Thoracoscopic microsurgical excision of herniated thoracic discs

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Resection of Calcified and Giant Thoracic Disc Herniation Through Bilateral Postero-Lateral Approach and 360° Cord Release: A Technical Note

Background/Objectives: Surgical treatment of thoracic disc herniation (TDH) is risky and technically demanding due to its proximity to the spinal cord and the high possibility of the TDH being calcified (up to 40%), making the resection even more complex. Calcified TDH may be resected from an anterior via thoracotomy/thoracoscopy, lateral extra-cavitary, or a postero-lateral approach. Here, we present our experience in managing such pathology with an original technique Methods: This original technique, used successfully in more than 40 patients, is introduced, with a precise description of the surgical anatomy and the surgical steps to take. Indications for surgical management and neurological outcomes are also analyzed. This surgical approach consisted of transverso-pediculectomy, most often bilaterally, partial vertebral body drilling, 360° release of the cord, and short fixation. Results: A total of 44 patients were collected, with a mean age of 52.4 ± 11.7 years. Seven patients (15.9%) had complete calcifications, and thirty-one had partial calcifications (70.5%), while the remaining six did not have signs of calcifications. There were only 4 intraoperative complications (2 dural tears and 2 loss of evoked potentials). The TDH could be resected in total for 39 patients (88.6%) and partially, according to the "floating" technique, in 5 patients (11.4%). In the postoperative follow-up, all of the patients except two (presenting with sensory aggravation) reported an improvement in neurological conditions leading to an overall risk of neurological aggravation of 4.5%. Conclusions: The bilateral postero-lateral approach provides a large decompression of the cord (360°) and gives safe access to the TDH, even calcified, permitting high rates of total resection. It also prevents any prejudicial pressure on the spinal cord, reducing the risk of severe postoperative deficits and permitting optimal instrumentation (pedicle screw-based) of the spinal segment. The surgical sequence to resect the bony structures around the spinal cord is of great importance.

The Thoracoscopic Approach in Spinal Cord Disease

Video-assisted thoracic surgery (VATS) has been growing in popularity over the past 2 decades as an alternative to open thoracotomy for the treatment of several spinal conditions, and in the field of minimally invasive surgery, it now acts as a keyhole to the thoracic spine.

MATERIALS AND METHODS

Most VATS approaches are from the right side for pathologies involving the middle and upper thoracic spine because there is a greater working spinal surface area lateral to the azygos vein than that lateral to the aorta. Below T-9, a left-sided approach is made possible because the aorta moves away from the left posterolateral aspect of the spine to an anterior position as it passes through the diaphragm.

RESULTS

VATS has been used extensively in spinal deformities such as scoliosis. The use of VATS in spine surgery includes the treatment of thoracic prolapsed disk diseases, vertebral osteomyelitis, fracture management, vertebral interbody fusion, tissue biopsy, anterior spinal release, and fusion without or with instrumentation (VAT-I) for spinal deformity correction. As the knowledge and the comfort of using such techniques have expanded, the indications have extended to corpectomy for tumor resections.

DISCUSSION AND CONCLUSIONS

In the field of minimally invasive surgery, VATS now acts as a keyhole to the thoracic spine and an alternative to open thoracotomy for the treatment of several spinal conditions.Although VATS can be performed in such spine conditions, it is most beneficial in the treatment of scoliotic deformity, which requires taking a multilevel approach, from the upper to the lower thoracic spine.

Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance

OBJECTIVE

Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs.

METHODS

A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores.

RESULTS

A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade.

CONCLUSIONS

The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon's arsenal for the confident tackling of all TDHs.

Thoracoscopic Microdiscectomy with Preservation of Rib and Costovertebral Joint

INTRODUCTION

Thoracic disc herniations (TDH) may cause major morbidity. While thoracoscopic microdiscectomy (TMD) is an excellent technique, postoperative band-like pain is an important drawback.

MATERIAL AND METHODS

We performed 181 consecutive TMDs (including 39 high-risk cases) with preservation of rib and costovertebral joint (CVJ). We shave a few mm of the rib, drill straight to target, and avoid opening the canal before the TDH is completely free and (in case of giant TDHs) internally debulked, creating initial decompression and limiting epidural venous oozing. Subsequently, we gently mobilize and remove the residual TDH while avoiding leverage.

RESULTS

Skin-to-skin time was <90' in 64, 90-120' in 48, >120' in 20, unknown in 10, and 162' mean in 39 high-risk procedures. Blood loss was <100 mL in 76, <250 mL in 48, and 537 mL mean in 39 high-risk procedures. The technique was successfully applied in all (including nine dural repairs) without a single conversion. We observed an increased neurological deficit in two (1.1%) and inadequate decompression in merely one (wrong level). Complications (mainly pulmonary) were few and managed conservatively, except for a segmental artery pseudoaneurysm treated endovascularly. We observed a substantial decrease in acute and chronic postoperative pain.

DISCUSSION

The technique is fast, straightforward, minimizes bone resection and blood loss, improves orientation, safely and effectively deals with any TDH, and prevents postoperative band-like pain as the CVJ is preserved.

CONCLUSION

We hope this technique will find broader acceptance among a new generation of spine surgeons to benefit patients suffering TDH-related myelopathy or merely intractable pain.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Revision surgery in thoracic disc herniation

PURPOSE

Surgical treatment failures or strategies for the reoperation of residual thoracic disc herniations are sparsely discussed. We investigated factors that led to incomplete disc removal and recommend reoperation strategies.

METHODS

As a referral centre for thoracic disc disease, we reviewed retrospectively the clinical records and imaging studies before and after the treatment of patients who were sent to us for revision surgery for thoracic disc herniation from 2013 to 2018.

RESULTS

A total of 456 patients were treated from 2013 to 2018 at our institution. Twenty-one patients had undergone previously thoracic discectomy at an outside facility and harboured residual, incompletely excised and symptomatic herniated thoracic discs. In 12 patients (57%), the initial symptoms that led to their primary operation were improved after the first surgery, but recurred after a mean of 2.8 years. In seven patients (33%) they remained stable, and in two cases they were worse. All patients were treated via all dorsal approaches. In all 21 cases, the initial excision was incomplete regarding medullar decompression. All of the discs were removed completely in a single revision procedure. After mean follow-up of 24 months (range 12-57 months), clinical neurological improvement was demonstrated in seven patients, while three patients suffered a worsening and 11 patients remained stable.

CONCLUSION

Our data suggest that pure dorsal decompression provides a short relief of the symptoms caused by spinal cord compression. Progressive myelopathy (probably due to mechanical and vascular deficits) and scar formation may cause worsening of symptoms. These slides can be retrieved under Electronic Supplementary Material.

Calcified Thoracic Disc Herniations in the Elderly: Revisiting the Laminectomy for Single Level Disease

STUDY DESIGN

Retrospective case series.

OBJECTIVES

Calcified thoracic disc herniations in the elderly present with a variety of clinical conditions and the treatment is a source of significant debate. Decompression of the disc space is done through anterior, lateral, posterolateral, and posterior approaches. There is significant morbidity of thoracic disc herniation and associated decompression.

METHODS

The present report is a case series of 8 elderly patients with calcified discopathy who received a simple laminectomy without decompression of the disc space.

RESULTS

Postoperatively, 5 patients mobilized independently, 2 with a walker, and 1 patient was nonambulatory. Two patients improved 1 ASIA (American Spinal Injury Association Impairment Scale) score, 1 patient improved 2 ASIA scores, and 3 patients had no change in ASIA score.

CONCLUSION

In our experience, thoracic disc herniations require a technically difficult decompression and overall the complications are significant. We present a series of 8 patients who generally improved from a simple laminectomy and consider this a viable procedure for patients too unwell to undergo direct disc decompression.

A Novel Surgical Technique for Management of Giant Central Calcified Thoracic Disk Herniations: A Dual Corridor Method Involving Tubular Transthoracic/Retropleural Approach Followed by a Posterior Transdural Diskectomy

BACKGROUND

Thoracic disk herniations (TDHs) represent only 0.15% to 1.8% of surgically managed disk herniations but have posed a particular challenge to spine surgeons. Numerous surgical approaches have been cited in the literature with varying degrees of success, technical complexity, and complication profiles.

OBJECTIVE

To report a case of a combined lateral retropleural and dorsal transdural approach for complex thoracic discectomy.

METHODS

In this report, we describe a combined lateral/retropleural and posterior transdural approach for a patient with a giant calcified TDH that was not amenable to safe removal using a single approach.

RESULTS

In complex situations such as this, a dual corridor approach allows for improved visualization and maximal resection opportunity and opens up yet another option to address recalcitrant TDH.

CONCLUSION

The staged dual corridor approach is safe and represents a further surgical option for extremely difficult TDH.

Surgical Approaches for the Treatment of Thoracic Disk Herniation: Results of a Decision Analysis

STUDY DESIGN

A decision analysis.

OBJECTIVE

To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH).

SUMMARY OF BACKGROUND DATA

Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options.

METHODS

We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL.

RESULTS

Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P<0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P<0.001).

CONCLUSIONS

The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.

The Initial Exploration of Adamkiewicz Artery Computed Tomographic Angiography With Monochromatic Reconstruction of Gemstone Spectral Imaging

OBJECTIVE

The study aimed to explore whether optimal monochromatic reconstruction can improve the depiction of the Adamkiewicz artery (AKA) on gemstone spectral computed tomographic angiography (GSCTA) compared with the polychromatic reconstruction protocol.

METHODS

The prospective study was approved by the ethics committee, and written informed consent was obtained from each patient. The 58 consecutive patients suspected of aortic aneurysm or dissection underwent aortic GSCTA. All images were reconstructed with both polychromatic (group A) and optimal monochromatic (group B) protocol. The CT values of the descending aorta and muscle, background noise, and the contrast-to-noise ratio were measured and calculated. With the criterion standard display of AKA, characteristic hairpin curve sign, 2 blinded radiologists analyzed data independently with the paired samples t, χ, and Mann-Whitney U test.

RESULTS

The CT value of the descending aorta and the contrast-to-noise ratio of group B were significantly superior to group A (t = 12.7, P < 0.01; t = 15.2, P < 0.01). The visual rate of AKA (94.8%) in group B was significantly higher (χ = 4.2, P = 0.04) than group A (82.8%). Using a 5-point scale to assess, the score of the visualization efficiency of group B (226) was significantly higher (Z = -2.4, P = 0.02) than group A (192).

CONCLUSIONS

The optimal monochromatic reconstruction for GSCTA can improve the visualization efficiency and quality of the AKA compared with the polychromatic reconstruction protocol.

Treatment of symptomatic thoracic disc herniations with lateral interbody fusion

BACKGROUND

Symptomatic thoracic herniated discs have historically been treated using open exposures (i.e., thoracotomy), posing a clinical challenge given the approach related morbidity. Lateral interbody fusion (LIF) is one modern minimally disruptive alternative to thoracotomy. The direct lateral technique for lumbar pathologies has seen a sharp increase in procedural numbers; however application of this technique in thoracic pathologies has not been widely reported.

METHODS

This study presents the results of three cases where LIF was used to treat symptomatic thoracic disc herniations. Indications for surgery included thoracic myelopathy, radiculopathy and discogenic pain. Patients were treated with LIF, without supplemental internal fixation, and followed for 24 months postoperatively.

RESULTS

Average length of hospital stay was 5 days. One patient experienced mild persistent neuropathic thoracic pain, which was managed medically. At 3 months postoperative all patients had returned to work and by 12 months all patients were fused. From preoperative to 24-month follow-up there were mean improvements of 83.3% in visual analogue scale (VAS), 75.3% in Oswestry Disability Index (ODI), and 79.2% and 17.4% in SF-36 physical (PCS) and mental component scores (MCS), respectively.

CONCLUSIONS

LIF is a viable minimally invasive alternative to conventional approaches in treating symptomatic thoracic pathology without an access surgeon, rib resection, or lung deflation.

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

Background

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

Case Presentation

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

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

Conclusions

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

Indications and Techniques for Spinal Instrumentation in Thoracic Disk Surgery

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To identify the indications, techniques, and outcomes for instrumented fusion during thoracic discectomy.

SUMMARY OF BACKGROUND DATA

Thoracic discectomy may require extensive bone removal to avoid spinal cord manipulation, but the indications and techniques for instrumented fusion during thoracic discectomy remain poorly delineated.

METHODS

The authors identified 220 consecutive patients who underwent thoracic discectomy between 1992 and 2012. Clinical and radiographic variables were compared between patients who underwent instrumented fusion and patients without instrumentation, and among surgical approaches utilized for discectomy.

RESULTS

Patient age for the entire cohort averaged 49±13.01 years, and mean clinical follow-up was 45 months (range, 1-218 mo). Patients underwent 226 thoracic discectomy procedures, including 48 thoracotomy, 136 thoracoscopy, and 42 posterolateral approaches. Seventy-eight patients required instrumented fusion and, compared with patients without instrumentation, were more likely to present with myelopathy (P<0.0001) and harbor giant (P=0.0012), calcified (P=0.019), or transdural (P=0.0004) herniated disks. Surgery with instrumentation resulted in greater blood loss (P<0.0001), longer hospital stay (P<0.0001), and a higher complication rate (22% vs. 9.9%), yet patients in both cohorts had similar rates of symptom resolution postoperatively. Of the patients who underwent thoracic discectomy without instrumentation, 3 (2.1%) developed delayed deformity or instability and required subsequent surgery for fixation and fusion at an average 6.3 months postoperatively (range, 4-8 mo). Patients who underwent instrumented fusion exhibited no nonunions or delayed deformity.

CONCLUSIONS

Thoracic discectomy without fixation is a reasonable clinical option in carefully selected patients, but instrumented fusion is safe and effective in other patients. Indications for fixation and fusion are thus proposed.

Thoracic disc disorders with myelopathy: treatment trends, patient characteristics, and complications

STUDY DESIGN

Retrospective review.

OBJECTIVE

To analyze trends in the use of 3 surgical treatments (anterior/anterolateral decompression and spinal fusion [ASF], posterior/posterolateral decompression and spinal fusion [PSF], and disc decompression/excision without fusion [DDE]) for patients with thoracic disc disorders with myelopathy (TDM), and how the treatments differ in terms of patient and hospital characteristics, complications, mortality, and resource utilization.

SUMMARY OF BACKGROUND DATA

Various approaches have been described in the literature, but the preferred method is not well established.

METHODS

Using the Nationwide Inpatient Sample database, we identified 13,837 patients with TDM who underwent spine surgery from 2000 through 2010. Analyses were performed using linear regression for trends, χ test for categorical variables, and analysis of variance test for discrete variables (significance, P < 0.05).

RESULTS

Over the study period, the preferred treatment of TDM shifted substantially from DDE being performed in two-thirds of the patients in 2000 to PSF being performed in almost half of all patients by 2010. Patients undergoing ASF were significantly younger and had significantly higher rates of private insurance than those in the other groups. DDE was performed significantly more frequently at nonteaching hospitals. Patients undergoing ASF had the highest complication rate (24.2%), especially pulmonary and cardiac complications. They also had a 2.8-fold and 2.0-fold mortality compared with DDE and PSF, respectively. Patients undergoing DDE had significantly shorter length of stay and lower total hospitalization charges than the other groups.

CONCLUSION

Over the last decade, there has been a significant increase in PSF use in the surgical treatment of TDM. Postoperative complication and mortality rates were highest with ASF; DDE approach was associated with significantly fewer complications, shorter length of stay, and lower hospitalization charges than other groups.

LEVEL OF EVIDENCE

4.

Surgical treatment for thoracic disc herniation: an update

STUDY DESIGN

Retrospective review of the literature.

OBJECTIVE

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

SUMMARY OF BACKGROUND DATA

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

METHODS

Review of the literature.

RESULTS

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

CONCLUSION

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

Transthoracic approach for the treatment of calcified giant herniated thoracic discs

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Circumspinal decompression and fusion through a posterior midline incision to treat central calcified thoracolumbar disc herniation: a minimal 2-year follow-up study with reconstruction CT

Purpose

There have been several surgical approaches used in the treatment of thoracolumbar disc herniation (TLDH) from T10/11 to L1/2. However, central calcified TLDH cases are still challenging to spine surgeons. The anterior transthoracic approaches and lateral/posterolateral approaches are all essentially performed from one side; thus, the compressive lesion and the dura matter on the other side of the spinal canal are not clearly visualized, predisposing the procedure to incomplete decompression or inadvertent cord manipulation. Moreover, a number of these approaches are technically demanding and require entry into the chest. The purpose of this study was to introduce a new surgical procedure—circumspinal decompression and fusion through a posterior midline incision—for the treatment of central calcified TLDH and to evaluate its surgical outcome.

Methods

In this study, 22 patients (15 males and 7 females; mean age 49 years) with central calcified TLDH underwent this procedure between April 2008 and April 2011. Altogether, 26 discs were excised, with two discs at T10/11, eight discs at T11/12, nine discs at T12/L1 and seven discs at L1/2. Of these patients, 16 returned for final follow-up, with a mean follow-up period of 41 months (range 24–57 months). Clinical outcomes, including operative time, blood loss, perioperative complications, post-operative time of hospitalization, neurological status improvement, extent of decompression, back pain, local spinal curvature and fusion, were investigated. The patients’ neurological status was evaluated by a modified Japanese Orthopedic Association scoring system of 11 points. Fusion and the extent of decompression were evaluated by reconstruction CT at final follow-up.

Results

The mean operative time was 185 min, the mean blood loss was 896 ml and the mean post-operative hospitalization time was 8 days. Four patients suffered perioperative complications, but only two were related to dura violation and none involved the respiratory system. All of the 16 patients who returned for the final follow-up showed improvement, and evidence of improvement was found in five of the other six patients who did not return for final follow-up through telephone interview or earlier follow-up evaluations. Complete decompression was achieved in 12 of the 16 patients who returned for final follow-up. In the 16 patients who returned for final follow-up, back pain was significantly reduced and local spinal curvature remained unaltered. In addition, based on reconstruction CT images, solid fusion was observed in 15 of the 16 patients who returned for final follow-up.

Conclusions

The circumspinal decompression and fusion through a posterior midline incision procedure can be used to treat central calcified TLDH patients with neurological deficits. This method’s greatest advantage is that it is a highly effective and safe procedure for decompression. Although it is a major and destructive procedure, spinal stability was well maintained in most of the cases. In this era when minimally invasive spine surgeries like thoracoscopy have been in an upward trajectory, spine surgeons still should be made aware of this procedure.

Subphrenic hematoma after thoracoscopic discectomy: description of a very rare adverse event and review of the literature on complications

The authors describe a very rare and previously unreported complication of thoracoscopic discectomy. Endoscopic spine surgery has evolved as a safe and effective treatment, and thoracoscopic discectomy, in particular, provides several advantages over open approaches, although it can be associated with intraoperative or postoperative complications. The most frequently observed adverse events are intercostal neuralgia, retained disc fragments, durotomies, atelectasis, extensive bleeding, and emergency conversion to open thoracotomy for vascular injuries. Even rare complications, such as chylorrhea or brain hemorrhagic infarction, have been reported. Nonetheless, a literature review did not reveal any case of postoperative intraabdominal hematoma following thoracoscopic discectomy. A 43-year-old woman, with no history of hematological or vascular disorders or thoracic surgery, underwent a right-sided thoracoscopic discectomy for T11–12 disc herniation. No apparent surgical technique–related complications were encountered, but intermittently repeated difficulties with single-lung ventilation occurred. The resultant dysventilation allowed partial right lung reexpansion, along with increased abdominal pressure. The latter induced an upward ballooning of the right diaphragm with consequent obstruction of the surgical field of view, requiring constant and continuous pressure applied to the thoracic surface of the diaphragm via a metal fan retractor and thus counteracting the increased abdominal pressure. Postoperatively, a large subdiaphragmatic hematoma originating from a bleeding right inferior phrenic artery was diagnosed and required urgent endovascular occlusion. The patient made an uneventful recovery with conservative treatment. A very rare and previously unreported complication—that is, early subdiaphragmatic hematoma after thoracoscopic discectomy—is described here. The authors submit that conversion to an open approach is safer when persistent anesthesia-related complications are encountered in thoracoscopic discectomy.

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.

Thoracoscopic anatomy and approaches of the anterior thoracic spine: cadaver study

PURPOSE

[corrected] In spite of the extensive case studies considering thoracoscopic approaches to the anterior thoracic spine, the literature lacks studies of the thoracoscopic anatomic dissection and approaches. In this article, the authors present their study of thoracoscopic anatomy of the anterior spine with illustrated step-wise dissection and approaches for sympathectomy, discectomy and corpectomy.

MATERIALS AND METHODS

Four adult cadavers with no history of disease, local trauma or surgery were studied and bilateral thoracoscopic anterior spinal approaches were performed. Thoracoscopic dissections were done in the Department of Anatomy, using Karl Storz 30°, 5 mm and 30 cm rod lens rigid endoscope (Karl Storz and Co., Tuttlingen, Germany). As surgical instrumentation, Karl Storz Rosenthal endoscopic surgical set and 15 mm portals were used for all approaches.

RESULTS

For sympathectomy, the cadaver is positioned supine and the port locations are in the third and fifth intercostal spaces in the anterior axillary line. The stellate ganglion is cephalad to the second rib, and the T2 and T3 ganglia are divided just superior to T2 ganglia and inferior to T3. For discectomy, the cadaver is positioned in the lateral decubitus position. The working portal is positioned directly over the affected disc in the posterior axillary line. The camera portal is positioned in the middle axillary line; 2-3 intercostal spaces caudal to the working portal. The rib head is removed and the lateral surface of the pedicle and neural foramen are exposed. The pedicle and the floor of the spinal canal are resected to decompress the ventral aspect of the spinal canal. For corpectomy, the position of the cadaver and ports are as same as for discectomy. The adjacent segmental vessels are divided first, and the discs above and below the targeted corpus are removed. The ipsilateral pedicle is then removed to decompress the anterior spinal cord, followed by median corpectomy.

CONCLUSIONS

Thoracoscopic approaches are minimally invasive procedures and they can be used safely in patients who need anterior exposure to the thoracic spine for the treatment of a spectrum of diseases. Knowledge of the normal anatomy and thoracoscopic cadaver dissection are essential steps in improving the learning curve.

Thoracoscopic resection of symptomatic herniated thoracic discs: clinical results in 121 patients

STUDY DESIGN

Retrospective review of a prospectively maintained surgical database.

OBJECTIVE

To report the indications, surgical procedures performed, and outcomes from the largest series of thoracoscopically treated herniated thoracic discs (HTDs). We also compared approach-related complications with an unmatched cohort undergoing thoracotomy for HTD.

SUMMARY OF BACKGROUND DATA

Symptomatic HTDs are rare, and their surgical management is technically challenging.

METHODS

A prospectively maintained surgical database of all patients undergoing surgery for symptomatic HTDs by the senior author (blinded for review) was reviewed. As needed, the database was supplemented with hospital and clinic charts and telephone conversations with patients. A triportal method of thoracoscopic discectomy was performed in all cases.

RESULTS

Between 1994 and 2008, 121 patients underwent 125 thoracoscopic-assisted operations for 139 HTDs. Their mean age at surgery was 46.6 years. Indications for thoracoscopic resection currently include small symptomatic disc, anterior location, nonmorbidly obese patient, favorable chest anatomy, and T4-T11 location. Symptom duration averaged 32 months. Radiculopathy was the most common presentation, followed by myelopathy and pain (radiculopathic or back). The mean hospital stay was 4.8 days. Chest tubes remained in place for a mean of 3.2 days. At a mean follow-up of 2.4 years, myelopathy, radiculopathy, and back pain had resolved or improved at a rate of 91.1%, 97.6%, and 86.5%, respectively. Patients reported worsening in 0%, 1.2%, and 0% of cases, respectively. Most patients (97.4%) would be willing to undergo the operation again. The complication rate was acceptable. Patients undergoing thoracoscopic excision had less approach-related morbidity than an unmatched cohort undergoing excision using thoracotomy.

CONCLUSION

Thoracoscopic-assisted microsurgical resection is a safe, effective, and minimally invasive method of treating symptomatic HTDs in appropriately selected patients. The symptoms of most patients improve or resolve with minimal morbidity.

Thoracoscopic treatment for single level symptomatic thoracic disc herniation: a prospective followed cohort study in a group of 167 consecutive cases

PROBLEM

Thoracic disc disease with radicular pain and myelopathic symptoms can have serious neurological sequelae. The authors present a relevant treatment option.

METHODS

Data of patients with single level symptomatic thoracic disc herniation treated with thoracoscopic microdiscectomy were prospectively collected over a period of 10 years. Data collection included the preoperative status and the follow-up status was 6, 12 and 24 months after surgery for every patient.

RESULTS

A total of 167 single level thorascoscopic discectomies without previous surgery on the level of the procedure were included in this study. The average preoperative duration of pain symptoms was 14.3 months, myelopathic symptoms were present for an average of 16.7 months before surgery. After the procedure pain scores measured with visual analog scale (VAS) decreased by 4.4 points and the muscle strength improved by a mean of 4.6 points (American Spinal Injury Association ASIA motor score). After 2 years, 79% of the patients reported a excellent or good outcome for pain and 80% of the patients reported a excellent or good outcome for motor function. The overall complication rate was 15.6%.

CONCLUSIONS

Thoracoscopic microdiscectomy for single level symptomatic disc herniation is a highly effective and reliable technique, it can be performed safely with low complication rate.

Tandem intercostal thoracic schwannomas resected using a thoracoscopic nerve-sparing technique: case report

BACKGROUND AND IMPORTANCE

To describe a novel nerve-sparing technique for the resection of intercostal nerve schwannomas. This case demonstrates that intercostal neuralgia can be caused by intercostal schwannomas and that it can be relieved by their removal.

CLINICAL PRESENTATION

A young woman with schwannomatosis had progressively worsening intercostal neuralgia caused by compression of the intercostal nerve against the rib by tandem intercostal schwannomas. After the tumors were removed, her symptoms were completely relieved. A thoracoscopic technique was used to define the involved fascicles and to facilitate removal of the tumors while sparing the uninvolved nerve.

CONCLUSION

The patient's radicular pain was relieved completely by the tumor resection. Thoracoscopic surgery offers a safe and minimally invasive technique for removal of intercostal schwannomas and is a valid alternative to open thoracotomy. Removal of thoracic schwannomas can relieve intercostal neuralgia.

Surgical treatment of thoracic disc herniations via tailored posterior approaches

We present clinical findings, radiological characteristics and surgical modalities of various posterior approaches to thoracic disc herniations and report the clinical results in 27 consecutive patients. Within an 8-year period 27 consecutive patients (17 female, 10 male) aged 30-83 years (mean 53 years.) were surgically treated for 28 symptomatic herniated thoracic discs in our department. Six of these lesions (21%) were calcified. In all cases surgery was performed via individually tailored posterior approaches. We evaluated the pre- and postoperative clinical status and the complication rate in a retrospective study. Nearly one half of the lesions (46.4%) were located at the three lowest thoracic segments. Clinical symptoms included back pain or radicular pain (77.8%), altered sensitivity (77.8%), weakness (40.7%), impaired gait (51.9%) or bladder dysfunction (22%). Costotransversectomy was performed in 8 patients, 1 lateral extracavitary approach, 2 foraminotomies, 15 transfacet and/or transpedicular approaches and 2 interlaminar approaches were used for removing the pathologies. After a mean follow-up of 38.6 months (3-100 months), complete normalization or reduction of local pain was recorded in 87% of the patients and of radicular pain in 70% of the cases, increased motor strength could be achieved in 55%, sensitivity improved in 76.2% and improvement of myelopathy was noted in 71.4%. Two patients suffered from postoperative impairment of sensory deficits, which in one case was discrete. The overall recovery rate within the modified JOA score was 39.5%. In 1 patient, two revisions were required because of instability and a persisting osteophyte, respectively. The rate of major complications was 7.1% (2/28). Surgical treatment of thoracic disc herniations via posterior approaches tailored to the individual patient produces satisfying results referring to clinical outcome. Posterior approaches remain a viable alternative for a large proportion of patients with symptomatic thoracic disc herniations.

Surgical management of multiple thoracic disc herniations via a transfacet approach: a report of 15 cases

OBJECTIVE

Symptomatic thoracic disc herniations (TDHs) are rare, and multiple TDHs account for an even smaller percentage of symptomatic herniated discs. Most TDHs are found in the lower thoracic spine, with more than 75% occurring below T-8. The authors report a series of 15 patients with multiple symptomatic TDHs treated with a modified transfacet approach.

METHODS

Fifteen patients (9 women and 6 men) with a total of 32 symptomatic TDHs were treated surgically at the authors' institution between 1994 and 2010. The average patient age was 51.1 years. Thirteen patients had 2-level herniation and 2 patients had 3-level disease. The most commonly involved level was T7-8 (10 herniations), followed by T6-7 and T8-9 (6 herniations each). All patients had long-standing myelopathic and/or radicular complaints at the time of presentation. Each disc that exhibited radiographically confirmed compression of the spinal cord or nerve root was considered for resection. Only patients with lateral disc herniations were considered for the modified transfacet approach; patients with a centrally herniated disc underwent ventral or ventral-lateral procedures. The average follow-up time was 30 months.

RESULTS

All patients had successful resection of their herniated discs. All patients with preoperative weakness demonstrated improved strength, and 11 of 12 patients with preoperative pain showed improvement in pain. Sensory loss was less consistently improved. The 2 patients who underwent posterior fixation and fusion achieved radiographically confirmed fusion by the 1-year follow-up. Nine of 10 patients who were working returned to their jobs. Eleven of 12 patients with preoperative back or radicular pain had drastic or complete pain resolution; 1 patient had no change in pain. All 7 patients with preoperative ambulatory difficulty had postoperative gait improvement. Complications were minimal.

CONCLUSIONS

Multiple symptomatic herniated thoracic discs are rare causes of pain and disability, but should be treated surgically because good outcomes can be achieved with acceptably low morbidity.

Percutaneous thoracic intervertebral disc nucleoplasty: technical notes from 3 patients with painful thoracic disc herniations

Symptomatic thoracic disc herniation is an uncommon condition and early surgical approaches were associated with significant morbidity and even mortality. We are the first to describe the technique of percutaneous thoracic nucleoplasty in three patients with severe radicular pain due to thoracic disc herniation. Two of the patients experienced more than 75% pain relief and one patient experienced more than 50% pain relief. Post-procedural pain relief was maintained up to an average of 10 months after nucleoplasty. One patient with preoperative neurological signs improved postoperatively. There were no reported complications in all three patients. In view of the reduced morbidity and shorter operating time, thoracic intervertebral disc nucleoplasty can be considered in patients with pain due to thoracic disc herniation, with no calcification of the herniated disc, and in patients who may be otherwise be unfit for conventional surgery.

Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome

OBJECT

Thoracic disc herniations (TDHs) may occasionally present with an acute myelopathy, defined as a variable degree of motor, sensory, and sphincter disturbances developing in less than 24 hours, and resulting in a Frankel Grade C or worse. Confronted with such a patient, the surgeon has to decide whether to perform an emergency operation and whether to use an anterior or posterior approach. The authors analyze their own experience and the pertinent literature, focusing on clinical presentation, imaging findings, surgical timing, technique, and outcome.

METHODS

Among 250 patients who underwent surgery for symptomatic TDH, 209 had at least 1 year of follow-up at the time of writing, including 8 patients who presented with an acute myelopathy. They were surgically treated using standard thoracoscopic microdiscectomy, careful blood pressure monitoring, and intravenous methylprednisolone. The authors analyzed pre- and postoperative neuroimaging, and Frankel scores preoperatively, at discharge, and 1 year postoperatively.

RESULTS

Although 5 patients had multiple TDHs, the symptomatic TDH was invariably situated between T9-10 and T11-12. Seven TDHs were giant, 6 were calcified, 6 were accompanied by myelomalacia, and 4 were accompanied by segmental stenosis. Although sudden dorsalgia was the initial symptom in 6, a precipitating event was noted in only 1. All patients had severe neurological deficits by the time they underwent surgery. Frankel grades improved from B to D in 2 patients, from C to E in 4, and from C to D and B to E in 1 patient each. All patients regained continence and ambulation. Transient complications were CSF leak (in 2 patients), and intraoperative blood loss greater than 1000 ml, reversible ischemic neurological deficit, and subileus (in 1 patient each).

CONCLUSIONS

Approximately 4% of TDHs present with an acute myelopathy. They are often situated between T9-10 and T11-12, large or giant, and even calcified. They almost invariably cause important cord compression (sometimes aggravated by an associated segmental stenosis) and myelomalacia. Their clinical presentation may be misleading, and diagnosis may be delayed until other causes (especially vascular) have been excluded and the clinical picture has become more complete. Interestingly, whereas a precipitating event or trauma is rarely present, dorsalgia frequently precedes profound myelopathy and may help to make an early diagnosis. Remarkable recovery is possible even with profound neurological deficit, a delay of several days, in the elderly, and in the presence of myelomalacia, provided the spinal cord is adequately decompressed and intraoperative hypotension is strictly avoided. Although alternative approaches more familiar to most neurosurgeons may be used, the anterior transthoracic approach has the advantage of reaching the TDH in front of the compromised spinal cord, avoiding any manipulation. In experienced hands, thoracoscopic microdiscectomy combines the advantage and versatility of an anterior approach with minimal postoperative discomfort. The authors conclude that TDH-related acute myelopathy may have a favorable outcome when managed correctly, and they strongly recommend that every single patient should undergo surgical treatment.

Endoscopic minimally invasive neurosurgery: emerging techniques and expanding role through an extensive review of the literature and our own experience - part II: extraendoscopic neurosurgery

BACKGROUND/AIMS

The field of minimally invasive neurosurgery has grown dramatically especially in the last decades. This has been possible, in the most part, due to the advancements in technology especially in tools such as the endoscope. The contemporary classification scheme for endoscopic procedures needs to advance as well.

METHODS

The present classification scheme for neuroendoscopic procedures has become confusing because it mainly describes the use of the endoscope as an assisting device to the microscope. The authors propose an update to the current classification that reflects the independence of the endoscope as a tool in minimally invasive neurosurgery.

RESULTS

The proposed classification groups the procedures as 'intraendoscopic' neurosurgery or 'extraendoscopic' neurosurgery (XEN) in relation to the 'axis' of the endoscope. A review of the literature for the XEN group together with exemplary cases is presented.

CONCLUSION

We presented our proposed classification for the endoscope-only surgical procedures. The XEN group is expanded in this article.

Resultados imediatos da correção cirúrgica de escoliose idiopática do adolescente por via posterior com instrumentação após liberação anterior por videotoracoscopia

OBJETIVO: descrever os resultados imediatos da aplicação da liberação anterior por videotoracoscopia, seguida de instrumentação por via posterior para correção cirúrgica da escoliose idiopática do adolescente. MÉTODOS: foram selecionados 20 pacientes, no período de agosto de 1989 a maio de 2001, com escoliose idiopática do adolescente, padrão de curva torácica direita rígida, King III. Inicialmente realizou-se a abordagem pela via anterior com liberação por videotoracoscopia e depois a via posterior para correção e fixação com instrumental de Hartshill, em um mesmo tempo cirúrgico. RESULTADOS: todos os procedimentos foram completados com sucesso com videotoracoscopia, sem necessidade de conversão para toracotomia. A média de idade dos pacientes foi de 15,7 anos (12 a 21 anos). Em relação aos dias de internação, obteve-se um tempo médio de permanência de 9,45 dias (5 a 26 dias). A média entre os valores angulares foi, no pré-operatório, de 66,25º Cobb (48º a 92º Cobb), e no pós-operatório, de 31,2º Cobb (15º a 45º Cobb). Como complicações, quatro pacientes tiveram nevralgia intercostal (20%) e um caso de atelectasia (5%). CONCLUSÕES: a discectomia por videotoracoscopia é um método efetivo e seguro para tornar flexíveis as curvas escolióticas rígidas. No entanto, trata-se de um procedimento tecnicamente difícil, que requer treinamento árduo e prolongado, com curva de aprendizado extensa.

Transvertebral herniotomy for T2/3 disc herniation--a case report

STUDY DESIGN

A case report of a 51-year-old man with acute myelopathy owing to T2/3 disc herniation that was treated with transvertebral herniotomy.

OBJECTIVES

To report surgical advantages of the transvertebral approach in the upper thoracic spine.

SUMMARY OF BACKGROUND DATA

Various surgical approaches to the upper thoracic spine have been reported because the approach is difficult owing to the specific anatomical structure. However, a lack of consensus still remains regarding the choice of operative procedure because of some problems for each approach.

METHODS

A 51-year-old man presented acute paraparesis of lower extremities and bladder paralysis owing to T2/3 disc herniation. The herniated disc was removed microscopically by the anterior approach through a 10-mm-diameter hole made in the T2 vertebral body without sternum splitting.

RESULTS

Satisfactory decompression was performed. After operation, the patient had full clinical motor and sensory recovery.

CONCLUSIONS

Transvertebral approach, which has been recently performed for cervical disc lesion, was also less invasive and safer than the conventional approaches, such as sternum splitting, transthoracic or posterolateral approaches, for our patient with T2/3 disc herniation.

ROD DEROTATION TECHNIQUES FOR THORACOLUMBAR SPINAL DEFORMITY

OBJECTIVE

The operative correction of scoliosis requires multiple intraoperative techniques and tools to achieve an adequate result. Frequently, multiple methods are used to accomplish this, such as rod cantilever techniques, in situ bending, Smith-Petersen and pedicle subtraction osteotomies, closed reduction methods, and rod derotation techniques. Rod derotation techniques will be reviewed and discussed in this article.

METHODS

A review of the available literature on anterior and posterior rod derotation is performed with a case example of the authors' experience utilizing this technique.

RESULTS

Rod derotation is one technique that can transform a pathological scoliotic curve to normal physiological kyphosis or lordosis by simply rotating a rod intraoperatively.

CONCLUSION

In this article, the authors present rod derotation as a valuable technique in the surgical arsenal for the treatment of scoliosis, including a discussion of the technique and its limitations.

The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment

Object

Thoracic disc herniations can be surgically treated with a number of different techniques and approaches. However, surgical outcomes comparing the various techniques are rarely reported in the literature. The authors describe a minimally invasive technique to approach thoracic disc herniations via a transpedicular route with the use of tubular retractors and microscope visualization. This technique provides a safe method to identify the thoracic disc space and perform a decompression with minimal paraspinal soft tissue disruption. The authors compare the results of this approach with clinical results after open transpedicular discectomy.

Methods

The authors performed a retrospective cohort study comparing results in 11 patients with symptomatic thoracic disc herniations treated with either open posterolateral (4 patients) or mini-open transpedicular discectomy (7 patients). Hospital stay, blood loss, modified Prolo score, and Frankel score were used as outcome variables.

Results

Patients who underwent mini-open transpedicular discectomy had less blood loss and showed greater improvement in modified Prolo scores (p = 0.024 and p = 0.05, respectively) than those who underwent open transpedicular discectomy at the time of early follow-up within 1 year of surgery. However, at an average of 18 months of follow-up, the Prolo score difference between the 2 surgical groups was not statistically significant. There were no major or minor surgical complications in the patients who received the minimally invasive technique.

Conclusions

The mini-open transpedicular discectomy for thoracic disc herniations results in better modified Prolo scores at early postoperative intervals and less blood loss during surgery than open posterolateral discectomy. The authors' technique is described in detail and an intraoperative video is provided.

Minimally Invasive Thoracoscopic Resection of Paraspinal Neurogenic Tumors: Technical Case Report

Objective:

The posterior mediastinum is a common location for benign neurogenic tumors. They are frequently asymptomatic but can present with local compressive or neurological symptoms.

Methods:

Thoracoscopy is used increasingly over posterolateral thoracotomy for the removal of these lesions.

Results:

Complete resection of these tumors through a thoracoscopic approach is possible in most cases, but dumbbell tumors present as special challenges, which require a combined thoracoscopic and open posterior approach.

Conclusion:

In this article, we outline the technique of thoracoscopic resection of paraspinal neurogenic tumors through an operative video and a review of the literature to summarize the surgical outcomes of patients with these lesions.

Clinical Analysis of Video-assisted Thoracoscopic Spinal Surgery in the Thoracic or Thoracolumbar Spinal Pathologies

OBJECTIVE

Thoracoscopic spinal surgery provides minimally invasive approaches for effective vertebral decompression and reconstruction of the thoracic and thoracolumbar spine, while surgery related morbidity can be significantly lowered. This study analyzes clinical results of thoracoscopic spinal surgery performed at our institute.

METHODS

Twenty consecutive patients underwent video-assisted thoracosopic surgery (VATS) to treat various thoracic and thoracolumbar pathologies from April 2000 to July 2006. The lesions consisted of spinal trauma (13 cases), thoracic disc herniation (4 cases), tuberculous spondylitis (1 case), post-operative thoracolumbar kyphosis (1 case) and thoracic tumor (1 case). The level of operation included upper thoracic lesions (3 cases), midthoracic lesions (6 cases) and thoracolumbar lesions (11 cases). We classified the procedure into three groups: stand-alone thoracoscopic discectomy (3 cases), thoracoscopic fusion (11 cases) and video assisted mini-thoracotomy (6 cases).

RESULTS

Analysis on the Frankel performance scale in spinal trauma patients (13 cases), showed a total of 7 patients who had neurological impairment preoperatively : Grade D (2 cases), Grade C (2 cases), Grade B (1 case), and Grade A (2 cases). Four patients were neurologically improved postoperatively, two patients were improved from C to E, one improved from grade D to E and one improved from grade B to grade D. The preoperative Cobb's and kyphotic angle were measured in spinal trauma patients and were 18.9+/-4.4 degrees and 18.8+/-4.6 degrees , respectively. Postoperatively, the angles showed statistically significant improvement, 15.1+/-3.7 degrees and 11.3+/-2.4 degrees , respectively (P<0.001).

CONCLUSION

Although VATS requires a steep learning curve, it is an effective and minimally invasive procedure which provides biomechanical stability in terms of anterior column decompression and reconstruction for anterior load bearing, and preservation of intercostal muscles and diaphragm.

Mini-thoracotomy or thoracoscopic treatment for medially located thoracic herniated disc?

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

Comparison of the mini-thoracotomy (mini-TTA) and thoracoscopy for the treatment of calcified thoracic herniated disc.

SUMMARY OF BACKGROUND DATA

Thoracoscopy has been popularized at the cost of the traditional thoracotomy for the treatment of calcified herniated discs. However, the learning curve is steep. Given the low incidence of herniated thoracic discs, it will be difficult for a group of spinal surgeons to gain experience. Newer, minimally invasive techniques with a nearly absent learning curve are evolving. One of these techniques is the mini-TTA.

METHODS

Retrospectively, the charts of patients that underwent a mini-TTA or thoracoscopy were retrieved.

RESULTS

Seven patients underwent a thoracoscopy, and 21 a mini-TTA. Although the groups are limited, a statistical significant difference in gender, age, duration of surgery, duration of the necessity of a chest drain, intraoperative blood loss, or duration of the postoperative stay on the intensive care unit was not reached. At the last follow-up in the thoracoscopic group, 2 patients had some neuropathic thoracic incisional pain. In all patients, a complete removal of the calcified disc was ascertained with a postoperative computed tomography scan.

CONCLUSION

The mini-TTA has some theoretical advantages over a thoracoscopy. It is also a minimally invasive approach. The thoracoscopy has a steep learning curve, whereas the mini-TTA is simple to apply. Classic microsurgical bimanual techniques can be used.

Thoracoscopic Debridement and Stabilization of Pyogenic Vertebral Osteomyelitis

The role of surgical debridement and internal fixation in treatment of vertebral osteomyelitis has been evolving. The standard surgical approach to thoracolumbar vertebral osteomyelitis requiring extensive thoracotomy or retroperitoneal exposure carries significant associated morbidity and postoperative pain. Minimally invasive thoracoscopic spine surgery is designed to improve postoperative morbidity associated with the traditional open surgery. We report a case of a 70-year-old man who developed T11-T12 pyogenic vertebral osteomyelitis 3 months after undergoing posterior laminectomy and microsurgical excision of a herniated thoracic disc. The patient underwent minimally invasive thoracoscopic radical debridement and anterior spinal reconstruction and fusion. Patients with vertebral osteomyelitis may benefit from the decreased postoperative morbidity that is associated with minimally invasive thoracoscopic spinal surgery.

Techniques for the operative management of thoracic disc herniation: minimally invasive thoracic microdiscectomy

Thoracic disc herniations are uncommon lesions that are asymptomatic in most patients; however, for individuals who present with persistent radiculopathy that is nonresponsive to conservative treatment or with myelopathic symptoms with or without radiculopathy attributed to a thoracic disc herniation, operative intervention of the thoracic spine is sought. Various procedures and approaches for the treatment of thoracic disc herniations have been reported, but they have been associated with numerous intraoperative complications and postoperative morbidities. This article discusses a novel minimally invasive procedure for the surgical treatment of thoracic disc herniations referred to as a minimally invasive thoracic microdiscectomy. It uses a series of muscle dilators, a tubular retractor, and microscopic visualization by way of a posterolateral approach in an effort to minimize many of the complications that are associated with the more traditional approaches.

POSTERIOR KEYHOLE CORPECTOMY WITH PERCUTANEOUS PEDICLE SCREW STABILIZATION IN THE SURGICAL MANAGEMENT OF LUMBAR BURST FRACTURES

OBJECTIVE

The authors present a new method of minimally invasive surgical management of lumbar burst fractures through the posterior approach. The method includes minimally invasive corpectomy and interbody fusion, both of which are performed through a keyhole approach, and percutaneous pedicle screw fixation of the fracture. The technique of the posterior keyhole corpectomy presented in this report is a novel and original concept of the first author (AM). The percutaneous pedicle screw stabilization is performed with the use of a percutaneous instrumentation system (Sextant; Medtronic, Inc., Minneapolis, MN). The Sextant system has been dedicated and used in nontrauma degenerative cases; the novel aspect of this system is its application in spine fractures. Indications for the method include Denis classification subtype B or Magerl subtype A.3.1 burst fractures. Both subtypes represent fractures with failure and retropulsion of the upper part of the vertebral body.

METHODS

The clinical experience of this study includes four cases of burst fractures with significant retropulsion and occlusion of the spinal canal. Long-term results were assessed at a minimum follow-up period of 1 year (maximum, 3.5 yr). The follow-up assessments included: 1) the quality of decompression and reconstruction of the spinal canal (computed tomographic and magnetic resonance imaging scanning); 2) the stability of the operated segment (dynamic x-rays); 3) the quality of interbody fusion (computed tomographic scanning and dynamic x-rays); and 4) correction of the fracture kyphosis and its postoperative loss (measurements of Cobb angles for the assessment of sagittal plane deformity). The minimum armamentarium requirements for this method include a typical micro lumbar discectomy retractor set; a surgical microscope; two-plane intraoperative fluoroscopy; and a system for percutaneous pedicle screw stabilization (Sextant). "Posterior keyhole corpectomy" indicates corpectomy of the posterior upper half of the vertebral body or removal of the retropulsed bone fragment via two keyhole skin incisions on both sides of the spinous process (each skin incision measures 2 to 3 cm long). Exposure of the retropulsed fragment (the posterior upper part of the vertebral body) is achieved by medial or complete facetectomy along with complete or medial resection of the pedicle. This has to be performed bilaterally. Percutaneous stabilization requires four additional stab skin incisions.

RESULTS

We observed no surgery-related complications (neurological, hardware, dural tears, or deep or superficial wound infections); there was perfect decompression and clearance of the spinal canal (confirmed by computed tomographic and magnetic resonance imaging scanning); and there was solid stability at the affected segments (confirmed by dynamic x-rays). Healed fusion was noted in all patients but one. The latter patient had no clinical symptoms of spinal instability. Kyphotic deformity was corrected and reversed into lordosis in three patients. Loss of deformity correction was noted in all patients; however, all patients retained lordotic alignment of the affected segment.

CONCLUSION

The advantages of this method include sparing the posterior elements (lamina, spinous process, supraspinous and interspinous ligaments, and paravertebral muscles), safety of the decompression provided by the use of a surgical microscope, and perfect illumination of the operating field. The drawbacks of the method include limitation to certain types of burst fractures, the method is surgically demanding, and the method requires development of a special retractor system to eliminate the cumbersome alternate insertion and the reinsertions of the typical microdiscectomy retractor set.