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Sofoluke N, Leyendecker J, Barber S, Reardon T, Bieler E, Patel A, Kashlan O, Bredow J, Eysel P, Gardocki RJ, Hasan S, Telfeian AE, Hofstetter CP, Konakondla S. Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01222. [PMID: 38899868 DOI: 10.1227/neu.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/25/2024] [Indexed: 06/21/2024] Open
Abstract
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.
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Affiliation(s)
- Nelson Sofoluke
- Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA
| | - Jannik Leyendecker
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Sean Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Eliana Bieler
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
| | - Akshay Patel
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Osama Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
- University Hospital Cologne, Cologne, Germany
| | - Jan Bredow
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Saqib Hasan
- Golden State Orthopedics and Spine, Oakland, California, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA
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Eghbal K, Zafarshamspour S, Sookhaklari M, Saffarian A, Taheri R. Clinical Outcome of Pedicle-Sparing Transfacet Diskectomy and Fusion with Segmental Instrumentation for Thoracic Disc Herniation. J Neurol Surg A Cent Eur Neurosurg 2024; 85:240-245. [PMID: 36584877 DOI: 10.1055/a-2005-0620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Thoracic disk herniations (TDHs) are relatively rare compared with their cervical and lumbar counterparts. Posterior approaches allow for a simpler and less invasive surgery than anterior and lateral approaches. A pedicle-sparing transfacet approach was initially described in 1995, and modified in 2010. A few clinical series have reported the outcome of this procedure in patients with TDH. This study aimed to evaluate the outcomes and complications of pedicle-sparing transfacet diskectomy with interbody fusion and segmental instrumentation in patients with TDH. METHODS Twenty-one consecutive patients with symptomatic TDH referred to our tertiary care center were included in this retrospective study. All patients underwent a pedicle-sparing transfacet diskectomy with polyetheretherketone (PEEK) cage interbody fusion and short segmental instrumentation. Distribution of TDH, operative duration, blood loss, Visual Analog Scale (VAS) pain scores, Nurick grades, modified Japanese Orthopaedic Association (mJOA) scores, and fusion rate were assessed. RESULTS All patients had single-level herniations. The most common location was T12-L1 (38.1%), followed by T11-T12 (33.3%). All patients were successfully operated on with no cerebrospinal fluid (CSF) leaks or wrong-level surgery. The VAS scores significantly diminished from 4.9 (preoperatively) to 2 (18 months after surgery). The average mJOA score increased from 4.6 to 8.5, and the average Nurick grade decreased from 3.1 to 1.6. All patients reported significant improvement in quality of life relative to their preoperative status. CONCLUSION A modified pedicle-sparing transfacet diskectomy combined with PEEK cage interbody fusion and segmental instrumentation offers a safe and less invasive approach for the treatment of TDHs.
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Affiliation(s)
- Keyvan Eghbal
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saber Zafarshamspour
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Surgery, Rafsanjan University of Medical Sciences, Kerman, Iran
| | | | - Arash Saffarian
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Taheri
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Kweh BTS, Khoo B, Asaid M, Donaldson C, Kam J, Barnett S, Seevanayagam S, Gonzalvo AC. Alexis retractor efficacy in transthoracic thoracoscopically assisted discectomy for thoracic disc herniations. Acta Neurochir (Wien) 2024; 166:135. [PMID: 38472445 DOI: 10.1007/s00701-024-06034-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE A transthoracic anterior or lateral approach for giant thoracic disc herniations is a complex operation which requires optimal exposure and maximal visualisation. Traditional metal rigid retractors may inflict significant skin trauma especially with prolonged operative use and limit the working angles of endoscopic instrumentation at depth. We pioneer the use of the Alexis retractor in transthoracic thoracoscopically assisted discectomy for the first time. METHODS The authors describe and demonstrate the technical use of the Alexis retractor during operative cases. Patient positioning, clinical rationale and operative nuances are elucidated for readers to gain an appreciation of the transthoracic approach to thoracic disc herniations. RESULTS The advantages of the Alexis retractor include minimally invasive circumferential flexible retraction, facilitation of bimanual instrument use, diminished risk of surgical site infections and reduced rib retraction leading to less postoperative pain. CONCLUSION Use of the flexible and intuitive Alexis retractor maximises operative exposure and is an effective adjunct when performing complex transthoracic approaches for thoracic disc herniations.
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Affiliation(s)
- Barry Ting Sheen Kweh
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
- National Trauma Research Institute, Melbourne, VIC, 3004, Australia.
| | - Boyuan Khoo
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Mina Asaid
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
- Department of Neurosurgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher Donaldson
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Jeremy Kam
- Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Stephen Barnett
- Department of Cardiothoracic Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Siven Seevanayagam
- Department of Cardiothoracic Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Augusto Carlos Gonzalvo
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia
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Lisitzky IY, Lychagin AV, Zarov AY, Korkunov AL, Cherepanov VG, Vyazankin IA. [Surgical treatment of herniated thoracic discs using transthoracic extrapleural approach]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:50-59. [PMID: 35942837 DOI: 10.17116/neiro20228604150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- I Yu Lisitzky
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Lychagin
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A Yu Zarov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A L Korkunov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V G Cherepanov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - I A Vyazankin
- Sechenov First Moscow State Medical University, Moscow, Russia
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Elkatatny AAAM, Hamdy TM, Moenes KM. Comparison between Results of Microdiscectomy and Open Discectomy in Management of High-Level Lumbar Disc Prolapse. Open Access Maced J Med Sci 2019; 7:2851-2857. [PMID: 31844448 PMCID: PMC6901859 DOI: 10.3889/oamjms.2019.679] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 06/08/2019] [Accepted: 06/09/2019] [Indexed: 11/09/2022] Open
Abstract
AIM This work aims to compare between results of microdiscectomy and open discectomy in management of high-level lumbar disc prolapse. METHODS This is a controlled randomised study, where patients having upper lumbar disc herniations were evaluated preoperatively both clinically and radiologically, randomisation was planned to perform open discectomy in odd number patients and to perform microdiscectomy in even number patients, patients were evaluated and followed up for deficits and outcomes. RESULTS We operated ten patients in this study, five cases were operated upon with microdiscectomy, and five cases were operated upon with open discectomy, the median age of presentation in this study was 44 years, there were five males and five females, postoperative pain improvement was better in microdiscectomy. Hospital stay, blood loss, bone loss and postoperative complications were less in microdiscectomy. CONCLUSION Microdiscectomy allows good surgical visualisation and is less traumatic to the involved tissues. The results of this study indicated that microsurgery reduces hospitalisation time, improves the overall surgery-related outcome. The main differences between the two procedures were the length of the incision and blood loss. We found that lumbar microdiscectomy allows patients earlier return to work and normal life with less reliance on postoperative narcotic analgesic agents.
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Affiliation(s)
| | - Tarek M. Hamdy
- Department of Neurosurgery Kasr Alainy Medical school, Cairo University, Cairo, Egypt
| | - Khaled Mamoun Moenes
- Department of Neurosurgery Kasr Alainy Medical school, Cairo University, Cairo, Egypt
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Lin TY, Wang YC, Chang CW, Wong CB, Cheng YH, Fu TS. Surgical Outcomes for Upper Lumbar Disc Herniation: Decompression Alone versus Fusion Surgery. J Clin Med 2019; 8:jcm8091435. [PMID: 31514297 PMCID: PMC6780085 DOI: 10.3390/jcm8091435] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 08/25/2019] [Accepted: 09/09/2019] [Indexed: 02/05/2023] Open
Abstract
Upper lumbar herniated intervertebral disc (HIVD), defined as L1-2 and L2-3 levels, presents with a lower incidence and more unfavorable surgical outcomes than lower lumbar levels. There are very few reports onthe appropriate surgical interventions for treating upper lumbar HIVD. This study aimed to evaluate the surgical outcome of decompression alone, when compared with spinal fusion surgery. A retrospective study involving a total of 7592 patients who underwent surgery due to HIVD in our institution was conducted. A total of 49 patients were included in this study: 33 patients who underwent decompression-only surgery and 16 patients who underwent fusion surgery. Demographic data, perioperative information, and functional outcomes were recorded. The visual analog scale (VAS) scores showed improvement in both groups postoperatively. The three-month postoperative Oswestry Disability Index score was significantly better in the fusion group. Additionally, 10 patients (76.9%) in the decompression group and 5 patients (83.3%) in the fusion group reported improvement in preoperative motor weakness. The final “satisfactory” rate was 66.7% in the decompression group and 93.8% in the fusion group (p = 0.034). The overall surgical outcomes of patients with upper lumbar HIVD were satisfactory in this study without any major complications. More reliable satisfactory rates and better functional scores at the three-month postoperative follow-up were reported in the fusion group.
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Affiliation(s)
- Tung-Yi Lin
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Ying-Chih Wang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chia-Wei Chang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Chak-Bor Wong
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - You-Hung Cheng
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Tsai-Sheng Fu
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital, Keelung branch, Keelung 204 and School of medicine, Chang Gung University, Taoyuan 333, Taiwan.
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Sharma SB, Kim JS. A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine 2019; 16:24-33. [PMID: 30943704 PMCID: PMC6449820 DOI: 10.14245/ns.1938014.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 11/19/2022] Open
Abstract
Thoracic disc herniation (TDH) is a rare, but technically challenging, disorder. Apart from their unfamiliarity with this condition, surgeons are often posed with challenges regarding the diverse methods available to address TDH, the neurological disturbances accompanying the disorder, the prospect of iatrogenic cord damage during surgical procedures, and the complications associated with various surgical approaches. In today's era, when minimally invasive surgery has been incorporated into almost every aspect of managing spine disorders, it is necessary for surgeons to be aware of the various minimally invasive techniques available for the management of these rare and difficult conditions. In this review article, we provide a synopsis of the epidemiology, clinical features, and technical aspects of TDH, starting from level identification to intraoperative neuromonitoring and including important steps and guidance for all the minimally invasive approaches to TDH. We conclude the review by providing insights into the clinical decision-making process and outline the specific aspects of "giant" thoracic discs and indications for fusion in certain conditions. Outcomes of minimally invasive surgery for these conditions are generally favorable. The location of herniation is an important factor for surgical planning.
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Affiliation(s)
- Sagar B. Sharma
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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Thoracic disc herniation, avoidance, and management of the surgical complications. INTERNATIONAL ORTHOPAEDICS 2019; 43:817-823. [DOI: 10.1007/s00264-018-04282-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/26/2018] [Indexed: 02/06/2023]
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9
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Yüce İ, Kahyaoğlu O, Çavuşoğlu HA, Çavuşoğlu H, Aydın Y. Midterm outcome of thoracic disc herniations that were treated by microdiscectomy with bilateral decompression via unilateral approach. J Clin Neurosci 2018; 58:94-99. [DOI: 10.1016/j.jocn.2018.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/07/2018] [Accepted: 09/26/2018] [Indexed: 10/28/2022]
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Bouthors C, Benzakour A, Court C. Surgical treatment of thoracic disc herniation: an overview. INTERNATIONAL ORTHOPAEDICS 2018; 43:807-816. [PMID: 30406842 DOI: 10.1007/s00264-018-4224-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Charlie Bouthors
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
| | - Ahmed Benzakour
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Charles Court
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
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Anterior versus posterior approaches for thoracic disc herniation: Association with postoperative complications. Clin Neurol Neurosurg 2018; 167:17-23. [DOI: 10.1016/j.clineuro.2018.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 01/31/2018] [Accepted: 02/04/2018] [Indexed: 11/24/2022]
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12
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Court C, Mansour E, Bouthors C. Thoracic disc herniation: Surgical treatment. Orthop Traumatol Surg Res 2018; 104:S31-S40. [PMID: 29225115 DOI: 10.1016/j.otsr.2017.04.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- C Court
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
| | - E Mansour
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - C Bouthors
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
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Abstract
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.
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14
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Technical modifications and decision-making to reduce morbidity in thoracic disc surgery: An institutional experience and treatment algorithm. Clin Neurol Neurosurg 2015; 133:75-82. [DOI: 10.1016/j.clineuro.2015.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 03/08/2015] [Accepted: 03/21/2015] [Indexed: 11/24/2022]
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15
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Minimally invasive transforaminal interbody fusion surgery for the old fracture of the thoracolumbar junction. ACTA ACUST UNITED AC 2014; 27:E55-60. [PMID: 24795945 DOI: 10.1097/bsd.0b013e318292b24e] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Retrospective analysis of the clinical outcomes of 15 patients with the old thoracolumbar junction fracture treated by minimally invasive surgery (MIS) transforaminal interbody fusion surgery. OBJECTIVE To investigate the efficacy and safety of MIS for the old fracture of the thoracolumbar junction in a pilot study. SUMMARY OF BACKGROUND DATA MIS have demonstrated efficacy in the treatment of lumbar degenerative diseases. There is some controversy regarding the ideal management of thoracolumbar fractures, especially those without an associated neurologic deficit. Reports concerning MIS for old thoracolumbar junction fracture with chronic pain are quite rare. METHODS A total of 15 MIS fusion, performed between October 2006 and May 2011, were examined in a retrospective study. The clinical and radiological data were collected and analyzed. Fusion levels were T10–T11 (2 patients), T11–T12 (5 patients), T12–L1 (6 patients), L1–L2 (2 patients). Clinical outcome was assessed using the visual analogue scale and the Oswestry disability index. Radiographic evaluation of the lumbar spine was performed at the second day and 12 months postoperatively. RESULTS The average follow-up period was 26.3 months, with a minimum of 17 months. The mean operating time, intraoperative blood loss, and x-ray exposure time were 125±31 minutes, 226±45 mL, and 47±12 seconds, respectively. At last followup,the visual analogue scale for back pain and the Oswestry disability index decreased significantly postoperatively from 7.4±2.3 to 1.8±0.6 (P<0.01) and from 38.9±7.1 to 13.5±4.5 (P<0.01), respectively. The average Cobb angle was improved from 19.1–15.1 degrees in this series. No significant correction of local kyphosis was found postoperatively (P>0.05). Radiographic evaluation showed satisfactory bony union at the fixed level in all cases except for 2 patients. There were no other major complications at last follow-up. CONCLUSIONS MIS transforaminal interbody fusion is a safe and effective procedure for old thoracolumbar junction fracture with chronic pain. Improvement of kyphosis is limited and occurrence of nonunion is relatively high.
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Wang J, Zhou Y, Zhang ZF, Li CQ, Zheng WJ, Huang B. Disc herniation in the thoracolumbar junction treated by minimally invasive transforaminal interbody fusion surgery. J Clin Neurosci 2014; 21:431-5. [DOI: 10.1016/j.jocn.2013.04.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 04/09/2013] [Accepted: 04/13/2013] [Indexed: 11/26/2022]
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Kim DS, Lee JK, Jang JW, Ko BS, Lee JH, Kim SH. Clinical features and treatments of upper lumbar disc herniations. J Korean Neurosurg Soc 2010; 48:119-24. [PMID: 20856659 PMCID: PMC2941853 DOI: 10.3340/jkns.2010.48.2.119] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 07/04/2010] [Accepted: 08/03/2010] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Disc herniations at the L1-L2 and L2-L3 levels are different from those at lower levels of the lumbar spine with regard to clinical characteristics and surgical outcome. Spinal canals are narrower than those of lower levels, which may compromise multiple spinal nerve roots or conus medullaris. The aim of this study was to evaluate the clinical features and surgical outcomes of upper lumbar disc herniations. METHODS We retrospectively reviewed the clinical features of 41 patients who had undergone surgery for single disc herniations at the L1-L2 and L2-3 levels from 1998 to 2007. The affected levels were L1-L2 in 14 patients and L2-L3 in 27 patients. Presenting symptoms and signs, patient characteristics, radiologic findings, operative methods, and surgical outcomes were investigated. RESULTS The mean age of patients with upper lumbar disc was 55.5 years (ranged 31 to 78). The mean follow-up period was 16.6 months. Most patients complained of back and buttock pain (38 patients, 92%), and radiating pain in areas such as the anterior or anterolateral aspect of the thigh (32 patients, 78%). Weakness of lower extremities was observed in 16 patients (39%) and sensory disturbance was presented in 19 patients (46%). Only 6 patients (14%) had undergone previous lumbar disc surgery. Discectomy was performed using three methods : unilateral laminectomy in 27 cases, bilateral laminectomy in 3 cases, and the transdural approach in 11 cases, which were performed through total laminectomy in 10 cases and unilateral laminectomy in 1 case. With regard to surgical outcomes, preoperative symptoms improved significantly in 33 patients (80.5%), partially in 7 patients (17%), and were aggravated in 1 patient (2.5%). CONCLUSION Clinical features of disc herniations at the L1-L2 and L2-L3 levels were variable, and localized sensory change or pain was rarely demonstrated. In most cases, the discectomy was performed successfully by conventional posterior laminectomy. On the other hand, in large central broad based disc herniation, when the neural elements are severely compromised, the posterior transdural approach could be an alternative.
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Affiliation(s)
- Duk-Sung Kim
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jung-Kil Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jae-Won Jang
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Byung-Soo Ko
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Jae-Hyun Lee
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
| | - Soo-Han Kim
- Department of Neurosurgery, Chonnam National University Medical School & Research Institute of Medical Sciences, Gwangju, Korea
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Choi JW, Lee JK, Moon KS, Hur H, Kim YS, Kim SH. Transdural approach for calcified central disc herniations of the upper lumbar spine. Technical note. J Neurosurg Spine 2007; 7:370-4. [PMID: 17877277 DOI: 10.3171/spi-07/09/370] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Disc herniations of the upper lumbar spine (L1-2 and L2-3) have a frequency of 1 to 2% of all disc herniations. During posterior discectomy after laminectomy, significant manipulation of the exiting nerve root is unavoidable because of the narrow lamina and the difficulty in mobilizing the nerve root. The authors adopted a transdural approach in patients with calcified central disc herniation at the L1-2 level to reduce the risk of nerve root injury. Four patients suffering from radiating pain together with back pain were treated using the transdural approach. Preoperative neuroimaging studies revealed severe central disc herniation with calcification at the L1-2 level. After laminectomy or laminotomy, the incised dura mater was tacked, and the cauda equina rootlets were gently retracted. An intentional durotomy was performed over its maximal bulging of the ventral dura. After meticulous dissection of dense adhesions between the disc herniation and the dural sac, adequate decompression with removal of calcified disc fragments and osteophytes was accomplished. Clinical symptoms improved in all patients. Postoperative permanent cerebrospinal fluid leakage and pseudomeningocele were not observed, and no patient had a progressive lumbar deformity at an average follow-up of 53 months. Transient mild motor weakness and sensory change were observed in two patients postoperatively; however, these symptoms resolved completely within 1 week. The posterior transdural approach offers an alternative in central calcified upper lumbar disc herniation when root retraction is dangerous.
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Affiliation(s)
- Jeong-Wook Choi
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
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