The Transaxillary Approach as a Direct Route in the Management of Upper Thoracic Spine Pathology: A Technical Note with Case Series

This retrospective case series of prospective data aims to describe the transaxillary approach for the treatment of upper thoracic spine pathology. Various surgical techniques and approaches have been reported across the literature to address upper thoracic spine pathology, including the cervicothoracic approach, anterior transsternal approach, posterolateral approach, supraclavicular approach, and lateral parascapular approaches. These techniques are invasive. A minimally invasive, less morbid, and direct access approach to the pathology of the upper thoracic spine has not been reported in the literature. Patients with pathology affecting the first thoracic vertebra up to the sixth thoracic vertebra were classified into the upper thoracic spine group. Patients with pathology below the sixth thoracic vertebra were excluded. Patients not having a minimum follow-up of 12 months were also excluded. The study analyzed 18 patients. The mean preoperative modified Japanese Orthopedic Association score was 7.2±1.44, which improved to 10.16±1.2 (p<0.05). The majority (14/18) of the patients had an excellent outcome. Three patients had good outcomes, and one patient had a fair outcome. Five cases of intraoperative dural leak were recorded, and one patient had postoperative neurological deficit. The transaxillary approach is a safe, viable, muscle-sparing, and minimally invasive approach for ventral pathologies of the upper thoracic spine.

Transdural Ventral Sling Technique for Calcified Thoracic Disk Herniations

BACKGROUND

Surgery for thoracic disc herniations remains an ongoing challenge, with numerous surgical approaches, all with their own inherent risks. Discectomy via a posterior laminectomy was historically the treatment of choice; however, it was deemed very high risk with elevated rates of neurologic injury. The posterior transdural approach is an alternative surgical option for soft and calcified thoracic disc herniations.

METHODS

A 56-year-old female with many years of numbness/tingling in her hands and difficulty with fine motor tasks presented with progressive weakness and loss of balance in her legs. Imaging revealed a prominent focal central calcified disc herniation at the T5-T6 level causing severe effacement and distortion of the spinal cord. A posterior transdural approach for direct visualization of a large calcified disc herniation was performed, removing the calcified disc without the need for extensive exposure or entry into the thoracic cavity. A ventral sling of the dura was created to allow rotation of the spinal cord while removing the disc.

RESULTS

Intraoperative ultrasound confirmed complete disc resection, restoring cerebral spinal fluid flow circumferentially without residual impingement or cerebrospinal fluid leaks. At six months postsurgery, the patient's gait imbalance had resolved, and she had full lower extremity strength (5/5). Radiographic evaluation indicated stable implants without subsidence, pullout, fracture, or alignment loss.

CONCLUSIONS

The transdural approach is less invasive in nature, minimizes surgical exposure, patient morbidity, and provides better intraoperative control of the spinal cord. This constitutes an effective alternative surgical approach to both soft and calcified central thoracic disc herniations.

Perspective: Transthoracic, posterolateral, or transpedicular approaches to thoracic disks, not laminectomy

Background

Anterior transthoracic, posterolateral (i.e., costotransversectomy/lateral extracavitary), and transpedicular approaches are now utilized to address anterior, anterolateral, or lateral thoracic disk herniations (TDH). Notably, laminectomy has not been a viable option for treating TDH for decades due to the much lower rate of acceptable outcomes (i.e., 57% for decompressive laminectomy vs. over 80% for the posterolateral, lateral, and transthoracic procedures), and a higher risk of neurological morbidity/paralysis.

Methods

Patients with TDH averaged 48-56.3 years of age, and presented with pain (76%), myelopathy (61%-99%), radiculopathy (30%-33%), and/or sphincter loss (16.7%-24%). Those with anterior/anterolateral TDH (30-74%) were usually myelopathic while those with more lateral disease (50-70%) exhibited radiculopathy. Magnetic resonance (MR) studies best defined soft-tissue/disk/cord pathology, CAT scan (CT)/Myelo-CT studies identified attendant discal calcification (i.e. fully calcified 38.9% -65% vs. partial calcification 27.8%), while both exams documented giant TDH filling > 30 to 40% of the canal (i.e., in 43% to 77% of cases).

Results

Surgical options for anterior/anterolateral TDH largely included transthoracic or posterolateral approaches (i.e. costotransversectomy, lateral extracavitary procedures) with the occasional use of transfacet/transpedicular procedures mostly applied to lateral disks. Notably, patients undergoing transthoracic, lateral extracavitary/costotransversectomy/ transpedicular approaches may additionally warrant fusions. Good/excellent outcomes were quoted in from 45.5% to 87% of different series, with early postoperative adverse events reported in from 14 to 14.6% of patients.

Conclusion

Anterior/anterolateral TDH are largely addressed with transthoracic or posterolateral procedures (i.e. costotransversectomy/extracavitary), with a subset also utilizing transfacet/transpedicular approaches typically adopted for lateral TDH. Laminectomy is essentially no longer considered a viable option for treating TDH.

Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts

Thoracic herniated disks are relatively rare. They account for approximately 2% of all intervertebral herniated disks in large series. Traditional surgery via laminectomy has frequently yielded disappointing results, although the recent literature reports that anterior calcified thoracic herniation was successfully treated with this approach. This issue has encouraged a search for alternatives, such as anterolateral, lateral, and posterolateral approaches to the thoracic spine. From January 2009 to December 2019, we selected 66 patients harboring a symptomatic median-paramedian herniated disk at the level of the thoracic spine, treated at the authors' institutions. The present experience would give further support to the use of costotrasversectomy, along with its "mini-invasive" modifications, as a suitable and safe approach for thoracic disk disease. Although we must admit that endoscopy is likely to become the gold standard of surgical method in the future and that the anterior approach with mini-toracotomy without rib removal will become popular, the future scenario could certainly reserve an important place for the approach we have used in the surgical management of this challenging spinal pathology, mainly because of the approach's versatility and short learning curve.

Radiographic and clinical features of thoracic disk disease associated with myelopathy: a retrospective analysis of 257 cases

PURPOSE

To analyze the clinical and radiographic characteristics of thoracic disk disease associated with myelopathy (TDM).

METHODS

This is a retrospective clinical review of prospectively collected imaging data based at a single institute. Based on preoperative CT and MRI, we classified TDM as thoracic disk herniation (TDH), THD with ossification (THDO), TDH with posterior bony avulsions of the vertebrae (TDH with PBA), TDH with posterior vertebral osteophytes (TDH with PVO), giant thoracic osteophyte and calcific discitis with herniation (CDH). Patient characteristics and radiographic data were compared between different types of TDM.

RESULTS

Among the 257 patients included, 12.06% of patients presented with symptoms after traumatic events. The most frequent complaint at onset and preoperative was back pain (29.2%) and subjective lower limb weakness (75.5%), respectively. All TDH with PBA is distributed at the lower thoracic segments, while CDH predominantly in the middle and lower thoracic segments. TDH with PBA was more frequent in men than TDH and CDH. Compared with TDH, TDHO, and TDH with PVO, TDH with PBA was younger in surgery age, and TDH and CDH had lower preoperative JOA scores than TDH with PBA. CDH had a larger ventral occupying ratio than TDH, TDHO, and TDH with PBA.

CONCLUSIONS

The onset of TDM was generally insidious but may be triggered acutely by apparently trivial events. With a low prevalence, TDM varied clinical symptoms. Different types of TDM had various clinical features, which might indicate different pathological mechanisms.

Posterior Percutaneous Endoscopic Technique Through Bilateral Translaminar Osseous Channels for Thoracic Spinal Stenosis Caused by Ossification of the Ligamentum Flavum Combined with Disk Herniation at the T10-11 Level: A Technical Note

BACKGROUND

The occurrence rate of thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation is lower than that of ossified ligamentum flavum in the thoracic spine, and the treatment method has rarely been reported. In this paper, we applied an endoscopic technique to a patient with thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation at the T10-11 level.

METHODS

We performed surgical decompression of the thoracic spinal cord for a patient diagnosed with thoracic spinal stenosis at the T10-11 level caused by ossification of the ligamentum flavum combined with disk herniation using percutaneous endoscopic surgery via the bilateral translaminar osseous channel approach. Pre- and postoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) examinations were performed, and pre- and postoperative neurologic status was evaluated using the Modified Japanese Orthopaedic Association and visual analog scale scores.

RESULTS

The ossified ligamentum flavum and herniated disk material were removed through this osseous channel. Postoperative CT and MRI scanning revealed adequate decompression of the spinal cord at the T10-11 level. The patient was discharged home on postoperative day 3. At 6-month postoperative follow-up, the patient experienced complete resolution of T12 dermatomal numbness. The strength in her bilateral lower extremities improved slightly to grade 5.

CONCLUSIONS

We have applied percutaneous endoscopic surgery via bilateral translaminar osseous channels for the treatment of thoracic spinal stenosis caused by ossification of the ligamentum flavum combined with disk herniation. This surgery could provide sufficient decompression for thoracic spinal cord with minimum trauma.

Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach

Although symptomatic thoracic disk herniation (TDH) is relatively rare, its treatment is quite difficult. Our aim is to present the outcomes and complications in patients with thoracic disk herniation treated with minimally invasive lateral transthoracic approach (LTTA). Fifty-nine consecutive patients with 69 symptomatic disk herniations that underwent minimally invasive LTTA to treat TDH between 2007 and 2016 were enrolled. Medical records were reviewed retrospectively. The numbers of TDH were as follows: 41 central, 10 paracentral, and 18 both central and paracentral. The number of calcified disk herniations was found to be 32. No patient developed neurological deficit. Postoperative neurological improvement occurred in 39 (90.7%) of 43 patients with myelopathy. Preoperative VAS scores, ODI scores, and SF-36 scores improved at the follow-up, respectively. Mean blood loss, hospitalization period, and follow-up period were found to be 391.2 mL, 4.7 days, and 60 months; respectively. The following complications were observed: dural tear (five patients), intercostal neuralgia (three patients), rib fracture (one patient), pleural effusion requiring chest tube (two patients), hydropneumothorax requiring chest tube (one patient), small pneumothorax (one patient), atelectasis (one patient), pulmonary embolism (one patient), and pneumonia (one patient). Minimally invasive LTTA not only minimizes the manipulation of the thecal sac decreasing the risk for neurological injury compared to traditional posterior methods but also significantly decreases the pulmonary complications associated with traditional open procedures. Based on the authors' experience, anterior approach should be preferred especially in calcified central disk herniations regardless of surgeon's experience.

Superficial Siderosis of Central Nervous System as Primary Clinical Manifestation Secondary to Intradural Thoracic Disk Herniation

BACKGROUND

Superficial siderosis of the central nervous system is a rare neurologic disorder characterized by the superficial deposition of hemosiderin in the subpial layer resulting in iron-related progressive neurodegeneration.

CASE DESCRIPTION

In this report, we present a case of superficial siderosis of the central nervous system secondary to an intradural thoracic disk herniation causing a cerebrospinal fluid (CSF) leak.

CONCLUSIONS

The patient was successfully treated with T6-T8 transpedicular partial corpectomy, as well as diskectomy with decompression followed by watertight closure of the CSF leak. Intraoperative watertight closure of the CSF leak was achieved.

T1-T2 Herniated Disk Presenting with Horner Syndrome

BACKGROUND

The incidence of thoracic disk herniation is estimated to be 1000 to 1,000,000. Upper thoracic disk herniation is an exceedingly rare pathology with unique neurologic features. We report a case of a young patient who presented with Horner syndrome caused by a T1-T2 disk herniation.

CASE DESCRIPTION

A 34-year-old female patient was admitted to the emergency department presenting a sudden-onset history of ptosis and miosis on the left eye (Horner syndrome). She reported a 2-month history of neck, scapular, and medial left arm and forearm pain and numbness. The cervical magnetic resonance image showed a T1-T2 left disk herniation with intraforaminal compression of the T1 nerve root. A microdiskectomy was performed, and both left arm pain and Horner syndrome have completely regressed.

CONCLUSIONS

Symptomatic T1-T2 disk herniation is an uncommon condition in a spine surgeon daily routine. The differential diagnosis for patients presenting upper limb pain and Horner's Syndrome should include upper thoracic disk herniation. Patients' outcomes can be excellent if an adequate surgical treatment is timely provided.

Preliminary study and technical note

Purpose Thoracic disk herniation is uncommon. It still represents a challenge for spinal surgeons. Multiple surgical strategies are available and, often, they are matter of debate. We describe a preliminary experience about a combined extra-intra dural approach for posterolateral disk herniation in patients affected by spinal cord compression.

METHODS

We performed a combined extra-intra dural approach in two preliminary cases. We performed bilateral laminectomy of adjacent vertebrae and unilateral partial medial arthrectomy of the involved segment. After a lateral extradural diskectomy, we, subsequently, performed a median longitudinal durotomy. The conflict between disk herniation and spinal cord was identified. We removed disk herniation moving disk fragments in the extradural compartment without ventral spinal dura opening.

RESULTS

We solved spinal cord compression in both cases. Postoperative neurological improvement was observed in both cases. No major complications were observed.

CONCLUSION

Our preliminary results are probably insufficient to establish surgical criteria but offer another surgical perspective to especially treat patients with contraindication to anterior approaches.