Thoracic microendoscopic discectomy

Evolution, Current Trends, and Latest Advances of Endoscopic Spine Surgery

Background: The aging of the population in developing and developed countries has led to a significant increase in the health burden of spinal diseases. These elderly patients often have a number of medical comorbidities due to aging. The need for minimally invasive techniques to address spinal disorders in this elderly population group cannot be stressed enough. Minimally invasive spine surgery (MISS) has several proven benefits, such as minimal muscle trauma, minimal bony resection, lesser postoperative pain, decreased infection rate, and shorter hospital stay. Methods: A comprehensive search of the literature was performed using PubMed. Results: Over the past 40 years, constant efforts have been made to develop newer techniques of spine surgery. Endoscopic spine surgery is one such subset of MISS, which has all the benefits of modern MISS. Endoscopic spine surgery was initially limited only to the treatment of lumbar disc herniation. With improvements in optics, endoscopes, endoscopic drills and shavers, and irrigation pumps, there has been a paradigm shift. Endoscopic spine surgery can now be performed with high magnification, thus allowing its application not only to lumbar spinal stenosis but also to spinal fusion surgeries and cervical and thoracic pathology as well. There has been increasing evidence in support of these newer techniques of spine surgery. Conclusions: For this report, we studied the currently available literature and outlined the historical evolution of endoscopic spine surgery, the various endoscopic systems and techniques available, and the current applications of endoscopic techniques as an alternative to traditional spinal surgery.

Posterior video-assisted trans pedicular surgery for calcified midline thoracic disc herniation

BACKGROUND

In the treatment of patients with calcified midline thoracic disc herniation (CMTDH), the posterior video-assisted transpedicular surgery (VATPS) technique is employed. Both anterior and posterior surgical approaches for treating CMTDH carry a significant risk of surgical complications and potential morbidity. This technical note introduces a surgical procedure that avoids the drawbacks associated with these approaches.

METHODS

The VATPS technique presents a comprehensive approach for treating thoracic disc herniation, combining both microscopic and endoscopic stages. The microscopic phase entails a small thoracoscopic incision, muscle release, hemilaminotomy, facet joint resection, and vertebra removal, culminating in creating a corpectomy cavity for endoscope access. Careful separation of adhesions between the dura and ligaments marks this stage. Transitioning to the endoscopic phase, an endoscope is inserted into the cavity, allowing for precise visualization and separation of residual adhesions, removal of calcified disc fragments using specialized instruments, and ensuring complete discectomy.

RESULTS

Fourteen patients underwent VATPS for CMTDH. During the procedure, evoked responses were reduced in one patient. However, no postoperative neurological deficits were observed. We also noted significant improvements in the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) scores when comparing the preoperative and postoperative assessments.

CONCLUSION

VATPS, a minimally invasive technique, offers excellent anterior visibility comparable to that of the anterolateral approach, all while avoiding the adverse effects associated with thoracotomies and the complications resulting from spinal cord encroachment often seen in the posterolateral approach. Moreover, it is a safer alternative to conventional endoscopic posterior thoracic surgery. The cavity formed within the vertebral corpus provides ample working space for the use of an endoscope.

Microendoscopic Posterior Decompression for Treating Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum: Case Series

Background and Objectives: Ossification of the ligamentum flavum (OLF) is a relatively common cause of thoracic myelopathy. Surgical treatment is recommended for patients with myelopathy. Generally, open posterior decompression, with or without fusion, is selected to treat OLF. We performed minimally invasive posterior decompression using a microendoscope and investigated the efficacy of this approach in treating limited type of thoracic OLF. Materials and Methods: Microendoscopic posterior decompression was performed for 19 patients (15 men and four women) with thoracic OLF with myelopathy aged between 35 to 81 years (mean age, 61.9 years). Neurological examination and preoperative magnetic resonance imaging (MRI) and computed tomography (CT) were used to identify the location and morphology of OLF. The surgery was performed using a midline approach or a unilateral paramedian approach depending on whether the surgeon used a combination of a tubular retractor and endoscope. The numerical rating scale (NRS) and modified Japanese Orthopedic Association (mJOA) scores were compared pre- and postoperatively. Perioperative complications and the presence of other spine surgeries before and after thoracic OLF surgery were also investigated. Results: Four midline and 15 unilateral paramedian approaches were performed. The average operative time per level was 99 min, with minor blood loss. Nine patients had a history of cervical or lumbar spine surgery before or after thoracic spine surgery. The mean pre- and postoperative NRS scores were 6.6 and 5.3, respectively. The mean recovery rate as per the mJOA score was 33.1% (mean follow-up period, 17.8 months), the recovery rates were significantly different between patients who underwent thoracic spine surgery alone (50.5%) and patients who underwent additional spine surgeries (13.7%). Regarding adverse events, one patient experienced dural tear, another experienced postoperative hematoma, and one other underwent reoperation for adjacent thoracic stenosis. Conclusion: Microendoscopic posterior decompression was applicable in limited type of thoracic OLF surgery including beak-shaped type and multi vertebral levels. However, whole spine evaluation is important to avoid missing other combined stenoses that may affect outcomes.

A New High-Speed Shielded Curved Device Allowing Safe Posterior Thoracic Discectomy Through a Modified Transforaminal Thoracic Interbody Fusion Approach: Technique Description and Case Series

Background

The appropriate approach for surgical removal of thoracic disc herniations is controversial. The posterior approach historically acquired a bad reputation due to high rates of neurologic deterioration subsequent to spinal cord manipulation. The anterior approach has consequently gained popularity but entails a larger magnitude of surgery if open and is technically demanding if approached thoracoscopically. Approaching the thoracic disc posteriorly following unilateral facetectomy and pediculectomy was suggested in 1978. This study presents a technique for posterior unilateral thoracic discectomy through a hemilaminectomy, unilateral facetectomy, and hemipediculectomy, facilitated by a novel curved dorsally shielded high-speed device. Introducing the device ventral to the dural sac allows removal of calcified and soft disc fragments without relying on forceful manual maneuvers and avoiding manipulation of the spinal cord.

Methods

The maximal disc protrusion side is approached through a hemilaminectomy, unilateral facetectomy, and hemipediculectomy removing the superior half of the pedicle and exposing the disc transforaminally, allowing its removal using the device. Pedicle fixation and fusion concluded all procedures (TTIF). Between June 2014 and November 2018, 12 patients (6 men and 6 women) ages 23 to 74 years underwent posterior thoracic discectomy applying the above approach. The affected levels were D3 to D4 (1), D5 to D6 (1), D7 to D8 (1), D9 to D10 (1), D10 to D11 (3), D11 to D12 (4), and D12 to L1 (1).

Results

All patients presented with neurologic deterioration and all but 2 with pyramidal signs. All procedures were uneventful, without dural tears. None of the patients deteriorated neurologically. Average back pain visual analog scale scores decreased by 1.2, from 6.6 to 5.4. Average leg pain visual analog scale scores decreased by 2.2, from 6.6 to 4.4. Improvement was noted in Oswestry Disability Index scores and 6 SF-36 metrics.

Conclusions

The new curved device and approach allow for a faster, safer thoracic disc herniation removal.

Clinical Relevance

The proposed technique allows a safer treatment for thoracic disc herniations, reducing complication rates and improving patient outcome.

A Novel, Minimally Invasive Hybrid Technique to Approach Intracanal Herniated Thoracic Discs

BACKGROUND

Multiple options exist for thoracic disc herniation (TDH). However, when a specific technique is chosen, the goal is to avoid the manipulation of the spinal cord, which is already compressed.

OBJECTIVE

To describe a hybrid endoscopic technique for intracanal TDH by combining an oblique paraspinal approach (OPA) and transforaminal full-endoscopic discectomy.

METHODS

We describe the step-by-step operative technique and present the clinical and radiological outcomes of a case series of hybrid endoscopic thoracic discectomy.

RESULTS

A total of 3 patients were treated. We observed the usefulness of an OPA to enlarge the intervertebral foramen through the rigid tubular retractor and the feasibility of a full-endoscopic transforaminal approach to reach intracanal TDHs.

CONCLUSION

Early experience with the hybrid endoscopic technique for TDHs demonstrated acceptable clinical and radiological outcomes in the 3 patients treated; however, a larger sample size and a methodologically advantageous study to compare this procedure with conventional options are necessary to probe the full benefits of the hybrid technique.

Full-endoscopic interlaminar discectomy for the treatment of a dorsal migrated thoracic disc herniation: Case report

RATIONALE

Thoracic disc herniation (TDH) is an infrequent spinal disease and difficult to treat well. Various surgical approaches and procedures were introduced in many literatures. The authors report a patient with dorsal migrated TDH compressing the spinal cord at T10-11 level.

PATIENT CONCERNS

A 65-year-old male patient presented with complaints of severe paresthesia of both legs and progressive motor weakness for 1 week.

DIAGNOSES

Magnetic resonance imaging (MRI) of the thoracic and lumbar spine revealed TDH and migration of dorsal side on spinal cord at T10-11 level.

INTERVENTIONS

Successful decompressive surgery was performed through a posterior interlaminar approach using only endoscopic instruments.

OUTCOMES

After the operation, patient's symptoms, paraparesis and paresthesia, immediately improved.

LESSONS

The successful results of this case suggest that full endoscopic laminotomy and discectomy may be an attractive minimally invasive surgical technique for treating TDH with dorsal migrated fragments.

The evolution of minimally invasive spine surgery

The field of minimally invasive spine surgery (MISS) has rapidly evolved over the past 3 decades. This review follows the evolution of techniques and principles that have led to significant advances in the field. While still representing only a subset of spine surgeries, MISS’s goals of reducing soft-tissue trauma and mitigating the morbidity of surgery are being realized, translating into more rapid recovery, lower infection rates, and higher cost savings. Future advances in technology and techniques can be anticipated.

Transfacet and Transpedicular Posterior Approaches to Thoracic Disc Herniations: Consecutive Case Series of 24 Patients

OBJECTIVE

Various approaches are advocated for symptomatic thoracic disc herniation (TDH). The aim of this series is to demonstrate the feasibility, safety, and results of posterior transfacet or transpedicular approaches for excision of all types of extradural TDH. We report a consecutive series of patients undergoing posterior approach surgery for TDH.

METHODS

Twenty-four patients (17 women, 7 men) underwent surgery at 25 disc levels. Mean age was 56.3 years (range, 23-79 years). A posterior transfacet or transpedicular approach was used. Patients presented with myelopathy (n = 21, 88%), radiculopathy (n = 8, 33%), sphincter dysfunction (n = 16, 67%), and axial back pain (n = 10, 43%). Preoperative imaging revealed 7 (30%) central, 14 (61%) calcified, and 10 (43%) large disc herniations. The mean follow-up period was 6.0 months (range, 2-36 months).

RESULTS

Eighteen patients underwent unilateral approach surgery (5 transfacet and 13 transfacet plus transpedicular), and 7 patients required bilateral approach laminectomy for unilateral (n = 4) or bilateral (n = 3) discectomy. One patient required unplanned reoperation for resection of residual disc. Average operative time was 95 minutes (range, 40-175 minutes). Mean hospital stay was 4.9 days (range, 2-35 days). There were no major complications. Postoperative Frankel scores were maintained or improved in all patients at last review.

CONCLUSIONS

TDH including large central calcified discs can be safely removed through posterior transfacet or transpedicular approaches with reduced morbidity in comparison with more invasive anterior approaches. Careful microsurgical technique and use of specialized instruments are important for successful excision of TDH from a posterior approach.

The posterior approach operation to treat thoracolumbar disc herniation: A minimal 2-year follow-up study

Thoracolumbar disc herniation (TLDH) is a rare and progressively disabling disorder; surgical procedures predispose the subjects to high incidence of complications including recurrence, neurological aggravation, and adjacent segment degeneration.Ten patients with TLDH underwent posterior approach operation in our institution from January, 2006 to December, 2015. The mean preoperative duration of clinical symptoms was 16.5 months. The clinical data including operative time, blood loss, and hospitalization duration were investigated. Furthermore, pre and postoperative neurological status was evaluated by the modified Japanese Orthopedic Association (JOA) scoring system and pain by visual analog scale (VAS) scoring system.The mean operative time was 176.50 ± 20.55 minutes, the mean blood loss was 435.00 ± 89.58 mL, and the mean hospitalization length was 13.30 ± 2.97 days. All patients were followed with a mean period of 35.1 months. The mean JOA score of all patients before operation, at discharge, 3 months after operation, and at last follow-up was 6.50 ± 1.28, 7.60 ± 1.22, 8.90 ± 0.99, and 9.00 ± 0.92, respectively. The differences between the pre and postoperative JOA and VAS scores were significant (P < .05). However, the differences of JOA and VAS scores at postoperative 3 months and final follow-up were not statistically significant.Posterior approach operation is an ideal surgical technique for treatment of TLDH; the operative time, blood loss, hospitalization duration, and symptomatic improvement are favorable.

Anterior Versus Posterior Thoracic Discectomy: A Systematic Review

STUDY DESIGN

Systematic literature review.

OBJECTIVE

The aim of this study was to systematically review the current evidence in the literature on thoracic discectomies, to compare the clinical outcomes, and to determine whether there is evidence to support the use of either the anterior or posterior approach.

SUMMARY OF BACKGROUND DATA

Thoracic disc herniations (TDHs) often present with myelopathy, radiculopathy, or a combination of both. The posterior approach for thoracic discectomy has been associated with a lower complication rate, but no systematic review exists comparing the clinical outcomes.

METHODS

MEDLINE, EMBASE, and The Cochrane Library databases were searched in accordance with the PRISMA guidelines for studies performing an anterior or posterior thoracic discectomy. The methodological quality was assessed using the Methodological Index for Non-Randomized Studies checklist. The reported clinical outcomes were evaluated using risk ratio, with a P < 0.05 being considered statistically significant.

RESULTS

Thirty-seven clinical studies with 1156 patients with 1300 TDHs were included in this review. There was no statistically significant difference in the total neurological improvement or neurological worsening using either an anterior approach or a posterior approach (P = 0.02812 and P = 0.5232, respectively). However, there was a statistically significant higher rate of total complications in the anterior approach (P = 0.0024).

CONCLUSION

The anterior approach and posterior approach have been shown to be very similar in terms of neurological outcomes. Although the posterior approach was shown to have a lower rate of total complications, this was largely because of a decrease in minor respiratory complications seen in the anterior approach. The optimal approach may therefore be based on surgeon preference as well as patient factors, specifically cardiorespiratory with American Society of Anaesthesiologists grading.

LEVEL OF EVIDENCE

4.

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.

Minimally Invasive Foraminotomy Through Tubular Retractors via a Contralateral Approach in Patients With Unilateral Radiculopathy

BACKGROUND:

Radiculopathy caused by foraminal nerve root compression is a common pathology in the lumbar spine. Surgical decompression via a conventional open foraminotomy is the treatment of choice when surgery is indicated. Minimally invasive tubular foraminotomy through a contralateral approach is a potentially effective surgical alternative.

OBJECTIVE:

The aim of this retrospective cohort study was to evaluate the efficacy and benefits of this approach for treatment of radiculopathy.

METHODS:

Patients with unilaterally dominant lower extremity radiculopathy, who underwent minimally invasive lumbar foraminotomy through tubular retractors via a contralateral approach between 2010 and 2012, were included. Oswestry Disability Index (ODI) and the Visual Analogue Scale (VAS) for back and leg pain were evaluated preoperatively, postoperatively, and at the latest follow-up. Functional outcome was evaluated by using the MacNab criteria.

RESULTS:

For the total 32 patients, postoperatively there was significant improvement in the ODI (P = .006), VAS back pain (P &lt; .001), and VAS leg pain on the pathology and the approach side (P = .004, P = .021, respectively). At follow-up of 12.3 ± 1.7 months, there was also significant improvement in the ODI (P &lt; .001), VAS back pain (P = .001), and VAS leg pain on the pathology and the approach side (P &lt; .001, P = .001, respectively). The functional outcome was excellent and good in 95.2%. One patient required fusion (3.1%).

CONCLUSION:

A minimally invasive, facet-sparing contralateral approach is an effective technique for treatment of radiculopathy due to foraminal compression. It also allows for decompression of lumbar spinal stenosis and bilateral lateral recess decompression without the need for fusion.

The technological development of minimally invasive spine surgery

Minimally invasive spine surgery has its roots in the mid-twentieth century with a few surgeons and a few techniques, but it has now developed into a large field of progressive spinal surgery. A wide range of techniques are now called "minimally invasive," and case reports are submitted constantly with new "minimally invasive" approaches to spinal pathology. As minimally invasive spine surgery has become more mainstream over the past ten years, in this paper we discuss its history and development.

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.

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

Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery.

The Prolo Scale: history, evolution and psychometric properties

BACKGROUND

The Prolo Scale (PS) is a widely accepted assessment tool for lumbar spinal surgery results. Nevertheless, in the literature there is a dearth of consensus about its application, interpretation and accuracy. The purpose of this review is to investigate the evolution of the PS from its introduction in 1986 to the present, including an analysis of different versions of the scale and research on the existing studies investigating its psychometric properties.

MATERIALS AND METHODS

PubMed, Cochrane Library and PEDro databases were searched. Studies in English, Italian, French, Spanish and German published from 1986 to December 2012 were analyzed.

RESULTS

The original lumbar surgery outcome scale consisted of two Likert-type scales (economic and functional). There are three more versions of the scale: Schnee proposed one consisting of 10 items, Brantigan made one with 20 items and introduced 2 more subscales (pain and medication), and Davis adapted the scale for the cervical spine. PS is often mentioned without any specific reference to the version used; therefore, a homogeneous comparison of studies is difficult to achieve. Several authors agree on the need to embrace a multidimensional measuring system to evaluate low back pain (LBP), but there is still no consensus regarding the most reliable tool. To date, PS has been mostly used as secondary outcome measure in association with validated primary measures for LBP.

CONCLUSIONS

The Prolo Scale has been adopted for clinical examination for 20 years because it is easy to administer and useful to compare significant amounts of data from surgical studies carried out at different times. Although several authors demonstrated the scale sensitivity among a battery of tests, no thorough validation study was found in the current literature.

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69 %), 31 had radiculopathy (94 %), and 31 had axial pain (94 %). Among patients with myelopathy, 14 (42.4 %) had bladder and/or bowel dysfunction. In the last eight cases (24 %), the approach was retropleural instead of transpleural. Patients were followed up for 18.2 months on average. The mean length of hospital stay was 5 days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91 %) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1 %), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.

Operative Management of a Sacral Gunshot Injury via Minimally Invasive Techniques and Instrumentation

Gunshot wounds to the spine account for 13% to 17% of all gunshot injuries and occur predominantly in the thoracic region. Minimally invasive spine surgery procedures implementing serial muscle dilation and the use of a tubular retracting system with a working channel minimize soft tissue trauma, facilitate less bony and soft tissue resection, decrease blood loss, minimize scarring and improve cosmesis, decrease hospitalization, and reduce postoperative pain and narcotic usage in comparison to more open, traditional approaches. Although minimally invasive spine surgery techniques and instrumentation have gained considerable attention, their application in the management of gunshot injuries to the sacrum has not been reported. The following is a brief case report of a 21-year-old male who sustained a gunshot injury to the sacrum who was managed operatively via minimally invasive spine surgery techniques and instrumentation.

Minimally invasive transforaminal, thoracic microscopic discectomy: technical report and preliminary results and complications

BACKGROUND CONTEXT

Surgical decompression of thoracic disc herniations is technically challenging because retraction of the thecal sac in this area must be avoided. Standard open thoracic discectomy procedures require fairly extensive soft tissue dissection and vertebral resection to provide safe decompression of the spinal cord.

PURPOSE

To describe our experience using a minimally invasive, transforaminal thoracic discectomy (MITTD) technique for the treatment of thoracic disc herniation.

STUDY DESIGN

Technical report and preliminary results and complications.

METHODS

Twelve patients undergoing MITTD were evaluated preoperatively and postoperatively at 1-, 3-, and 6-month intervals with neurologic examination, and were graded using the American Spinal Injury Association (ASIA) impairment scale and a pain visual analog scale (VAS). Thoracic instability and bony fusion were assessed clinically and radiographically with plain radiographs and computed tomography (CT) scans. Surgical time, blood loss, complications, and hospital length of stay were recorded.

RESULTS

Twelve patients (seven men and five women) underwent MITTD. The median surgical time was 128 (80 to 185) minutes, the median estimated blood loss was 100 (30 to 250) mL, and the median hospital stay was 2 (1 to 4) nights. All discs were successfully removed, and a CT or magnetic resonance imaging confirmed adequate cord decompression in all cases. All patients reported easing of neurologic symptoms and improved walking ability. The median VAS scores improved from 4.5 to 2 for back pain. The ASIA score improved from D to E in the two patients who suffered from motor weakness. Preoperative sensory deficit was reduced in three of the five patients. Patients who suffered from sexual and urinary disturbances did not report improvement. Serious systemic or local complications and neurologic deterioration were not reported.

CONCLUSIONS

The transforaminal approach enabled sufficient access to the midline of the spinal canal without extensive resection of the facet joint or the adjacent pedicle. Because most of the osseous and ligamentous structures were preserved, additional instrumentation was not required to prevent postoperative instability. Our early results suggested that minimally invasive thoracic discectomy by transforaminal microscopic technique is a valuable choice in the management of thoracic disc herniation.

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

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Thoracoscopic discectomy and instrumented fusion using a minimally invasive plate system: surgical technique and early clinical outcome

OBJECT

The use of minimally invasive noninstrumented fusions has increased as thoracoscopic approaches to the spine have evolved. The addition of instrumentation is infrequent, in part because of the lack of a minimally invasive implant system. The authors describe a technique for thoracoscopic plating after discectomy and report early clinical outcomes.

METHODS

After a standard endoscopic discectomy and partial corpectomy and before exposure of the ventral thecal sac, the authors implanted a polyaxial screw and clamping element under fluoroscopic guidance. Reconstruction involves placement of autograft in the defect and subsequent placement of the remainder of the screw/plate construct with 2 screws per vertebral level.

RESULTS

Twenty-five patients underwent thoracoscopic and thoracoscopy-assisted discectomies and fusion in which the aforementioned plate system was used. Of 19 patients presenting with pain, 10 had 6-month clinical follow-up with a greater than 50% reduction in visual analog scale score, which continued to improve up to 2 years postoperatively. There were 3 cases of pneumonia, 3 CSF leaks, 1 chyle leak, and 1 death due to a massive pulmonary embolus on the 1st postoperative day.

CONCLUSIONS

The authors conclude that thoracoscopic discectomy and plate-instrumented fusion can be achieved with acceptable results and morbidity. Further studies should evaluate the role of instrumented fusions after thoracoscopic discectomy in larger groups of patients and during a longer follow-up period.

Video-assisted thoracoscopic surgery combined with a tubular retractor system for minimally invasive thoracic discectomy

BACKGROUND

Several approaches have been proposed for the treatment of thoracic disc herniations. Posterior approaches include transpedicular, costotransversectomy, and lateral extracavitary; anterior approaches include retropleural and transpleural thoracotomy and thoracoscopy.

OBJECTIVE

We present a novel minimally invasive approach to thoracic discectomies, combining thoracoscopy and a tubular retractor system. We discuss the utility and safety of this technique.

METHODS

The patient is placed in a lateral decubitus position, with a double-lumen endotracheal tube for single-lung ventilation. With use of thoracoscopic techniques, the disc space is identified; approximately 2 cm of the head and neck of the rib is removed to expose the pedicle of the lower vertebral body. The tubular retractor is deployed with continuous thoracoscopic visualization and a trough is created anterior to the canal by drilling the adjacent vertebral bodies straddling the disc space. The operative microscope is utilized to dissect the disc, pulling it anteriorly into the trough.

RESULTS

There were 5 patients in the past 9 months who were candidates for anterior thoracic discectomy. Disc herniations from T3-4 to T10-11 were treated without any significant complications. Patients were followed up clinically and radiographically.

CONCLUSION

Combining thoracoscopy with the tubular retractors allows continuous monitoring of the lung, aorta, and vena cava during the placement of the retractors. Additionally, use of the tubular retractors, as opposed to a complete thoracoscopic discectomy reduces the working distance and allows the use of the microscope with 3- dimensional visualization, thus enhancing the safety of this approach.

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.

Mayo International Spine Symposium 2010

This annual 5-day Continued Medical Education event featured the latest in new treatment strategies and techniques for orthopedists, neurosurgeons, physiatrists, primary care providers and other professionals involved in treating patients with spinal disorders. This year's program content focused on: minimally invasive surgery, motion-preservation surgery, nonoperative spine care, value (quality/cost) and maintenance of certification self-assessment examination.

Surgical results of the oblique paraspinal approach in upper lumbar disc herniation and thoracolumbar junction

OBJECTIVE

This study was conducted to investigate the efficacy of treating central or paramedian disc herniations of the upper lumbar levels, including the thoracolumbar junction, through the oblique paraspinal approach. We published a technical case report on this subject in 2004.

METHODS

Nineteen consecutive patients with intracanalicular disc herniations of the upper lumbar levels underwent the oblique paraspinal approach, which utilizes an operating microscope, from March 2005 through January 2008. Their clinical and radiological data were collected and analyzed. The patients were assessed with standard examinations preoperatively and evaluated with dynamic lumbar x-rays, 3-dimensional computed tomographic scans, magnetic resonance imaging, standard pain and disability measurements, a visual analogue scale, the Oswestry disability index, and a patient satisfaction rate that checked their pain scores postoperatively.

RESULTS

The average follow-up period was 28.1 months, with a maximum of 48 months. The visual analogue scale for back and leg pain and the Oswestry disability index, which recorded a preoperative mean of 6.7%, 7.2%, and 64.7% and a postoperative mean of 3.2%, 3.0%, and 21.47%, respectively, showed statistically significant improvement at the time of the last follow-up evaluation, compared with preoperative scores. There have been neither recurrent disc herniations nor spinal instability during the follow-up period.

CONCLUSION

In this study, 19 cases of intracanalicular disc herniations at the upper lumbar levels, including the thoracolumbar junction, were successfully excised with the oblique paraspinal approach without recurrence or instability. We found that the oblique paraspinal approach, which resulted in satisfactory clinical outcomes with few complications, could be one of the main surgical procedures used to treat intracanalicular disc herniations at the upper lumbar levels.

Endoscopic thoracic laminoforaminoplasty for the treatment of thoracic radiculopathy: report of 12 cases

BACKGROUND

Spinal stenosis of the thoracic spine is less common than that of the cervical and lumbar regions. Due to the close proximity to thoracic and abdominal organs, surgical operations can be difficult and carry a greater risk of complications. The most efficacious intervention for thoracic stenosis, whether central or foraminal, refractory to conservative management is uncertain. We aimed to evaluate the efficacy of endoscopic laminoforaminoplasty (ELFP) in the treatment of thoracic radiculopathy.

METHODS

Twelve patients with radicular pain involving the lower thoracic levels (at or below T6) were treated with ELFP.

RESULTS

Seven of twelve patients showed marked improvement in pain scores. Average follow-up scores were 2.9 and 12.08 on the Visual Analog Scale (VAS) and Oswestry Disability Index, respectively. The significance was 0.005 between the pre and post surgical data. One patient with moderate symptoms, two with severe symptoms, and two with crippling symptoms did not report significant improvement on VAS or Oswestry. No complications were encountered.

CONCLUSIONS

Endoscopic laminoforaminoplasty offers an alternative to fusion or conventional laminotomy with similar success rates. Patients additionally benefit from a decrease risk of complications, short hospital stay, and faster recovery.

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.

Endoscopic laminoforaminoplasty success rates for treatment of foraminal spinal stenosis: report on sixty-four cases

BACKGROUND

Foraminal stenosis is an important cause of radicular and generalized back pain. In patients who do not respond to conservative interventions, endoscopic spinal surgery provides similar results to open surgical approaches with lower rates of complication, postoperative pain, and shorter duration of hospital stay.

METHODS

We performed a prospective, open, uncontrolled trial of 64 patients to evaluate endoscopic laminoforaminoplasty for the treatment of refractory foraminal stenosis.

RESULTS

Fifty-nine percent of patients had at least 75% improvement in Oswestry Disability Index (Oswestry) and Visual Analog Scale (VAS) scores. All patients were discharged the day of surgery. Dural leaks occurred in two patients, which were repaired intraoperatively. No other adverse events occurred.

CONCLUSIONS

Endoscopic laminoforaminoplasty appears to be a safe alternative to open decompression in patients with spinal foraminal stenosis; additional controlled trials are warranted.

MINIMALLY INVASIVE POSTERIOR OSTEOTOMIES

OBJECTIVE

Surgery for thoracolumbar deformity can lead to significant muscle injury, excessive blood loss, and severe postoperative pain. The aim of the following studies was to determine the feasibility of minimally invasive posterior thoracic corpectomy and thoracolumbar osteotomy techniques for deformity in human cadavers and select clinical cases.

METHODS

Human cadaveric specimens were procured for thoracic corpectomy and Smith-Petersen and pedicle subtraction osteotomy using a minimally invasive approach. Post-procedural computed tomography was used to assess the degree of decompression following corpectomy and the extent of bone resection after osteotomy. Pre and post-osteotomy closure Cobb angles were measured to evaluate the degree of correction achieved.

RESULTS

The minimally invasive lateral extracavitary approach for thoracic corpectomy provided adequate exposure and allowed excellent spinal canal decompression while minimizing tissue disruption. Nearly complete osteotomies of both types could be achieved through a tubular retractor with a modest change in Cobb angle.

CONCLUSION

These techniques may play a role in deformity surgery for select cases with further technological advancements.

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 transpedicular vertebrectomy for metastatic disease to the thoracic spine

STUDY DESIGN AND OBJECTIVE

We present a series of 8 patients with thoracic metastatic disease causing acute neurologic decline. We present minimally invasive posterolateral vertebrectomy and decompression as an effective approach in patients with significant comorbidities and as palliative care.

BACKGROUND

Metastatic disease to the spine is common and frequently occurs in the thoracic vertebrae. Posterior laminectomy alone has generally been found to be ineffective in the management of spinal metastatic disease with neurologic compromise as most compression occurs ventrally. Patients with significant comorbidities are often unable to tolerate extensive surgery involving a thoracotomy. Limited life expectancy and quality of life issues also often argue against extensive surgery.

METHODS

Eight patients (mean age 74 y) with thoracic metastatic disease and acute neurologic compromise underwent a minimally invasive posterolateral vertebrectomy and partial tumor resection. Patients were considered unsuitable for an open anterior approach owing to age, comorbidities, and limited life expectancies. In the operating room, patients were positioned prone. A paramedian incision measuring 3 cm allowed the introduction of sequential dilators and the placement of a 22-mm diameter tubular retractor. Dorsal decompression was accomplished and partial vertebrectomy was performed for ventral decompression. Radiation was used postoperatively in all patients.

RESULTS

There were no complications due to the procedure. Improvement of at least 1 grade on the Nurick scale was noted in 5 of 8 (62.5%) patients. Two patients were able to ambulate independently immediately after surgery despite having significant paraparesis preoperatively. Pain improved in 5 of 8 (62.5%) patients postoperatively according to the numerical pain score. Average inpatient length of stay was 4 days after the procedure. Mean blood loss was 227 mL and mean length of the procedure was 2.2 hours.

CONCLUSIONS

Minimally invasive transpedicular vertebrectomy is an effective palliative treatment option for thoracic metastatic disease in patients not eligible for more extensive anterior transthoracic surgery and stabilization.

Clinical applications of the tubular retractor on spinal disorders

Tubular retractor system as a minimally invasive surgery (MIS) technique has many advantages over other conventional MIS techniques. It offers direct visualization of the operative field, anatomical familiarity to spine surgeons, and minimizing tissue trauma. With technical advancement, many spinal pathologies are being treated using this system. Namely, herniated discs, lumbar and cervical stenosis, synovial cysts, lumbar instability, trauma, and even some intraspinal tumors have all been treated through tubular retractor system. Flexible arm and easy change of the tube direction are particularly useful in contralateral spinal decompression from an ipsilateral approach. Careful attention to surgical technique through narrow space will ensure that complications are minimized and will provide improved outcomes. However, understanding detailed anatomies and keeping precise surgical orientation are essential for this technique. Authors present the technical feasibility and initial results of use a tubular retractor system as a minimally invasive technique for variaties of spinal disorders with a review of literature.

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.

Minimally invasive spine surgery: a historical perspective

Minimally invasive spine surgery has gained considerable momentum and increased acceptance among spine surgeons throughout the years. An understanding and awareness of the development of minimally invasive spine surgery and its role in the operative treatment of various spine conditions is imperative. This article provides a succinct historical perspective of the development of spine surgery from the more traditional, open procedures to the use of more "minimal access" or minimally invasive spine surgery procedures.

An oblique paraspinal approach for intracanalicular disc herniations of the upper lumbar spine: technical case report

OBJECTIVE

To present our experience of treating the central or paramedian disc herniations of the upper lumbar levels through a paraspinal approach.

CLINICAL PRESENTATION

We present four patients with intracanalicular disc herniations at the L1-L2 or L2-L3 level. All patients had unilateral or bilateral radicular leg pain and motor weakness.

TECHNIQUE

Considering the unique characteristics of the upper lumbar spine, we performed the oblique paraspinal approach to expose the central portion of disc and removed the herniated disc effectively. Postoperatively, their symptoms were improved. There was no instability during the follow-up period.

CONCLUSION

The oblique paraspinal approach for the treatment of central disc herniations at the upper lumbar levels is an effective nonfusion technique that preserves most of the facet joint and provides a wide surgical field.

Preoperative localization of herniated thoracic discs using myelo-CT guided transpleural puncture: technical note

OBJECTIVE

In recent years, video-assisted thoracoscopic microdiscectomy has gained acceptance as a minimally invasive, safe, and efficient technique suited for herniated thoracic discs from T4T5 until T11T12. However, correct localization is difficult and wrong level exploration is an ever-present threat. We present a reliable and time-efficient localizing technique.

MATERIALS AND METHODS

In 86 consecutive cases, 1 day preoperatively intrathecal contrast was administered and a computed tomography (CT) scan was performed in prone position. Using local anesthesia, a hollow needle was advanced above the corresponding rib and through the pleura. The inner wire and corresponding pathological level were easily identified endoscopically.

CONCLUSION

Myelo-CT provides detailed anatomical information, which is often helpful in determining the side of operative approach and the extent of bone removal needed. Needle localization obviates fluoroscopy, saves OR time, and allows the surgeon to focus on the technically demanding procedure. Furthermore, it is a relatively simple and safe technique.

Contralateral neurologic deficits following microendoscopic lumbar surgery. Can it happen?

A contralateral neurologic deficit following microendoscopic discectomy (MED) or laminectomy (MEL) had not previously been reported. Between September 1999 and April 2004, 60 patients with symptomatic lumbar disc herniations or spinal stenotic syndrome received MED or MEL at the authors' institution. Three out of 60 patients were found to exhibit a contralateral neurologic deficit following unilateral microendoscopic surgery. All three patients complained of a newly developed, contralateral neurologic deficit following their operations. One MED patient with a concomitant contralateral disc herniation developed contralateral motor and sensory deficits and required immediate open surgery. At the two-year follow-up, a residual motor deficit was noted. The other two patients (1 MED, 1MEL) with temporary sensory deficits were only treated conservatively and experienced complete recovery one week and six weeks following the operation, respectively. Surgeons should pay close attention to the possibility that contralateral neurologic deficits may occur following MED or MEL. Our reports indicate that caution should be exercised when performing microendoscopic procedures on patients with substantial dural compromise, a concomitant contralateral disc herniation, or a lateral spinal stenosis, which may be etiologies.

The Development of Minimally Invasive Spine Surgery

The modern era of minimally invasive spine surgery has its roots in percutaneous techniques developed in the mid-twentieth century. The widespread application of minimally invasive techniques seen today is predicated on technologic developments of only the past 10 years, however. This article reviews the development of minimally invasive spinal surgery as it has evolved for the cervical, thoracic, and lumbar spine. Each new development has sought to equal or improve on the effectiveness demonstrated by comparable open surgical techniques while reducing iatrogenic tissue trauma and resultant postoperative pain and disability, to produce overall better outcomes for patients.

Two-level disc herniation in the cervical and thoracic spine presenting with spastic paresis in the lower extremities without clinical symptoms or signs in the upper extremities

BACKGROUND CONTEXT

There is no report in the literature of two-level disc herniation in the cervical and thoracic spine presenting with spastic paresis/paralysis exclusively in the bilateral lower extremities.

PURPOSE

To identify the clinical characteristics of specific myelopathy resulting from C6-C7 disc herniation through a case with spastic paresis in the lower extremities without upper extremities symptoms due to separate disc herniation in the cervical and thoracic spine, which was surgically removed in two stages.

STUDY DESIGN/SETTING

A case report.

METHODS

A 48-year-old man developed a gait disturbance as well as weakness and numbness in the lower extremities. Thoracic magnetic resonance imaging (MRI) showed a T11-T12 disc herniation, which was removed under the surgical microscope through a minimally invasive posterior approach. He improved, but 2 months after surgery developed recurrent numbness and spasticity. On this occasion, no evidence of recurrence of the thoracic disc herniation could be identified, but cervical MRI demonstrated a compressed spinal cord at the C6-C7 level. The patient had no neurological findings in the upper extremities. The herniated disc at C6-C7 was removed under the surgical microscope with laminoplasty.

RESULTS

The symptoms gradually improved after surgery. At the present time, 2 years and 9 months after the initial operation, the patient had a stable gait and was able to work.

CONCLUSIONS

Our experience suggests that in the diagnosis of patients with spastic paresis and sensory disturbances in the lower extremities, spinal cord compression should be explored by imaging studies not only in the thoracic spine but also in the cervical spine, especially at the C6-C7 level, even if the symptoms and abnormal neurological findings are absent in the upper extremities.

Neuroendoscopy for spinal disorders: a brief review

Neuroendoscopy has grown rapidly in the last 20 years as a therapeutic modality for treating a variety of spinal disorders. Spinal endoscopy has been widely used to treat patients with cervical, thoracic, and lumbosacral disorders safely and effectively. Although it is most commonly used with minimally invasive lumbar spine surgery, endoscopy has gained widespread acceptance for the treatment of thoracic disc herniations and for anterior release and rod implantation in the correction of thoracic spinal deformity. The authors review the use of endoscopy in spine surgery and in the treatment of spinal disorders as well as in the treatment of intrathoracic nonspinal lesions. Endoscopy has some significant advantages over open or other minimally invasive techniques in that it can allow for better visualization of the lesion, smaller incision sizes with reduced morbidity and mortality, reduced hospital stays, and ultimately lower cost. In addition, spinal endoscopy allows observers and operating room staff to be more involved in each case and fosters education. Spinal endoscopy, like any novel modality, carries with it additional risks and the surgeon must always be prepared to convert to an open procedure. The learning curve for spinal endoscopy is steep and the procedure should not be attempted alone by a novice surgeon. Nevertheless, with training and experience, the spine surgeon can achieve better outcomes, reduced morbidity, and better cosmesis with spinal endoscopy, and the operating times are comparable to open procedures. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve further roles as a mainstay in spine surgery.