Thoracoscopic microdiscectomy

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.

Image-guided navigation and video-assisted thoracoscopic spine surgery: the second generation

Object

Video-assisted thoracoscopic surgery (VATS) has evolved for treatment of a variety of spinal disorders. Early incorporation with image-guided surgery (IGS) was challenged due to reproducibility and adaptability, limiting the procedure's acceptance. In the present study, the authors report their experience with second-generation IGS and VATS technologies for anterior thoracic minimally invasive spinal (MIS) procedures.

Methods

The surgical procedure is described in detail including operating room set-up, patient positioning (a lateral decubitus position), placement of the spinal reference frame and portal, radiographic localization, registration, surgical instruments, and the image-guided thoracoscopic discectomy.

Results

Combined IGS and VATS procedures were successfully performed and assisted in anatomical localization in 14 patients. The mean patient age was 59 years (range 32–73 years). Disc herniation pathology represented the most common indication for surgery (n = 8 patients); intrathoracic spinal tumors were present in 4 patients and the remaining patients had infection and ossification of the posterior longitudinal ligament. All patients required chest tube drainage postoperatively, and all but 1 patient had drainage discontinued the following day. The only complication was a seroma that was presumed to be due to steroid therapy for postoperative weakness. At the final follow-up, 11 of the patients were improved neurologically, 2 patients had baseline neurological status, and the 1 patient with postoperative weakness was able to ambulate, albeit with an assistive device.

The evolution of thoracoscopic surgical procedures occurring over 20 years is presented, including their limitations. The combination of VATS and IGS technologies is discussed including their safety and the importance of 3D imaging. In cases of large open thoracotomy procedures, surgeries require difficult, extensive, and invasive access through the chest cavity; using a MIS procedure can potentially eliminate many of the complications and morbidities associated with large open procedures. The authors report their experience with thoracic spinal surgeries that involved MIS procedures and the new technologies.

Conclusions

The most significant advance in IGS procedures has resulted from intraoperative CT scanning and automatic registration with the IGS workstation. Image guidance can be used in conjunction with VATS techniques for thoracic discectomy, spinal tumors, infection, and ossification of the posterior longitudinal ligament. The authors' initial experience has revealed this technique to be useful and potentially applicable to other MIS procedures.

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.

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

STUDY DESIGN

A retrospective review of a case series.

OBJECTIVES

Giant thoracic disc herniations remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less-invasive approaches. With the current study, we describe a surgical technique to treat giant thoracic disc herniations while minimizing approach-related morbidity.

METHODS

Demographic and radiographic data; clinical outcome and perioperative complications were retrospectively analysed for patients with single-level giant thoracic disc herniations who underwent mini-thoracotomy and selective microsurgical anterior spinal cord decompression without instrumented fusion.

RESULTS

Between 2007 and 2012, 7 consecutive patients with giant thoracic disc herniations were treated (average age of 53 years; range 45-66 years). The average canal encroachment was 73.2 % (range 40-92 %) with 5 grossly calcified discs of which 3 had transdural components. All patients had gradual myelopathic progression. The average Nurick grade was 3.5 (range 2-5). All patients were successfully treated with anterior microsurgical decompression without instrumentation. Uninstrumented fusion with rib graft was performed only in one patient with advanced degenerative changes. Average time of surgery was 337.8 min (range 220-450 min). The average length of hospital stay was 7.4 days (range 6-11 days). The average neurological status at follow-up (average 23.5 months; range 9-36 months) using the modified Nurick grading scale was 1.28. No vertebral collapse or loss of spinal alignment developed. There were no neurological complications. One patient developed an acute headache and diplopia, 10 days after surgery, following sneezing associated with a post-operative thoracic cerebrospinal fluid leakage requiring revision. Two patients suffered an approach-related complication in form of intercostal neuralgia; one was persistent.

CONCLUSIONS

Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment.

Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience

OBJECT

Symptomatic herniated thoracic discs remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less invasive approaches. Many of these techniques, such as thoracoscopy, have not been widely adopted due to technical difficulties. The current study was performed to examine the safety and early results of a minimally invasive lateral approach for symptomatic thoracic herniated intervertebral discs.

METHODS

Sixty patients from 5 institutions were treated using a mini-open lateral approach for 75 symptomatic thoracic herniated discs with or without calcification. The mean age was 57.9 years (range 23-80 years), and 53.3% of the patients were male. Treatment levels ranged from T4-5 to T11-12, with 1-3 levels being treated (mean 1.3 levels). The most common levels treated were T11-12 (14 cases [18.7%]), T7-8 (12 cases [16%]), and T8-9 (12 cases [16%]). Symptoms included myelopathy in 70% of cases, radiculopathy in 51.7%, axial back pain in 76.7%, and bladder and/or bowel dysfunction in 26.7%. Instrumentation included an interbody spacer in all but 6 cases (10%). Supplemental internal fixation included anterolateral plating in 33.3% of cases and pedicle screws in 10%; there was no supplemental internal fixation in 56.7% of cases. Follow-up ranged from 0.5 to 24 months (mean 11.0 months).

RESULTS

The median operating time, estimated blood loss, and length of stay were 182 minutes, 290 ml, and 5.0 days, respectively. Four major complications occurred (6.7%): pneumonia in 1 patient (1.7%); extrapleural free air in 1 patient (1.7%), treated with chest tube placement; new lower-extremity weakness in 1 patient (1.7%); and wound infection in posterior instrumentation in 1 patient (1.7%). Reoperations occurred in 3 cases (5%): one for posterior reexploration, one for infection in posterior instrumentation, and one for removal of symptomatic residual disc material. Back pain, measured using the visual analog scale, improved 60% from the preoperative score to the last follow-up, that is, from 7.8 to 3.1. Excellent or good overall outcomes were achieved in 80% of the patients, a fair or unchanged outcome resulted in 15%, and a poor outcome occurred in 5%. Moreover, myelopathy, radiculopathy, axial back pain, and bladder and/or bowel dysfunction improved in 83.3%, 87.0%, 91.1%, and 87.5% of cases, respectively.

CONCLUSIONS

The authors' early experience with a large multicenter series suggested that the minimally invasive lateral approach is a safe, reproducible, and efficacious procedure for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional surgical techniques and without the use of endoscopes. Symptom resolution was achieved at similar rates using this approach as compared with the most efficacious techniques in the literature, and with fewer complications in most circumstances.

Minimally invasive thoracoscopic approach for anterior decompression and stabilization of metastatic spine disease

Object

The choices available in the management of metastatic spine disease are complex, and the role of surgical therapy is increasing. Recent studies have indicated that patients treated with direct surgical decompression and stabilization before radiation have better functional outcomes than those treated with radiation alone. The most common anterior surgical approach for direct spinal cord decompression and stabilization in the thoracic spine is open thoracotomy; however, thoracotomy for spinal access is associated with morbidity that can be avoided with minimally invasive techniques like thoracoscopy.

Methods

A minimally invasive thoracoscopic approach was used for the surgical treatment of thoracic and thoracolumbar metastatic spinal cord compression. This technique allows ventral decompression via corpectomy, inter-body reconstruction with expandable cages, and stabilization with an anterolateral plating system designed specifically for minimally invasive implantation. This technique was performed in 5 patients with metastatic disease of the thoracic spine, including the thoracolumbar junction.

Results

All patients had improvement in preoperative symptoms and neurological deficits. No complications occurred in this small series.

Conclusions

The minimally invasive thoracoscopic approach can be applied to the treatment of thoracic and thoracolumbar metastatic spine disease in an effort to reduce access morbidity. Preliminary results have indicated that adequate decompression, reconstruction, and stabilization can be achieved with this technique.

Endoscopic thoracic microdiscectomy

Object

The purpose of this investigation was to evaluate surgical and neurological outcomes in thoracic disc surgery in a prospective fashion.

Methods

Quantifiable outcome data such as operating time, blood loss, duration of chest tube drainage, narcotic drug use, length of hospital stay (LOS), and long-term follow up of neurological function and pain-related symptoms were collected prospectively.

In patients with myelopathy there was an improvement of two Frankel grades in the thoracoscopic discectomy group and one Frankel grade in the patients treated with thoracotomy; however, patients in the thoracotomy group were significantly worse preoperatively. None of the patients experienced worsened pain, and pain related to radiculopathy was improved by 75% in the thoracoscopic group.

Conclusions

Thoracoscopic discectomy yields acceptable surgical results and has several distinct advantages, with reduced postoperative pain, morbidity, and LOS.