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Pojskić M, Bopp MHA, Nimsky C, Saß B. 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). MEDICINA (KAUNAS, LITHUANIA) 2024; 60:887. [PMID: 38929504 PMCID: PMC11206109 DOI: 10.3390/medicina60060887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
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.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
| | - Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35032 Marburg, Germany;
| | - Christopher Nimsky
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35032 Marburg, Germany;
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
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Farber SH, Walker CT, Zhou JJ, Godzik J, Gandhi SV, de Andrada Pereira B, Koffie RM, Xu DS, Sciubba DM, Shin JH, Steinmetz MP, Wang MY, Shaffrey CI, Kanter AS, Yen CP, Chou D, Blaskiewicz DJ, Phillips FM, Park P, Mummaneni PV, Fessler RD, Härtl R, Glassman SD, Koski T, Deviren V, Taylor WR, Kakarla UK, Turner JD, Uribe JS. Reliability of a Novel Classification System for Thoracic Disc Herniations. Spine (Phila Pa 1976) 2024; 49:341-348. [PMID: 37134139 DOI: 10.1097/brs.0000000000004701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/14/2022] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN This is a cross-sectional survey. OBJECTIVE The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.
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Affiliation(s)
- S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Shashank V Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Bernardo de Andrada Pereira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Robert M Koffie
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - David S Xu
- Department of Neurosurgery, Baylor University, Houston, TX
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra University, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami Hospital, Miami, FL
| | | | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Frank M Phillips
- Department of Neurological Surgery, Rush University, Chicago, IL
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Medicine, New York, NY
| | | | - Tyler Koski
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Vedat Deviren
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | - William R Taylor
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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Cho SS, Farber SH, Zhou JJ, Alan N, O'Neill LK, Giraldo JP, Snyder LA, Turner JD, Uribe JS. Stable Regional and Global Alignment in Patients Treated With Minimally Invasive Lateral Retropleural Thoracic Diskectomy Without Fixation. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00978. [PMID: 38032217 DOI: 10.1227/ons.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Thoracic disk herniations are challenging to treat, and open transthoracic or minimally invasive thoracoscopic approaches are associated with significant morbidity, substantial costs, and steep learning curves. The minimally invasive lateral retropleural thoracic diskectomy (MIS-LRP-TD) approach is straightforward and is associated with lower perioperative morbidity. With MIS-LRP-TD, the overlying rib, ipsilateral pedicle, ligamentum flavum, posterior longitudinal ligament, and posterior third of the adjacent vertebral bodies are resected. Adjunct fixation is typically not performed, eliminating hardware-related complications and costs. This radiographic study investigates long-term global and thoracic spine alignment after MIS-LRP-TD without fixation. METHODS This study was a single-institution, retrospective evaluation of all patients who underwent MIS-LRP-TD without fixation between November 7, 2017 and July 19, 2022. Preoperative and the most recent postoperative radiographs were used to determine the C7 plumb line to central sacral vertical line, thoracic Cobb angle (TCA), segmental Cobb angle, C7 to sagittal vertical axis, thoracic kyphosis, and segmental kyphosis. RESULTS In total, 22 patients with 24 disk herniations underwent MIS-LRP-TD without fixation. The mean (SD) radiographic follow-up was 12.9 (11.2) months. Overall, no significant differences were seen in C7 plumb line to central sacral vertical line (P = .65), C7 to sagittal vertical axis (P = .99), thoracic kyphosis (P = .30), TCA (P = .28), segmental kyphosis (P = .27), or segmental Cobb angle (P = .56) at follow-up. One patient demonstrated a >5° change in TCA but remained asymptomatic. CONCLUSION Despite requiring extensive resection of the middle column and ipsilateral costovertebral joint at the index level, MIS-LRP-TD without adjunct fixation does not lead to significant global, regional, or segmental deformity. Thus, MIS-LRP-TD appears to be a safe, effective treatment approach for challenging thoracic disk herniations.
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Affiliation(s)
- Steve S Cho
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Stonnington HO, Zeeshan Q, Bendok BR, Kalani MA. Commentary: Minimally Invasive Thoracic Discectomy Instructional Video: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e244-e245. [PMID: 37534893 DOI: 10.1227/ons.0000000000000841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 06/12/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Henry O Stonnington
- Mayo Clinic Alix School of Medicine, Mayo Clinic, Scottsdale, Arizona, USA
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
| | - Qazi Zeeshan
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Bernard R Bendok
- Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Precision Neuro-Therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona, USA
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix, Arizona, USA
- Department of Radiology, Mayo Clinic, Phoenix, Arizona, USA
| | - Maziyar A Kalani
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
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