Endoscopic transforaminal thoracic foraminotomy and discectomy for the treatment of thoracic disc herniation

A modified percutaneous transforaminal endoscopic surgery for central calcified thoracic disc herniation at the T11/T12 level using foraminoplasty and decompression: A case report

Background

Thoracic disc herniation (TDH) is uncommon. Central calcified TDH (CCTDH) is even rare. Traditional open surgery was considered a gold standard to treat CCTDH, but it was accompanied by a high risk of complications. Recently, a technique called percutaneous transforaminal endoscopic decompression (PTED) was adopted to treat TDH. Gu et al. designed a simplified PTED technique and named it percutaneous transforaminal endoscopic surgery (PTES) to treat various types of lumbar disc herniation; it offered the advantages of simple orientation, easy puncture, reduced steps, and little x-ray exposure. However, PTES to treat CCTDH has not been reported in the literature.

Methods

Here, we describe the case of a patient with CCTDH treated with a modified PTES through the unilateral posterolateral approach under local anesthesia and conscious sedation by using a flexible power diamond drill. First, we report that the patient was treated with PTES with later-stage endoscopic foraminoplasty, with an inside-out technique employed at the initial endoscopic decompression stage.

Results

A 50-year-old male with progressive gait disturbance and bilateral leg rigidity with paresis and numbness was diagnosed with CCTDH at the T11/T12 level on MRI and CT examinations. A modified PTES was performed on November 22, 2019. The total mJOA (modified Japanese Orthopedic Association) score preoperatively was 12. The method of the determination of incision and the soft tissue trajectory establishment process were the same as those in the original PTES technique. The foraminoplasty process was divided into initial fluoroscopic and final endoscopic stages. At the fluoroscopic stage, the hand trephine's saw teeth were just rotated into the lateral portion of the ventral bone from the superior articular process (SAP) to seize the SAP firmly, while at the endoscopic stage, in order to remove the ventral bone from the SAP safely under direct endoscopic visualization, adequate foramen enlargement was achieved without causing any risk of damage to the neural structures in the spinal canal. During the endoscopic decompression process, the soft disc fragments ventral to the calcified shell were undermined to form a cavity using an inside-out technique. Then, a flexible endoscopic diamond burr was introduced to degrade the calcified shell, and a curved dissector or a flexible radiofrequency probe was used to dissect the thin bony shell from the dural sac. Eventually, the shell was fractured within the cavity piece by piece to remove the whole CCTDH and achieve adequate dural sac decompression, resulting in minimal blood loss and no complications. The symptoms were gradually alleviated and the patient almost completely recovered at the 3-month follow-up, with no symptom recurrence found at the 2-year follow-up. The mJOA score improved to 17 at the 3-month follow-up and to 18 at the 2-year follow-up compared with 12 points preoperatively.

Conclusions

A modified PTES may be an alternative minimally invasive technique for the treatment of CCTDH and provide similar or better outcomes over traditional open surgery. However, this procedure requires good endoscopic experience on the part of the surgeon and is beset with technical challenges and therefore should be performed with utmost care.

Complications and Management of Endoscopic Spinal Surgery

In the past, the use of endoscopic spine surgery was limited to intervertebral discectomy; however, it has recently become possible to treat various spinal degenerative diseases, such as spinal stenosis and foraminal stenosis, and the treatment range has also expanded from the lumbar spine to the cervical and thoracic regions. However, as endoscopic spine surgery develops and its indications widen, more diverse and advanced surgical techniques are being introduced, and the complications of endoscopic spine surgery are also increasing accordingly. We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and key words were set as “endoscopic spinal surgery,” “endoscopic cervical foramoinotomy,” “PECD,” “percutaneous transforaminal discectomy,” “percutaneous endoscopic interlaminar discectomy,” “PELD,” “PETD,” “PEID,” “YESS” and “TESSYS.” We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic lumbar surgery was divided into full endoscopic interlaminar and transforaminal approaches and a unilateral biportal approach. We performed a comprehensive review of available literature on complications of endoscopic spinal surgery. This study particularly focused on the prevention of complications. Regardless of the surgical methods, the most common complications related to endoscopic spinal surgery include dural tears and perioperative hematoma. transient dysesthesia, nerve root injury and recurrence. However, Endoscopic spinal surgery, including full endoscopic transforaminal and interlaminar and unilateral biportal approaches, is a safe and effective a treatment for lumbar as well as cervical and thoracic spinal diseases such as disc herniation, lumbar spinal stenosis, foraminal stenosis and recurrent disc herniation.

Full-endoscopic discectomy for thoracic disc herniations: a single-arm meta-analysis of safety and efficacy outcomes

INTRODUCTION

Surgical intervention is the treatment of choice in patients with thoracic disc herniation with refractory symptoms and progressive myelopathy. Due to high occurrence of complications from open surgery, minimally invasive approaches are desirable. Nowadays, endoscopic techniques have become increasingly popular and full-endoscopic surgery can be performed in the thoracic spine with low complication rates.

METHODS

Cochrane Central, PubMed, and Embase databases were systematically searched for studies that evaluated patients who underwent full-endoscopic spine thoracic surgery. The outcomes of interest were dural tear, myelopathy, epidural hematoma, recurrent disc herniation, and dysesthesia. In the absence of comparative studies, a single-arm meta-analysis was performed.

RESULTS

We included 13 studies with a total of 285 patients. Follow-up ranged from 6 to 89 months, age from 17 to 82 years, with 56.5% male. The procedure was performed under local anesthesia with sedation in 222 patients (77.9%). A transforaminal approach was used in 88.1% of the cases. There were no cases of infection or death reported. The data showed a pooled incidence of outcomes as follows, with their respective 95% confidence intervals (CI)-dural tear (1.3%; 95% CI 0-2.6%); dysesthesia (4.7%; 95% CI 2.0-7.3%); recurrent disc herniation (2.9%; 95% CI 0.6-5.2%); myelopathy (2.1%; 95% CI 0.4-3.8%); epidural hematoma (1.1%; 95% CI 0.2-2.5%); and reoperation (1.7%; 95% CI 0.1-3.4%).

CONCLUSION

Full-endoscopic discectomy has a low incidence of adverse outcomes in patients with thoracic disc herniations. Controlled studies, ideally randomized, are warranted to establish the comparative efficacy and safety of the endoscopic approach relative to open surgery.

Comparative Analysis of Transforaminal Endoscopic Thoracic Discectomy and Microscopic Discectomy for Symptomatic Thoracic Disc Herniation

OBJECTIVE

To evaluate the clinical outcomes of transforaminal endoscopic thoracic discectomy (TETD) and microscopic discectomy (MD) for the treatment of symptomatic thoracic disc herniation (TDH).

METHODS

Seventy-seven patients (mean, 55.9 years; follow-up, 11.2 months) with symptomatic TDH were retrospectively reviewed (39 TETD and 38 MD). Radiological factors and perioperative outcomes were reviewed. Visual analogue scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association impairment scale were used to evaluate clinical and functional outcomes. Patient satisfaction was evaluated using modified MacNab criteria.

RESULTS

The levels of surgery and the location of hernia were evenly distributed in the both groups. The operative time (70.6 minutes vs. 175.7 minutes), estimated blood loss (3.8 mL vs. 357.4 mL), and length of hospital stay (7.0 days vs. 13.0 days) were significantly different between the TETD and MD groups (p < 0.05). VAS scores for dorsal back pain and ODI scores were significantly improved in both groups (p < 0.05). Patients who underwent TETD tended to be more satisfied with the outcome in terms of the modified MacNab criteria (89.7% vs. 73.0%, p = 0.059). Two patients in the MD group underwent revision surgery, whereas one patient in the TETD group underwent MD because of incomplete decompression.

CONCLUSION

TETD for the symptomatic TDH is a feasible and safe procedure that could be used for a wider range of surgical levels with a shorter operative time and hospital stay and less blood loss. While achieving similar outcomes, TETD achieved better patient satisfaction because of the use of local anesthesia and its minimal invasiveness.

Full Endoscopic Thoracic Discectomy: Is the Interlaminar Approach an Alternative to the Transforaminal Approach? A Technical Note

BACKGROUND

Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches.

METHODS

Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated.

RESULTS

The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery.

CONCLUSIONS

Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives.

CLINICAL RELEVANCE

Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

LEVEL OF EVIDENCE: 4

Five-Year Outcomes After Transforaminal Endoscopic Foraminotomy and Discectomy for Soft and Calcified Thoracic Disc Herniations

BACKGROUND

The aim of this study was to evaluate the safety and long-term clinical outcomes of transforaminal full endoscopic discectomy and foraminotomy performed with manual reamers under local anesthesia on soft and calcified herniated discs in the mid and lower thoracic spine.

METHODS

Postoperative pain relief was self-evaluated by 16 patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patients were scored at 6, 12, 24, and 60 months after surgery.

RESULTS

Significant pain reduction of more than 50% in the VAS score was achieved in 15 out of 16 patients at all review points throughout this study. Similarly, a decrease of more than 50% in ODI scores was achieved in 15 out of 16 patients in all 4 review points. There were no surgical complications. Good postoperative results were achieved in patients regardless of the consistency of the disc herniation.

CONCLUSIONS

Transforaminal full endoscopic discectomy and foraminotomy with manual reamers performed under local anesthesia produces sustained reduction in pain and improves functionality in patients with mid and lower thoracic spine soft and calcified disc herniations. The surgery is safe and straightforward to perform with the correct training.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Thoracic transforaminal endoscopic discectomy and foraminotomy, performed in TIVA, may be a useful adjunct for treatment of patients with soft and calcified disc herniations in thoracic spine.

Full endoscopic surgery for thoracic pathology: an assessment of supportive evidence

In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology.

The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis.

An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language.

We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients.

Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection.

Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46–100%) with a complication rate of 8% (range 0–15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing ‘self-neuromonitoring’ by allowing patients to respond to cord and/or nerve stimuli.

Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080

Transforaminal Endoscopic Discectomy for Large, Two Level Calcified, Thoracic Disc Herniations With 5-Year Follow-up

To describe technical details and benefits of transforaminal endoscopic discectomy for treatment of patients with large, dorsomedial, calcified thoracic disc herniations at 2 levels and to report on their clinical outcomes in long follow-up period of 5 years using 4 different outcome tools. We present 2 patients with large, calcified disc herniations at 2 levels in mid and lower thoracic spine treated endoscopically in local anesthesia. Clinical outcomes were analyzed using verbal numeric scale (VNS), Roland-Morris low back pain and disability questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria at 6-, 12-, 24-, 60-month follow-up. After transforaminal endoscopic discectomy, both patients had significant postoperative reduction of back pain using VNS and significant outcome improvement using ODI, RMQ score, and modified MacNab criteria. These results did not change during all 4 follow-up periods. Transforaminal percutaneous full-endoscopic discectomy and hand reamers foraminotomy in local anesthesia is feasible and effective surgical technique for patients with large, calcified thoracic disc herniations at 2 levels even in long follow-up period of 5 years using 4 different outcome measuring tools. All 3 outcome measuring tools correlated well with pain reduction using VNS.

Thoracic Endoscopic Spine Surgery: A Comprehensive Review

BACKGROUND

From the 1990s, there has been growth in the literature demonstrating the feasibility of minimally invasive approaches for treating diverse spinal disorders. There is still much work to be done in circumnavigating the technical challenges and elucidating relative advantages of endoscopic techniques in spine surgery. In this comprehensive literature review, we discuss the history, advantages, disadvantages, approaches, and technology of, and critically examine peer-reviewed studies specifically addressing, endoscopic thoracic spinal surgery.

METHODS

Literature review was conducted with the key words "endoscopic," "minimally invasive," and "thoracic spinal surgery," using PubMed, Web of Science, and Google Scholar.

RESULTS

Review of 241 thorascopic procedures showed a success rate of 98% to 100%, low morbidity, and favorable complication profile. Review of 115 thoracic fixation procedures demonstrated high success rate, and 87% of screw positions were rated "good." Review of 55 full endoscopic uniportal decompressions showed sufficient decompression in most patients. Match pair analysis of 34 patients comparing video-assisted thoracoscopy surgery (VATS) or posterior spinal fusion reported the VATS group had increased operative duration but reduced blood loss.

CONCLUSIONS

Based on our literature review, there is a high rate of positive outcomes with endoscopic thoracic spine surgery, which reduces tissue dissection, intraoperative blood loss, and epidural fibrosis. However, the technical challenge highlights the importance of further training and innovation in this rapidly evolving field.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

There is growing evidence demonstrating the success of endoscopic thoracic spinal surgery. Populations that could be helped include the elderly and immunocompromised, who would benefit from decreased hospital stay and enhanced recovery time.

Transforaminal Endoscopic Thoracic Discectomy: Technical Review to Prevent Complications

For all the spine surgeons, thoracic disc herniations (TDHs) entrust a real challenge in terms of patient diagnosis, proper selection, surgical technique, and potential adverse events. TDHs are relatively uncommon compared to the lumbar and cervical levels. Literature reports a variable prevalence of TDHs around 6% to 40%, but less than 1% of all disk herniations are symptomatic TDHs, evidencing as a relatively unusual condition. Nowadays, transforaminal endoscopic thoracic discectomy (TETD) has been implemented as an alternative to classic open procedures with results that are as good as and, in some situations, better than those in traditional discectomy. However, the surgeon must be familiar with endoscopic lumbar spine surgery before opting to perform a TETD, considering that the learning curve is much harder. We describe all the steps and safety considerations during TETD based on the anatomic differences compared to lumbar endoscopic procedures. TETD is an effective and safe method that yields more benefits, provides a direct route to the lesion with less morbidity, and is performed in a minimally invasive way. Many severe complications related to the thoracic region could be avoided having the proper knowledge, adequate technique, and safety routes and considerations.

Transforaminal endoscopic thoracic discectomy with foraminoplasty for the treatment of thoracic disc herniation

Background

Symptomatic thoracic disc herniation (TDH) is a rare clinical entity and surgical intervention for it is even more uncommon. Despite several surgical techniques being described for thoracic discectomy, considering the unique surgical challenges, none of them have been accepted universally. Minimally invasive techniques have brought in a paradigm shift in the management of cervical/lumbar spinal disorders and similar techniques have been extrapolated to the thoracic region too. The purpose of this paper is to describe our technique, surgical experience, and the clinical results of transforaminal endoscopic thoracic discectomy (TETD).

Methods

Consecutive patients who underwent TETD (2001-2018) were reviewed. Patients who had a minimum of 6 months of follow-up, and without cervical and lumbar spine surgery or trauma during the follow-up period were included in the study. TETD was performed in patients who presented with symptomatic disc herniation of the thoracic spine and did not respond to conservative treatments. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament (OPLL) were excluded. Under local anesthesia and intravenous sedation, a 4.7-mm endoscope (TESSYS, Joimax GmbH, Germany) was introduced via transforaminal approach with foraminoplasty using reamer. Patient outcome was evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Patient satisfaction was measured using Macnab's criteria.

Results

Ninety-two consecutive patients (mean age was 48.9 years, 57 males) who underwent TETD from 2001 to 2018 met the inclusion criteria. Patients underwent surgery at different levels: 16 patients for T2-3 to T5-6 level, 41 cases for T6-7 to T8-9, and 35 patients for T9-10 to T12-L1. During follow-up for an average of 38.4 months, all patients showed a significant improvement of pain (7.6 to 1.6 in VAS and 68.2 vs. 13.2 for ODI, P<0.05 for both). There was one patient who had transient motor weakness.

Conclusions

TETD for soft, paramedian or lateral symptomatic TDH is a feasible and effective minimally invasive treatment option with favorable clinical results.

AOSpine Consensus Paper on Nomenclature for Working-Channel Endoscopic Spinal Procedures

STUDY DESIGN

International consensus paper on a unified nomenclature for full-endoscopic spine surgery.

OBJECTIVES

Minimally invasive endoscopic spinal procedures have undergone rapid development during the past decade. Evolution of working-channel endoscopes and surgical instruments as well as innovation in surgical techniques have expanded the types of spinal pathology that can be addressed. However, there is in the literature a heterogeneous nomenclature defining approach corridors and procedures, and this lack of common language has hampered communication between endoscopic spine surgeons, patients, hospitals, and insurance providers.

METHODS

The current report summarizes the nomenclature reported for working-channel endoscopic procedures that address cervical, thoracic, and lumbar spinal pathology.

RESULTS

We propose a uniform system that defines the working-channel endoscope (full-endoscopic), approach corridor (anterior, posterior, interlaminar, transforaminal), spinal segment (cervical, thoracic, lumbar), and procedure performed (eg, discectomy, foraminotomy). We suggest the following nomenclature for the most common full-endoscopic procedures: posterior endoscopic cervical foraminotomy (PECF), transforaminal endoscopic thoracic discectomy (TETD), transforaminal endoscopic lumbar discectomy (TELD), transforaminal lumbar foraminotomy (TELF), interlaminar endoscopic lumbar discectomy (IELD), interlaminar endoscopic lateral recess decompression (IE-LRD), and lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD).

CONCLUSIONS

We believe that it is critical to delineate a consensus nomenclature to facilitate uniformity of working-channel endoscopic procedures within academic scholarship. This will hopefully facilitate development, standardization of procedures, teaching, and widespread acceptance of full-endoscopic spinal procedures.

The benefit zone of full-endoscopic spine surgery

Minimally invasive spine procedures have undergone rapid development during the last decade. Efforts to decrease muscle crush injuries during prolonged retraction, avoid significant soft tissue stripping and minimize bony resection are surgical principles that are employed to prevent iatrogenic instability and provide patients with decreased post-operative pain and disability. Full-endoscopic spine surgery represents a tool for the spine surgeon to provide targeted access to spinal pathology utilizing these principles. Endoscopic techniques have seen over 30 years of evolution and innovation, however, early iterations of these techniques largely focused on transforaminal lumbar microdiscectomies. Currently, endoscopic techniques are utilized for approaching pathology in the cervical, thoracic and lumbar spine. There has been a growing body of literature that not only confirms the efficacy of these procedures but also underscores the advantages these procedures offer with respect to less morbidity and safer complication profiles. Endoscopic decompressions have been utilized in the settings of degenerative spinal stenosis, spondylolisthesis, scoliosis, previous fusion, tumor and infection. Furthermore, endoscopic interbody fusion has also been utilized in the lumbar spine as technology continues to advance. As technological innovation continues to facilitate reproducible surgical technique and expand the indications for use, we believe that endoscopic spine surgical techniques will provide surgeons with a more powerful and less morbid approach to spinal pathology that ultimately elevates the standard of care when treating our patients. We present a brief review of the history of endoscopic spine surgery, an overview of current techniques and review current outcomes of endoscopic spine surgical procedures in the context of an invasiveness/complexity index to elucidate the benefit zone of these newer techniques.

Percutaneous Endoscopic Thoracic Discectomy in the Upper and Midthoracic Spine: A Technical Note

Despite the successful application of percutaneous endoscopic thoracic discectomy (PETD), its technical feasibility and outcomes for symptomatic upper and midthoracic disc herniation have not been reported yet. The purpose of this article was to evaluate the feasibility of the percutaneous transforaminal endoscopic approach to remove disc herniations in the upper and midthoracic spine. Fourteen consecutive patients (mean age, 42.4 years; 12 males, 2 females) who underwent PETD were included in the analysis. The procedure was performed under local anesthesia and intravenous sedation using the standard endoscopy instrument set. The transforaminal approach combined with foraminoplasty was used to access the herniated areas. Treatment outcomes were evaluated using visual analogue scale (VAS) scores, Oswestry Disability Index (ODI) scores, and the modified MacNab criteria. Four discectomies were performed at T2–3, 5 at T3–4, and 5 at T5–6. The mean follow-up period was 43.4 months, and all patients showed statistically significant postoperative improvement (VAS: 7.3 to 2.3, ODI: 53.5 to 16.9, p<0.05 for all). No serious complications were reported during follow-up. PETD for upper and midthoracic disc herniation is a feasible and effective minimally invasive treatment option with favorable clinical results.

A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations

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.

Retroperitoneoscopic Varicocelectomy in Adolescents: Long-term Follow-up in Two Italian Centres

BACKGROUND

The varicocele is the most commonly diagnosed pre-pubertal andrological condition with an incidence of 10%-15% between adolescents. The aim of this study was to evaluate the efficacy of retroperitoneoscopic varicocelectomy (RV) in two Italian centres with particular attention to post-operative testicular volume and semen analysis after 18 years of life.

MATERIALS AND METHODS

From 1999 to 2010, 286 adolescents underwent retroperitoneoscopic left varicocelectomy. Of these patients, 67 were evaluated by clinical examination, ultrasound and semen analysis, allowing an adequate long-term follow-up.

RESULTS

Surgery was performed at a mean age of 13 years (range 10-17) without intraoperative complications. There were two recurrences (3%), two left testis hypotrophy (3%) and four hydroceles (6%), not yet undergone surgery because asymptomatic or without tension. Currently, 44 patients accepted to perform semen analysis which showed a reduction in sperm motility in 12 cases, with associated morphological alterations in 3 and reducing number of spermatozoa in one case.

CONCLUSIONS

In consideration of morphological and biomolecular spermatic alterations reported in adolescent varicocele that could interfere with cellular migration, differentiation and nutrition, it is fundamental to consider the correction of varicocele, not only for the classical indications, but also as a choice for arresting the progressive damage that inevitably acts for several years on the adolescent testis. The RV in adolescents is a safe and feasible procedure for experienced paediatric laparoscopic surgeons with early good clinical outcomes, but more studies occur to understand the real impact of adolescent varicocelectomy on testicular function.

Clinical anatomy and significance of the thoracic intervertebral foramen: A cadaveric study and review of the literature

INTRODUCTION

The literature is lacking information on the anatomy and the osseous dimensions of the thoracic intervertebral foramen (IVF). We describe the anatomy of the broader area, and we proceed with morphometric data of the vertebrae and the foramina. Depiction of these features is provided with imaging and illustrations. The purpose of this paper is to survey and present the anatomy of the foramen as a whole and provide baseline statistical data.

MATERIALS AND METHODS

We review relevant literature, and we present data obtained from skeletal samples of known population and sex. One hundred and nineteen thoracic vertebrae of ten cadaveric spines from the prefecture of Eastern Macedonia and Thrace, Greece, were selected. Statistical analysis measuring the vertical height and the foraminal width of each vertebra was made in accordance with sex.

RESULTS

No statistically important differences referring to the descriptive data of both sexes were found. However, statistically, important positive correlation between the vertebral height and the foraminal width was observed, especially for men. The components of the foramen including arteries and veins passing through or neighboring it, and the spinal nerves and roots are described and depicted.

CONCLUSIONS

The osseous thoracic IVF reveals a glimpse of the in vivo structure and alterations of its width may be present in back pain and other degenerative diseases. Although it is crucial for surgeries and other interventional procedures of the thoracic spine, little is known about the precise anatomy and dimensions of this anatomical landmark.

Full Endoscopic Spinal Surgery Techniques: Advancements, Indications, and Outcomes

Advancements in both surgical instrumentation and full endoscopic spine techniques have resulted in positive clinical outcomes in the treatment of cervical, thoracic, and lumbar spine pathologies. Endoscopic techniques impart minimal approach related disruption of non-pathologic spinal anatomy and function while concurrently maximizing functional visualization and correction of pathological tissues. An advanced understanding of the applicable functional neuroanatomy, in particular the neuroforamen, is essential for successful outcomes. Additionally, an understanding of the varying types of disc prolapse pathology in relation to the neuroforamen will result in more optimal surgical outcomes. Indications for lumbar endoscopic spine surgery include disc herniations, spinal stenosis, infections, medial branch rhizotomy, and interbody fusion. Limitations are based on both non spine and spine related findings. A high riding iliac wing, a more posteriorly located retroperitoneal cavity, an overly distal or proximally migrated herniated disc are all relative contra-indications to lumbar endoscopic spinal surgery techniques. Modifications in scope size and visual field of view angulation have enabled both anterior and posterior cervical decompression. Endoscopic burrs, electrocautery, and focused laser technology allow for the least invasive spinal surgical techniques in all age groups and across varying body habitus. Complications include among others, dural tears, dysesthsia, nerve injury, and infection.

Endoscope-assisted resection of calcified thoracic disc herniations

PURPOSE

Resection of calcified thoracic disc herniations carries significant risks of neurological worsening, particularly in case of concomitant central location. Transthoracic approaches are a first-choice option to avoid spinal cord manipulation but entail drawbacks such as postoperative pain and the risk of bronchopulmonary complications. The purpose of this report is to describe a novel approach to resect calcified herniations, even centrally located, from a posterior perspective.

METHODS

Unilateral lamino-arthrectomy is performed, uncovering few millimeters of the disc space beside the dura. Following discectomy and drilling of the vertebral endplates, an angled endoscope is introduced allowing resection of the calcified herniation through an anterior perspective. The spinal cord can now be decompressed with a no-touch technique. Each maneuver aimed at resecting the calcified mass up to the contralateral side can be done under visual control.

RESULTS

The technique was used in two patients. The first was a 38-year-old man with a calcified mediolateral T9-T10 disc herniation and mild myelopathic symptoms. The second patient was a 73-year-old obese woman, with a T6-T7 central, calcified disc herniation and severe compression myelopathy. In both cases, complete decompression of the spinal cord could be achieved and rapid neurological recovery was observed postoperatively. No surgery-related complications were observed.

CONCLUSIONS

The endoscope-assisted posterior approach afforded safe and complete resection of calcified discs. The technique is particularly useful for central disc herniations, where transthoracic approaches are normally deemed mandatory.