the interlaminar, extraforaminal, or transthoracic retropleural approach

OBJECTIVE Surgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. The objective of the study was to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. METHODS Between 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months. RESULTS Sufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms. CONCLUSIONS The full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required.

Thoracic disc herniation: Surgical treatment

Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications.

Anterior Versus Posterior Thoracic Discectomy: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

The aim of this study was to systematically review the current evidence in the literature on thoracic discectomies, to compare the clinical outcomes, and to determine whether there is evidence to support the use of either the anterior or posterior approach.

SUMMARY OF BACKGROUND DATA

Thoracic disc herniations (TDHs) often present with myelopathy, radiculopathy, or a combination of both. The posterior approach for thoracic discectomy has been associated with a lower complication rate, but no systematic review exists comparing the clinical outcomes.

METHODS

MEDLINE, EMBASE, and The Cochrane Library databases were searched in accordance with the PRISMA guidelines for studies performing an anterior or posterior thoracic discectomy. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies checklist. The reported clinical outcomes were evaluated using risk ratio, with a P < 0.05 being considered statistically significant.

RESULTS

Thirty-seven clinical studies with 1156 patients with 1300 TDHs were included in this review. There was no statistically significant difference in the total neurological improvement or neurological worsening using either an anterior approach or a posterior approach (P = 0.02812 and P = 0.5232, respectively). However, there was a statistically significant higher rate of total complications in the anterior approach (P = 0.0024).

CONCLUSION

The anterior approach and posterior approach have been shown to be very similar in terms of neurological outcomes. Although the posterior approach was shown to have a lower rate of total complications, this was largely because of a decrease in minor respiratory complications seen in the anterior approach. The optimal approach may therefore be based on surgeon preference as well as patient factors, specifically cardiorespiratory with American Society of Anaesthesiologists grading.

LEVEL OF EVIDENCE

4.

Management of Thoracic Disc Herniations via Posterior Unilateral Modified Transfacet Pedicle-Sparing Decompression With Segmental Instrumentation and Interbody Fusion

STUDY DESIGN

Retrospective consecutive case series.

OBJECTIVE

The objective of this case series was to demonstrate the safety of a modified transfacet pedicle-sparing decompression and instrumented fusion in patients with thoracic disc herniations (TDHs).

METHODS

Consecutive patients undergoing operative management of TDH from July 2007 to December 2011 using a posterior unilateral modified transfacet pedicle-sparing approach were identified. All patients underwent open or minimally invasive modified transfacet pedicle-sparing discectomy and segmental instrumentation with interbody fusion, performed by four different surgeons. Pre- and postoperative visual analog scale (VAS) pain scores, Nurick grade, and American Spinal Injury Association Impairment Scale (AIS) were analyzed from a retrospective chart review. Estimated blood loss and complications were also obtained.

RESULTS

Fifty-one patients were included that had operations for TDH. Thirty-nine patients had single level decompression and 12 had multilevel decompression. The total number of levels operated on was 64. Five patients were treated with minimally invasive surgery. A herniated disc level of T11-12 (n = 17) was treated most often. One major complication of epidural hematoma occurred. Minor complications such as malpositioned hardware, postoperative hematoma, wound infection, pseudoarthrosis, and pulmonary complications occurred in a few patients. Follow-up ranged from 1 to 46 months with 1 patient lost to follow-up. From preoperative to final postoperative: mean VAS scores improved from 8.31 to 4.05, AIS in all patients remained stable or improved, and Nurick scores improved from 3 to 2.6 on average. No intraoperative or permanent neurological deficit occurred.

CONCLUSION

In our surgical series, 51 consecutive patients underwent modified transfacet pedicle-sparing approach to TDHs and experienced improvement of functional status as well as improvement of objective pain scales with no neurological complications. The posterior unilateral modified transfacet pedicle-sparing decompression and instrumented fusion approach to the thoracic spine is a safe and reproducible procedure for the treatment of TDHs.

Circumferential Decompression via a ModifiedCostotransversectomy Approach for the Treatment of Single Level Hard Herniated Disc between T10 -L1

OBJECTIVE

To describe a novel surgical strategy for circumferentially decompressing the T10 -L1 spinal canal when impinged upon by single level hard thoracic herniated disc (HTHD) via a modified costotransversectomy approach.

METHODS

This is a retrospective review of 26 patients (17 men, 9 women; mean age at surgery 48.5 years, range 20-77 years) who had undergone single level HTHD between T10 -L1 by circumferential decompression via a modified costotransversectomy approach. The characteristics of the approach are using a posterior midline covered incision, which keeps the paraspinal muscle intact and ensures direct visualization of circumferential spinal cord decompression of single level HTHD between T10 -L1 .

RESULTS

The average operative time was 208 ± 36 min (range, 154-300 min), mean blood loss 789 ± 361 mL (range, 300-2000 mL), mean preoperative and postoperative mJOA scores 5.2 ± 1.5 and 9.0 ± 1.3, respectively (t = 19.7, P < 0.05). The rate of recovery of neurological function ranged from 33.3% to 100%. The ASIA grade improved in 24 patients (92.3%) and stabilized (no grade change) in two (7.7%). MRI indicated that the cross-sectional area of the dural sac at the level of maximum compression increased from 45.0 ± 5.8 mm(2) preoperatively to 113.5 ± 6.1 mm(2) postoperatively (t = 68.2, P < 0.05). Anterior tibialis muscle strength of the 15 patients with foot drop had a mean recovery rate of 95% at final follow-up. One patient who resumed work early after the surgery showed a significantly augmented Cobb angle. One patient had transient postoperative cerebrospinal fluid leakage. No patients showed neurological deterioration.

CONCLUSIONS

This procedure achieves sufficient direct visualization for circumferential decompression of the spinal cord via a posterior midline covered costotransversectomy approach with friendly bleeding control and without muscle sacrifice. It is a reasonable alternative treatment option for thoracic myelopathy caused by single level HTHD between T10 -L1 .

A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax

PURPOSE

To highlight the importance of preventing visceral injury due to prominent anterior implants at the spinal column.

METHODS

A 52-year-old man with cord compression was treated with a T9/10 discectomy and instrumented fusion via a right thoracotomy and trans-pleural approach. Postoperatively, he had improved lower limb numbness. However, after a bout of coughing, there was sudden increase in chest drain output, hemodynamic instability and massive fluid collection in the right chest cavity.

RESULTS

Emergency re-exploration of the thoracotomy was performed and a 6 cm laceration of the right postero-medial diaphragm was identified as the bleeding source and was found to be in close proximity with the locking nut of the anterior implants. The laceration was repaired and a soft synthetic patch was used to cover the implants. Postoperatively, the hemothorax resolved and the patient recovered from the neurological deficit.

CONCLUSIONS

Prevention of diaphragmatic injury can be performed using lower profile and less sharp-edged implants. Implant coverage with a soft synthetic material is necessary if unable to perform direct repair of the parietal pleura over the implants.

Abducens nerve palsy as a postoperative complication of minimally invasive thoracic spine surgery: a case report

Background

Thoracic disc surgeries make up only a small number of all spine surgeries performed, but they can have a considerable number of postoperative complications. Numerous approaches have been developed and studied in an attempt to reduce the morbidity associated with the procedure; however, we still encounter cases that develop serious and unexpected outcomes.

Case Presentation

This case report presents a patient with abducens nerve palsy after minimally invasive surgery for thoracic disc herniation with an intraoperative spinal fluid fistula. A literature review of all cases related to this complication after spine surgery is included.

Despite the uncommon nature of this type of complication, understanding the procedure itself, the principle occurrences and outcomes following the procedure, the physiopathogical features of abducens nerve palsy, and the possible adverse effects of spinal surgery, including minimally invasive procedures, can enable an early diagnosis of complications and facilitate the procedure.

Conclusions

In spite of being very rare and multifactorial, uni- or bilateral abducens nerve paralysis carries significant morbidity and can occur as a postoperative complication after conventional or minimally invasive spine surgery. This condition requires an accurate diagnosis and adequate multidisciplinary follow up.

Surgical Treatment for Central Calcified Thoracic Disk Herniation: A Novel L-Shaped Osteotome

Few reports are available on the posterior transfacet approach for the treatment of central calcified thoracic disk herniation (TDH). The objective of this study was to assess outcomes and complications in a consecutive series of patients with TDH who underwent posterior transfacet decompression and diskectomy with segmental instrumentation and fusion. The data for 27 patients (16 males and 11 females) were retrospectively reviewed and analyzed, including clinical presentation, blood loss, operative time, pre- and postoperative complications, visual analog scale, Japanese Orthopedic Association (JOA) score, and Frankel grade. All patients underwent trans-facet decompression and segmental instrumentation with interbody fusion. Mean patient age at surgery was 55.2 years (range, 21-81 years). Average follow-up was 30±19 months (range, 12-50 months). All patients were successfully treated with posterior decompression and segmental instrumentation with interbody fusion. Average operative time was 124±58 minutes (range, 87-180 minutes). Mean blood loss was 439±225 mL (range, 300-1500 mL). Average pre- and postoperative JOA scores were 4.12±0.87 and 8.01±0.97 points, respectively. Overall JOA scores showed a significant postoperative improvement. Overall recovery rates were excellent in 12 patients, good in 6, fair in 5, and unchanged in 1. No patient was classified as worse. The results suggest that the posterior approach using a special L-shaped osteotome is feasible. No major complications occurred while achieving adequate decompression for central calcified TDH.

Mini-open transthoracic approach for resection of a calcified herniated thoracic disc and repair of the dural surface with fibrin glue: a case report

This study reports a case of severe anterior compression of the spinal cord by a calcified herniated thoracic disc at the T9/10 level in a 46-year-old woman. She underwent resection of the calcified herniated thoracic disc and the integrated dura, using a microscopically assisted mini-open transthoracic approach. The remaining dura mater was shaped and repaired by alternate overlapping without suture. The dural surface was reinforced with a combination of fibrin glue and a polyglycolic acid sheet. This novel procedure prevented postoperative cerebrospinal fluid leakage. The patient made an excellent recovery, without any complications.

Anterior or posterior approach of thoracic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies

BACKGROUND CONTEXT

The optimal surgical treatment of thoracic disc herniations remains controversial and depends on the consistency of the herniation and its location related to the spinal cord.

PURPOSE

To compare the outcomes of patients with symptomatic thoracic disc herniations treated with anterolateral mini-transthoracic approach (TTA) versus posterior transpedicular discectomy.

STUDY DESIGN

This is a prospective comparative cohort study.

PATIENT SAMPLE

One hundred consecutive patients with symptomatic thoracic herniated discs were operated by mini-TTA (56 patients) or transpedicular discectomy (44 patients).

OUTCOME MEASURES

Neurologic assessment by American Spinal Injury Association (ASIA) Impairment Scale and patients' self reported perceived recovery and complications.

METHODS

The consistency and location of the herniated disc in relation to the spinal cord was evaluated by preoperative computed tomography and magnetic resonance imaging. Patients were assessed neurologically before surgery and at regular outpatient controls at 2 months or later. Long-term follow-up was achieved by questionnaires sent by mail.

RESULTS

In both groups, most patients had symptoms of myelopathy and radicular pain; patients who underwent mini-TTA, more frequently suffered from spasticity. Fifty-eight percent of the herniated discs were calcified and 77% were larger than one-third of the spinal canal. All patients presented with ASIA Grade C or D (64%) or ASIA Grade E (36%). Postoperatively, 50% of the patients treated with mini-TTA and 37% of the transpedicular group improved at least one grade on the ASIA scale (p=.19). The duration of surgery, blood loss, hospital stay, and complication rate were significantly higher in patients treated with mini-TTA and were mainly related to the magnitude and consistency of the herniated disc. At long-term follow-up, 72% of the mini-TTA patients reported good outcome versus 76% of the transpedicular discectomy group (p=.80).

CONCLUSIONS

Surgical treatment of a symptomatic herniated disc contributed to a clinical improvement in most cases. The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc. Medially located large calcified discs should be operated through an anterolateral approach, whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers.

Surgical treatment for thoracic disc herniation: an update

STUDY DESIGN

Retrospective review of the literature.

OBJECTIVE

To update recent trends in the surgical treatment for thoracic disc herniation (TDH).

SUMMARY OF BACKGROUND DATA

TDH is rare; however, it is usually accompanied by myelopathy and is indicated for surgical treatment. A variety of surgical approaches have been described to reach these anatomically challenging lesions.

METHODS

Review of the literature.

RESULTS

Recently, minimally invasive techniques for TDH have gained popularity. These include thoracoscopic and mini-open anterolateral retropleural approaches, as well as microscopic and endoscopic surgery. In addition, this article updates important aspects of surgical treatment for TDH such as definition of surgical level, treatment of calcified and/or giant disc, multilevel lesions, and fusion requirements.

CONCLUSION

Definition of surgical level is imperative in the surgical treatment for TDH. Outcomes of minimum invasive surgery are satisfactory. Type of disc herniation and biomechanical stability are the important factors for surgical planning.

Calcified giant thoracic disc herniations: considerations and treatment strategies

INTRODUCTION

Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD.

METHODS

This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients' notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications.

RESULTS

During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31-83 years). The average canal encroachment was 62% (range 40-90%); mean follow-up 37 months (12-98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212-601 min) and estimated blood loss 1,230 ml (range 350-3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62%), 2 improved by 2 grades (15%) and 3 did not change their grade (23%). The complication rate was 4/13 (31%; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence).

DISCUSSION

Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23%) or improved by at least 1 grade (77%) neurologically, without radiographic failure at final follow-up.

Transthoracic approach for the treatment of calcified giant herniated thoracic discs

OBJECTIVE

This study aimed at reporting the results of a transthoracic approach in the treatment of patients with calcified giant herniated thoracic discs (HTDs).

METHODS

Fifteen consecutive patients, 11 males and 4 females with a mean age of 46 years (range 33-61), with calcified giant HTDs underwent transthoracic decompression and segmental instrumentation with interbody fusion from November 2004 to September 2010. Clinical data retrospectively examined and compared were levels and types of disc herniation, operative time, blood loss, pre- and postoperative Frankel grades and Japanese Orthopedic Association (JOA) score, and complications.

RESULTS

Of the 15 patients, 2 had HTDs at two levels and affected discs were primarily at the T11/12 level (60%). Presenting symptoms included myelopathy, axial back pain, urinary symptoms, and radiculopathy. Disc herniations were classified as central (40%) or paracentral (60%). All discs were successfully removed without dural tears or cerebral spinal fluid leakage. The mean operation time was 179 ± 27 min (range 140-210 min), and the mean estimated blood loss was 840 ± 470 ml (range 300-2,000 ml). Frankel grades improved in 9 patients postoperatively and 12 patients at the last follow-up. The mean JOA score improved from 4.9 to 7.7. All patients reported improvement in symptoms. The average duration of follow-up was 45 ± 24 months (range 7-77 months).

CONCLUSIONS

Transthoracic decompression combined with reconstruction, fusion, and fixation is an effective method for the treatment of these lesions and is associated with a low rate of complications, morbidity, and neurological impairment.

Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision

BACKGROUND

Thoracic cerebrospinal fluid (CSF) hygroma is a rare and potentially devastating complication of the anterior thoracic approach to the spine. We present two cases in which this complication resulted in acute cranial nerve palsy and discuss the pathoanatomy and management options in this scenario.

CASE REPORTS

Two male patients presented to our department with neurological deterioration due to a giant herniated thoracic disc. The extruded disc fragment was noted pre-operatively to be calcified in both patients. A durotomy was performed at primary disc prolapse resection in the first patient, whereas an incidental durotomy during the procedure caused complication in the second patient. These were repaired primarily or sealed with Tachosil(®). Both patients re-presented with acute diplopia. Imaging of both patients confirmed a massive thoracic cerebrospinal fluid hygroma and evidence of intracranial changes in keeping with intracranial hypotension, but no obvious brain stem shift. The hemithorax was re-explored and the dural repair was revised. The first patient made a full recovery within 3 months. The second patient was managed conservatively and took 5 months for improvement in his ophthalmic symptoms.

CONCLUSIONS

The risk of CSF leakage post-dural repair into the thoracic cavity is raised due to local factors related to the chest cavity. Dural repairs can fail in the presence of an acute increase in CSF pressure, for example whilst sneezing. Intracranial hypotension can result in subsequent hygroma and possibly haematoma formation. The resultant cranial nerve palsy may be managed expectantly except in the setting of symptomatic subdural haematoma or compressive pneumocephaly.

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69 %), 31 had radiculopathy (94 %), and 31 had axial pain (94 %). Among patients with myelopathy, 14 (42.4 %) had bladder and/or bowel dysfunction. In the last eight cases (24 %), the approach was retropleural instead of transpleural. Patients were followed up for 18.2 months on average. The mean length of hospital stay was 5 days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91 %) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1 %), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.