Surgical treatment of thoracic disc herniations using a modified transfacet approach

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.

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.

Evaluation of clinical outcomes, complication rate, feasibility, and applicability of transfacet pedicle-sparing approach in thoracic disc herniation: a systematic review and meta-analysis

OBJECTIVE

This study aimed to evaluate the clinical outcomes, complication rate, feasibility, and applicability of transfacet pedicle-sparing approach for treating thoracic disc herniation.

METHODS

We searched three databases including the Cochrane Library, PubMed, and Embase for eligible studies until Dec 2022. The quality of studies and their risk of bias were assessed using the methodological index for non-randomized studies. We evaluated the heterogeneity between studies using the I² statistic and the P-value for the heterogeneity.

RESULTS

A total of 328 patients described in 11 included articles were published from 2009 to 2022. Pain outcomes using the visual analog scale (VAS score) were reported in four studies. The standardized mean difference was reported as 0.749 (CI 95% 0.555-0.943). The obtained result showed the positive effect of the procedure and the improvement of patients' pain after the surgery. Myelopathy outcomes using the Nurick score were reported in five studies. The standardized mean difference was reported as 0.775 (CI 95% 0.479-1.071). The result showed the positive effect of the procedure. Eight studies assessed postoperative complications and neurological deterioration. The pooled overall complication was 12.4% (32/258) and 3.5% (9/258) neurological worsening.

CONCLUSION

The results of this study demonstrated a positive effect of the transfacet pedicle-sparing approach on the clinical outcomes of patients with thoracic disc herniation surgery. The technique has been shown to be safe and effective for the right patient. The technique is associated with lower rates of complications and a shorter hospital stay compared to other surgical approaches. This information can assist clinicians in making informed decisions when selecting the most appropriate surgical technique for their patients with thoracic disc herniation.

Trans-facet Pedicle Sparing Approach Versus Transthoracic Approach for Thoracic Disc Disease: A Review of 19 Cases

Background: Thoracic disc herniation is a rare illness and is mainly asymptomatic. There are some surgical approaches to treat symptomatic patients, and none has absolute dominance over the others. For this reason, there is a debate between spine surgeons to decide which method could help these patients with better efficacy and safety. Objectives: To seek the potential differences between the two of these methods, the conventional anterior transthoracic and the more recent modified transfacet approaches, we conducted this study. Methods: This is a retrospective case-series study comparing the anterior transthoracic and the modified transfacet method; each of these approaches was preferred and performed by one surgery team. Patients were divided into two groups based on the procedure and assessed using Frankel’s Score, Visual Along Scale (VAS) Score, Short-Form Health Survey Questionnaire (SF-36), and the spine functional index (SFI). Results: Eleven patients underwent a transthoracic approach, and eight patients had a posterior transfacet pedicle-sparing approach. The Frankel’s score improved at least one score in ten patients from the transthoracic group and seven patients from the transfacet pedicle-sparing group. No major difference was found between the two groups concerning SFI and SF-36 questionnaire. Conclusions: This study exhibited satisfying efficacy and safety of the modified transfacet pedicle-sparing method compared to the transthoracic approach. Both improved Frankel’s scores, SFI, and patients’ quality of life. Despite encountering some limitations, especially a small number of subjects, our study suggests that these surgical methods could be used efficiently considering the patient’s comorbidities, location of the herniated disc and its calcification, and experience and skill of the surgeon.

Lower Neurological Risk with Anterior Operations Compared to Posterior Operations for Thoracic Disc Herniations: Analysis of 697 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs).

SUMMARY OF BACKGROUND DATA

Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined.

METHODS

Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge.

RESULTS

Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01).

CONCLUSION

Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4.

[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.

Management of single-level thoracic disc herniation through a modified transfacet approach: A review of 86 patients

Background:

Symptomatic thoracic disc herniation (TDH) is rare and does not typically resolve with conservative management. Traditional surgical management is the transthoracic approach; however, this approach can carry significant risk. Posterolateral approaches are less invasive, but no single approach has proven to be more effective than the other results are often dependent on surgeon experience with a particular approach, as well as the location and characteristics of the disc herniation.

Methods:

This was retrospective review of a prospectively collected database. Eighty-six patients with TDH treated surgically through the modified transfacet approach were reviewed and evaluated for pain improvement, Nurick grade, and neurological symptoms. Patients were followed for 12 months postoperatively; estimated blood loss, length of hospital stay, hospital course, and postoperative complications were also assessed.

Results:

All attempts at disc resection were successful. Most patients reported improvement in pain, sensory involvement, and strength. Seventy-nine patients had complete resolution of their symptoms while four patients had unchanged symptoms. Three patients experienced mild neurologic worsening postoperatively, but this resolved back to baseline. One patient experienced myelopathy during the postoperative period that resolved with steroid administration. The procedure was well tolerated with minimal complications.

Conclusion:

TDH can be managed surgically through a variety of approaches. The selection of approach is dependent on surgeon experience with an approach, the patient’s health, and the location and type of disc. The transfacet approach is safe and efficacious.

Percutaneous endoscopic lumbar discectomy by transfacet joint approach: A case report

RATIONALE

The accurate and smooth establishment of a working cannula guarantees rapid and minimally invasive treatment effects using percutaneous endoscopic lumbar discectomy (PELD) for lumbar disc herniation (LDH). With anatomic variations such as a hyperplastic superior articular process (SAP), the conventional transforaminal approach cannot achieve an ideal result.

PATIENT CONCERNS

A 48-year-old male patient suffered waist and left lower limb pain, with exacerbation of symptoms after exertion.

DIAGNOSES

L5-S1 disc herniation, hyperplastic SAP of S1.

INTERVENTIONS

To demonstrate the segment responsible for compression, a lumbar nerve root block was carried out. This was followed by PELD via a transfacet joint approach at L5-S1.

OUTCOMES

The patient experienced an improved quality of life postoperatively (i.e., visual analog score for pain = 1 and Oswestry disability index  = 88). Lumbar function and stability were preserved as of the 1-month postoperative follow-up.

LESSONS

The transfacet joint approach could extend the indications for PELD and present an alternative option in selected cases. A new concept of "subsidence foramen" is raised to characterize this anatomic variation, and it may guide working access establishment of PELD. In addition, reading imaging results carefully and individualizing treatments promote the use of PELD as minimally invasive surgery.

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.