Evolution and current status of surgical management of thoracic disc herniation - A review

Thoracic disc herniations (TDH) are uncommon compared to cervical and lumbar disc herniations. Surgical treatment of TDH can be challenging due to the anatomical constraints and the high risk of morbidity due to proximity to the thoracic spinal cord. Moreover, the selection of appropriate surgical approach depends on various factors such as the size and location of disc herniation within the spinal canal, spinal level, presence or absence of calcification, degree of spinal cord compression, and familiarity with various approaches by the treating surgeon. While there is agreement that posterolateral approaches can be used to treat posterolateral and central soft disc herniation, there is a lack of consensus on the best surgical approach for central calcified and giant calcified TDH where an anterior approach is perceived as the best option. There is increasing evidence that support the safety and efficacy of posterolateral approaches even for central calcified and giant calcified TDH. This review highlights the evolution of surgical management for TDH based on the past and current literature and the author's experience at his institution.

Posterior-only approach in patients with poor general condition and spinal metastatic vertebral fracture

PURPOSE

The surgical treatment of spinal metastases is mostly palliative in nature and focuses on improving the quality of life of patients. The posterior transpedicular surgical approach provides circumferential 360° decompression, allows reconstruction and stabilisation to be achieved in a single session and can be performed using an open, mini-open or minimally invasive approach. We present and discuss the surgical techniques and outcomes for patients with single-level metastatic spinal disease and in poor general condition who underwent surgery via the posterior-only transpedicular corpectomy approach and reconstruction with expandable corpectomy cages.

METHODS

Patients with a single level thoracolumbar metastatic disease (T3-L5) and a Karnofsky score of ≤70, who underwent a complete posterior transpedicular corpectomy with expandable cage reconstruction of the anterior spinal column were retrospectively reviewed. Patients' demographics, SINS, modified Tokuhashi scores as well as preoperative and postoperative ASIA scale, Karnofsky scores, VAS scores and vertebral height/Cobb angle values were analysed.

RESULTS

A total of 44 patients (24 M/20 F) (mean age 53.25±21.26 years) met the inclusion criteria. The modified Tokuhashi scores were as follows: score 0-8, 5 (11.4%) patients; score 9-11, 14 (31.8%) patients; and score 12-15, 25 (56.8%) patients. There were significant improvements in the postoperative VAS scores (mean 7.7-2.9), Karnofsky scores (mean 63.3-79.6) as well as the Cobb angles (18.6-12.8°) and vertebral height. Thirtyfive patients showed improved neurological function by at least one ASIA grade, whereas 9 showed no improvement during the postoperative period.

CONCLUSIONS

This technique, which has a low complication rate and a short recovery time, can help achieve satisfactory results even in patients with poor metabolic profiles and Karnofsky scores in the preoperative period. Further clinical studies with large patient groups are warranted to confirm the results of this study.

Fluoroscopy guided transpedicular abscess infusion and drainage in thoracic-lumbar spondylitis with prevertebral abscess

PURPOSE

To evaluate the effectiveness of fluoroscopy guided transpedicular abscess infusion and drainage in thoracic-lumbar spondylitis with prevertebral abscess.

METHODS

We retrospectively reviewed 14 patients with infectious spondylitis with prevertebral abscesses from January 2019 to December 2022. All patients underwent fluoroscopy guided transpedicular abscess infusion and drainage. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analog scale (VAS), Macnab criteria, and magnetic resonance imaging (MRI) were compared before and after the operation to evaluate clinical outcomes.

RESULTS

Among the 14 patients with prevertebral abscesses, 64.29% (9/14) involved the lumbar spine and 35.71% (5/14) involved the thoracic spine. The ESR, CRP, and VAS scores decreased from 87.34 ± 9.21, 93.01 ± 11.17, and 8.38 ± 0.97 preoperatively to 12.35 ± 1.61, 8.52 ± 1.19, and 2.02 ± 0.64 at the final follow-up, respectively. MRI at the final follow-up showed the disappearance of the prevertebral abscess compared with that in the preoperative group (66.95 ± 12.63 mm in diameter). Ten patients achieved an "excellent" outcome, while the remaining four patients obtained a "good" outcome according to the Macnab criteria.

CONCLUSION

Fluoroscopy guided transpedicular abscess infusion and drainage is a safe and minimally invasive procedure for the management of thoracic-lumbar spondylitis with a prevertebral abscess.

A Comparison Between Modified Unilateral Extrapedicular and Bilateral Transpedicular Percutaneous Kyphoplasty in the Treatment of Lumbar Osteoporotic Vertebral Compression Fracture

BACKGROUND

Few researchers have verified the clinical efficacy and safety of the modified unilateral extrapedicular approach (mUEP) applied to the percutaneous kyphoplasty (PKP) in comparative studies with other puncture techniques. Compared with the bilateral transpedicular approach (BTP), whether mUEP PKP is a preferred treatment for lumbar osteoporotic vertebral compression fracture (OVCF) remains unclear.

METHODS

Patients treated by PKP for single-level lumbar OVCF in our institution from September 2019 to December 2020 were retrospectively enrolled. Patients were grouped according to the puncture techniques. Clinical and radiologic outcomes were evaluated preoperatively, postoperatively, and at follow-up. The clinical evaluation was performed by using visual analog scale for pain relief and Oswestry Disability Index for health status. Radiologic measurements contained anterior vertebral height, kyphotic angle, and bone cement distribution.

RESULTS

In total, 76 patients with a mean follow-up duration of 16.6 months were enrolled, including 34 patients in the mUEP PK group and 42 patients in the BTP PKP group. In the mUEP group, operation time, fluoroscopy times, and injected cement volume were significantly less than that in the BTP group (P < 0.01). Both visual analog scale and Oswestry Disability Index scores of all patients decreased significantly after surgery (P < 0.01), with no significant differences between the 2 groups at each follow-up. Both mUEP PKP and BTP PKP showed significant anterior height restoration and kyphotic angle correction (P < 0.01), with no significant differences between the 2 groups at each follow-up. Meanwhile, the mUEP PKP reduced the incidence of intraspinal cement leakage (P < 0.05), and no facet joint violation was found in mUEP PKP.

CONCLUSIONS

mUEP PKP could be clinically and radiographically equivalent to BTP PKP. However, it has advantages in reducing operation time and fluoroscopy times, lowering the risk of intraspinal cement leakage, and preventing the presence of facet joint violation. Compared with BTP PKP, the mUEP PKP seems to be an effective and alternative puncture technique for the treatment of lumbar OVCF after appropriate patient selection.

A novel technique of transpedicular opening-wedge osteotomy for treatment of rigid kyphosis in patients with ankylosing spondylitis

BACKGROUND

To investigate the effectiveness and feasibility of a novel vertebral osteotomy technique, transpedicular opening-wedge osteotomy (TOWO) was used to correct rigid thoracolumbar kyphotic deformities in patients with ankylosing spondylitis (AS).

METHODS

Eighteen AS patients underwent TOWO to correct rigid thoracolumbar kyphosis. Radiographic parameters were compared before surgery, 1 week after surgery and at the last follow-up. The SRS-22 questionnaire was given before surgery and at the last follow-up to evaluate clinical improvement. The operating time, estimated blood loss and complications were analyzed.

RESULTS

The mean operating time and estimated blood loss were 236 min and 595 ml, respectively. The mean preoperative sagittal vertical axis (SVA), thoracic kyphosis (TK), pelvic tilt (PT) and thoracolumbar kyphosis (TLK) were 158.97 mm, 51.24 mm, 43.63 mm and 41.74 mm, respectively, and decreased to 66.72 mm, 35.96 mm, 27.21 mm and 8.67 mm at the last follow-up. The mean preoperative lumbar lordosis (LL) and sacral slope (SS) were 8.30 ± 24.43 mm and 19.67 ± 9.40 mm, respectively, which increased to 38.23 mm and 28.13 mm at the last follow-up. The mean height of the anterior column of osteotomized vertebrae increased significantly from 25.17 mm preoperatively to 37.59 mm at the last follow, but the height of the middle column did not change significantly. SRS-22 scores were improved significantly at the last follow-up compared with preoperatively. Solid bone union was achieved in all patients after 12 months of follow-up, and no screw loosening, screw removal or rod breakage was noticed at the last follow-up.

CONCLUSIONS

TOWO could achieve satisfactory kyphosis correction by opening the anterior column instead of vertebral body decancellation and posterior column closing, thus simplifying the osteotomy procedure and improving surgical efficacy.

Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study

BACKGROUND

Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control.

METHODS

The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification.

RESULTS

92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05).

CONCLUSION

The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.

Posterior-only approach for the treatment of symptomatic central thoracic disc herniation regardless of calcification: A consecutive case series of 30 cases over five years

PURPOSE

To report the safety and efficacy of posterolateral approach for thoracic disc herniation (TDH) via a consecutive clinical case series of 30 central thoracic disc herniations that were all operated through a posterolateral approach.

METHODS

A retrospective review was conducted of all patients with symptomatic TDH who underwent surgical intervention from 2016 to 2021. A total of 23 patients comprising 30 central TDH were included in the study. Age, gender, location of the lesion, preoperative and post-operative Frankel and Nurick scores, surgical approach and instrumented vertebrae, and length of stay were recorded.

FINDINGS

23 patients with an average age of 62 were included in the study. 30 of the 32 symptomatic TDH were centrally located. 8/32 TDH were calcified while 24/32 TDH were non-calcified. Unilateral and bilateral transpedicular approach was used in the treatment of 12/32 and 10/32 disc herniations respectively. A transfacet-pedicle sparing approach was used in 10/32 disc herniations. 19/23 (82.6%) of the patients had improvement in Nurick score while 12/23 (52.2%) patients had improvement in their Frankel scores. The average length of stay was 4.5 days. No major complications were encountered. All patients underwent a short-segment instrumented construct with no need for revision surgery for thoracic disc herniation, worsening myelopathy, or instrumentation failure.

CONCLUSIONS

83% of the patients who underwent a transfacet or transpedicular decompression for the treatment of symptomatic TDH had improvement in their myelopathy with no neurological deterioration in any of the patients. Given the familiarity and low morbidity associated with a transfacet or transpedicular approach, posterolateral-based approaches remains an excellent alternative for surgical management of majority of the patients with thoracic disc herniations.

Clinical Outcomes of Thoracolumbar Burst Fracture Treated by Trans-Kambin triangle versus Transpedicular Bone Grafting Combined with Posterior Internal Fixation

OBJECTIVE

The ideal management of thoracolumbar burst fracture (TLBF) remains controversial. We conducted this study to compare the effectiveness and safety of trans-Kambin triangle versus transpedicular bone grafting combined with posterior internal fixation (PIF) for TLBF.

METHODS

Fifty-four patients were retrospectively analyzed and divided into 2 groups: the observation group (PIF combined with bone grafting via the Kambin triangle, n = 28) and the control group (PIF combined with bone grafting via transpedicular, n = 26). The anterior vertebral height ratio, sagittal Cobb angle, visual analog scale score, Oswestry Disability Index, bone healing rate, and neurologic complications were measured.

RESULTS

All patients were followed up regularly for a mean period of 17.94 months (12 - 24 months). The anterior vertebral height ratio in the observation group was higher than that in the control group (93.93 ± 2.92 vs. 89.90 ± 5.54%, P = 0.006), and the loss of correction was lower (1.59 ± 1.20 vs. 3.00 ± 1.98%, P = 0.008). The observation group had lower sagittal Cobb angle at final follow-up (8.68 ± 3.75 vs. 11.33 ± 4.77 degrees, P = 0.046) and less correction loss (1.96 ± 1.32 ± 1.15 vs. 3.90 ± 2.39 degrees, P = 0.002). The visual analog scale score and Oswestry Disability Index in the observation group were lower (0.61 ± 0.43 vs. 0.92 ± 0.38, P = 0.016; 15.86 ± 4.11 vs. 19.18 ± 4.04, P = 0.010), while the fracture healing rate showed no significant difference (P > 0.05). No internal fixation failure or neurologic complications occurred in both groups during the follow-up.

CONCLUSIONS

Bone grafting via the Kambin triangle combined with PIF is a safe and effective technology for thoracolumbar burst fracture.

Evaluation of the implantation of transpedicular screws in spinal instrumentation with free-hand technique and navigation-assisted with intraoperative computed tomography: An analytical-positional study

BACKGROUND

Spinal instrumentation using transpedicular screws has been used for decades to stabilize the spine. In October 2018, an intraoperative CT system was acquired in the Neurosurgery service of the University Hospital Complex of Vigo, this being the first model of these characteristics in the Spanish Public Health System, so we began a study from January 2015 to December 2019 to assess the precision of the transpedicular screws implanted with this system compared with a control group performed with the classical technique and final fluoroscopic control.

METHODS

The study was carried out in patients who required transpedicular instrumentation surgery, in total 655 screws were placed, 339 using the free-hand technique (Group A) and 316 assisted with intraoperative CT navigation (Group B) (p>0.05). Demographic characteristics, related to surgery and the screw implantation grades were assessed using the Gertzbein-Robbins classification.

RESULTS

92 patients were evaluated, between 12 and 86 years (average: 57.1 years). 161 thoracic screws (24.6%) and 494 lumbo-sacral screws (75.4%) were implanted. Of the thoracic screws, 33 produced a pedicle rupture. For the lumbo-sacral screws, 71 have had pedicle violation. The overall correct positioning rate for the free-hand group was 72.6% and for the CT group it was 96.5% (p<0.05).

CONCLUSION

The accuracy rate is higher in thoracic-lumbar instrumentation in the navigation group versus free-hand group with fluoroscopic control.

Thoracic Discectomy Through a Unilateral Transpedicular or Costotransversectomy Approach With Intraoperative Ultrasound Guidance

BACKGROUND

The disc location, extent of calcification, limited visualization of the ventral cord, and tenuous blood supply to the thoracic spinal cord pose unique technical challenges when surgically treating thoracic disc herniation.

OBJECTIVE

To report our initial experience with a series of cases in which intraoperative ultrasound image guidance was used for thoracic discectomy through a unilateral transpedicular or costotransversectomy approach.

METHODS

Five patients (n = 5) underwent a transpedicular approach and five (n = 5) underwent costotransversectomy for thoracic discectomy. Pre- and postoperative clinical records, operative reports, disc location/calcification, and complications were reviewed.

RESULTS

There were 6 (n = 6) males and 4 (n = 4) females with an average age of 54 yr (range: 33-74). All patients had symptoms attributable to a single-level of thoracic disc herniation. Discs were classified as central (n = 5) and paracentral (n = 5). Preoperative CT and/or intraoperative visualization demonstrated calcified disc material in 6 (n = 6) patients. Final outcomes data at last follow-up was available for 9 of 10 patients. Eight of these nine patients experienced a return to normal baseline functional status. Postoperative imaging confirmed that no wrong-level surgeries were performed. The mean length of follow-up was 20.4 wk (range 4-48).

CONCLUSION

Thoracic discectomy with ultrasound visualization via a unilateral transpedicular or costotransversectomy approach is safe and effective for treatment of central and paracentral calcified disc herniations. This tool improves the safety profile of thoracic discectomy and allows for treatment of thoracic discs through less invasive approaches.

Novel Strategy of Ventral Dural Repair for Idiopathic Thoracic Spinal Cord Herniation: Report of Outcomes and Review of Techniques

BACKGROUND

Idiopathic ventral thoracic spinal cord herniation is a rare condition that usually presents with progressive myelopathy or Brown-Séquard syndrome. More than 100 cases have been reported with significant variance in surgical treatment strategies and likewise, significant variance in patient outcomes. Although laminectomy has often been used, to date, there is no consensus regarding the optimal surgical approach or strategy for ventral dural repair.

OBJECTIVE

To report and illustrate a novel approach to repair the ventral dural defect with more than 2 yr of clinical follow-up. The specific approach and graft used are both detailed.

METHODS

A retrospective chart review of all known cases of idiopathic spinal cord herniation at the Cleveland Clinic over the last 15 yr was performed. Postoperative outcome scores (including the Japanese Orthopedic Association score, European Myelopathy score, and Nurick) were calculated preoperatively and postoperatively.

RESULTS

A total of 5 patients were identified. Four of five patients improved clinically after surgery and 1 patient remained unchanged at last follow-up (average 23.2 mo, range 12-60 mo). There were no complications. All patients had postoperative magnetic resonance imaging demonstrating realignment of the spinal cord and no recurrence of tethering.

CONCLUSION

A unilateral dorsolateral, transpedicular approach combined with laminectomy provides excellent exposure for ventral or ventrolateral dural defects associated with idiopathic spinal cord herniation and minimizes spinal cord manipulation. A collagen matrix graft used as an onlay between the spinal cord and ventral dural defect is a safe and effective option for ventral dural repair.

Full-endoscopic transpedicular discectomy (FETD) for lumbar herniations: Case report and review of the literature

INTRODUCTION

One of the most challenging occurrences in full-endoscopic surgery for lumbar disc protrusions are up-migrated or down-migrated herniations. Those occurrences are difficult to retrieve with transforaminal or interlaminar approaches.

PRESENTATION OF CASE

We describe our experience in dealing with a right paramedian down-migrated L3-L4 disc herniation. The patient underwent full endoscopic transpedicular endoscopic discectomy (FETD), by reaming the right L4 peduncle for intracanal access and fragment retrieval. We also reviewed the recent literature to summarize the advantages of transpedicular approaches, along with current indications and contraindications for this procedure.

DISCUSSION

We highlighted how FETD is safe and feasible for down-migrated and up-migrated disc herniation showing excellent results in our patient and in the small cohorts of patients already published in the literature.

CONCLUSION

FETD was effective in treating up-migrated and down-migrated disc herniation, as well as discal cysts, showing the feasibility and safety of the technique from any level from L1 to S1.

[One-stage transpedicular debridement, posterior internal fixation and fusion for the treatment of senile thoracolumbar tuberculosis]

OBJECTIVE

To evaluate the clinical outcomes of one-stage transpedicular debridement, posterior internal fixation, RBK mixed streptomycin filled bone grafting for the treatment of elderly patients with thoracolumbar tuberculosis.

METHODS

The clinical data of 20 elderly patients with thoracolumbar tuberculosis underwent one stage transpedicular debridement, posterior internal fixation, OSTEOSET RBK mixed streptomycin-filled bone grafting from September 2006 to July 2017 were retrospectively analyzed. There were 12 males and 8 females, aged from 62 to 83 years with an average of (72.4±6.9) years old. Visual analogue scale (VAS), Oswestry Disability Index (ODI)were used to evaluate the pain and spinal function. The kyphosis angle (Cobb angle) of the lesion segment and the bone growth of the lesion area were observed by the X-ray films.

RESULTS

All the operations were successful, the operation time was (160.9±23.8) min, and the intraoperative blood loss was (317.9± 112.7) ml. The incisions were healed by first intention, and no sinus and incision were delayed. Spinal tuberculosis was completely cured, Frankel grade has one or more improvements. The VAS score decreased from (7.50±1.15) points before surgery to (1.70±1.39) points at 12 months after surgery (P<0.05). The ODI score decreased from preoperative (92.50±1.17)% to (12.80±0.89)% at the final follow up (P<0.05). The sagittal Cobb angle of the lesion segment decreased from preoperative (24.2±1.6)° to (8.3±0.7)°at 12 months after surgery(P<0.05), the kyphosis deformity was significantly corrected. In all cases, bone fusion was achieved in bone graft area, without bone nonunion and device fracture complications.

CONCLUSION

One-stage transpedicular debridement, posterior internal fixation, RBK mixed streptomycin filled bone grafting is suitable for thoracolumbar tuberculosis patients with good general condition and less vertebral destruction.

Thoracolumbar Vertebral Column Resection With Rectangular Endplate Cages Through a Posterior Approach: Surgical Techniques and Early Postoperative Outcomes

BACKGROUND

Thoracolumbar pathology can result in compression of neural elements, instability, and deformity. Circumferential decompression with anterior column reconstruction is often required to restore biomechanical stability and minimize the risk of implant failure.

OBJECTIVE

To assess the safety and viability of wide-footprint rectangular cages for vertebral column resection (VCR).

METHODS

We performed VCR with wide-footprint rectangular endplate cages, which were designed for transthoracic or retroperitoneal approaches. We present our technique using a single-stage posterior approach.

RESULTS

A total of 45 patients underwent VCR with rectangular endplate cages. Mean age was 58 yr. Diagnoses included 23 tumors (51%), 14 infections (31%), and 8 deformities (18%). VCRs were performed in 10 upper thoracic, 17 middle thoracic, 14 lower thoracic, and 4 lumbar levels. Twenty-four cases involved a single level VCR (53%) with 18 two-level (40%) and 3 three-level (7%) VCRs. Average procedure duration was 264 min with mean estimated blood loss of 1900 ml. Neurological outcomes were stable in 27 cases (60%), improved in 16 (36%), and worse in 2 (4%). There were 7 medical and 7 surgical complications in 11 patients. There were significant decreases in postoperative thoracic kyphosis (47° vs 35°, P = .022) and regional kyphosis (34° vs 10°, P < .001). There were 2 cases of cage subsidence due to intraoperative endplate violation, neither of which progressed on CT scan at 14 and 35 mo.

CONCLUSION

Posterior VCR with rectangular footprint cages is safe and feasible. This provides improved biomechanical stability without the morbidity of a lateral transthoracic or retroperitoneal approach.

Comparison of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic spinal tuberculosis in adults

Background

The surgical procedures for mid-thoracic spinal tuberculosis mainly include anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion. Until now, the surgical choice is still controversial. This study aims to compare the clinical efficacy of anterior transthoracic debridement and fusion with posterior transpedicular debridement and fusion in the treatment of mid-thoracic (T5–9) spinal tuberculosis in adult patients.

Methods

Eighty-seven cases with mid-thoracic spinal tuberculosis were treated with anterior transthoracic debridement and fusion (Group A, n = 39) and posterior transpedicular debridement and fusion (Group B, n = 48) from January 2007 to June 2014. Parameters including the operation time, blood loss, time of ESR and CRP decreasing to the normal level, time of abscess disappearance, time of bone graft fusion, rate of surgical complications, Visual Analog Scale (VAS) score, kyphosis angle and SF-36 scale were compared between two groups to evaluate their therapeutic effects.

Results

All patients were followed up for 5–10 years with the mean of 6.2 ± 1.1 years. No significant differences were observed regarding the gender composition ratio, age, course of disease, number of lesion segments, and preoperative indexes of ESR, CRP, VAS score, kyphosis angle and SF-36 scale between the two groups. Besides, no significant differences were observed regarding VAS score, kyphosis angle and SF-36 scale between the two groups in the 5th postoperative year (P > 0.05). However, the operation time (158.2 ± 10.7 min vs. 183.7 ± 14.1 min), blood loss (517.9 ± 76.5 ml vs.714.6 ± 57.4 ml), time of ESR (2.3 ± 1.1 months vs.3.1 ± 1.4 months) and CRP (1.1 ± 0.3 months vs.1.2 ± 0.6 months) decreasing to the normal level, time of abscess disappearance (2.7 ± 1.6 months vs.4.9 ± 1.9 months), and time of bone graft fusion (6.6 ± 0.8 months vs.8.0 ± 9.6 months) in Group A were less than those in Group B (P < 0.05).

Conclusions

Both anterior transthoracic debridement and fusion and posterior transpedicular debridement and fusion have a low risk of surgical complications and provide good quality of life for the patients with mid-thoracic (T5–9) spinal tuberculosis followed up in the mid-term. Moreover, the anterior procedure leads to early resolution of the disease and faster fusion.

Circumferential Stabilization of the Thoracolumbar Junction Via Posterior-Only Approach for the Management of Burst Fractures

OBJECTIVE

The management of thoracolumbar burst fractures often includes combined anterior/posterior approaches with prolonged operative time and complications. The transpedicular approach offers a posterior only approach with circumferential reconstruction and decompression. We aim to present the experience of a single center in the management of thoracolumbar burst fractures using a posterior-only approach for circumferential stabilization and report on this technique's effectiveness in restoring the alignment of the thoracolumbar junction.

METHODS

A case review of the medical records of patients admitted to the adult neurosurgery service (from January 2011 through June 2014) with traumatic non-pathological thoracolumbar burst fractures and subsequently treated with a transpedicular corpectomy (including the placement of an expandable cage) was performed, retrospectively.

RESULTS

A total of 20 patients underwent a posterior transpedicular corpectomy consisting of anterior column reconstruction using an expandable cage with supplementary posterior fixation within 72 hours of injury. The average pre-operative canal compromise was 69%. The average pre-operative kyphotic angle was 21.6°. The average post-operative kyphotic angle was 5.15°, with an average correction of 16.45°. There were 11 patients with pre-operative neurological compromises, of which patients, 8 experienced variable degrees of recovery. The average operating time was 410.5 minutes (range, 240-550 min). The average blood loss was 880 mL (range, 650-1500). Three patients experienced complications during surgery; 1 patient died.

CONCLUSION

The transpedicular approach for circumferential reconstruction and stabilization provides an alternative technique for the management of thoracolumbar fractures, having an acceptable risk and the associated lower morbidity of a posterioronly approach.

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.

Percutaneous endoscopic transpedicular approach for high-grade down-migrated lumbar disc herniations

BACKGROUND

Surgical options for removing high-grade down-migrated lumbar disc herniations located medial to the pedicle include an extensive laminectomy and facetectomy. A direct percutaneous endoscopic approach through the pedicle for reaching the herniated disc without risk of iatrogenic instability is feasible.

METHOD

The transpedicular approach consists of creating a tunnel through the pedicle. Subsequently, access to the parapedicular epidural space is obtained, and downward migrated disc can be removed.

CONCLUSION

This technique allows to reach migrated herniations medially to the pedicle safely and effectively.

A "rising" transpedicular access to anterior vertebral body: A case report

INTRODUCTION

The transpedicular access is a common and effective procedure used to reach anterior vertebral body without passing through critical structures. after a transpedicular instrumentation, it is difficult to reach the anterior vertebral body because screws are placed in the way. We assume that an innovative transdiscal route could be used in patients with previous instrumentation, in order to perform a vertebroplasty or biopsy.

PRESENTATION OF CASE

We report the case of a 65-years-old woman who came to our Department complaining low back pain. Neurological examination showed a stable L4 wedge fracture under a previous lumbar L3-L4 posterolateral fusion performed 2 years before.

DISCUSSION

In order to perform a vertebroplasty and a biopsy of the collapsed L4 anterior vertebral body we had to deal with transpedicular screws, which prevent any standard transpedicular pproach.

CONCLUSION

In order to reach the L4 collapsed body we used an ascending transpedicular approach. We performed a biopsy and a subsequent vertebroplasty. Two days after surgery the patient reported a complete pain remission and was allowed to walk.

Biomechanical properties of posterior transpedicular-transdiscal oblique lumbar screw fixation with novel trapezoidal lateral interbody spacer: an in vitro human cadaveric model

PURPOSE

To investigate biomechanical properties of posterior transpedicular-transdiscal (TPTD) oblique lumbar screw fixation whereby the screw traverses the inferior pedicle across the posterior disc space into the super-adjacent body and lateral trapezoidal interbody spacer.

METHODS

Eight fresh-frozen osteoligamentous human cadaveric spines (L1-S1) were tested in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), with pure bending moment set at 7.5 Nm. Surgical constructs included (1) intact spine; (2) bilateral pedicle screw (BPS) fixation at L3-L4; (3) TPTD screw fixation at L3-L4; (4) lateral L3-L4 discectomy; (5) TPTD screw fixation with lateral interbody spacer (TPTD+S); and (6) BPS fixation with lateral interbody spacer (BPS+S). Peak range of motion (ROM) at L3-L4 was normalized to intact for statistical analysis.

RESULTS

In FE and LB, all posterior fixation with or without interbody spacers significantly reduced motion compared with intact and discectomy. BPS and BPS+S provided increased fixation in all planes of motion; significantly reducing FE and LB motion relative to TPTD (p = 0.005, p = 0.002 and p = 0.020, p = 0.004, respectively). In AR, only BPS significantly reduced normalized ROM to intact (p = 0.034); BPS+S provided greater fixation compared with TPTD+S (p = 0.005).

CONCLUSIONS

Investigators found less stiffness with TPTD screw fixation than with BPS regardless of immediate stabilization with lateral discectomy and spacer. Clinical use should be decided by required biomechanical performance, difficulty of installation, and extent of paraspinal tissue disruption.

Evaluation of Outcome of Transpedicular Decompression and Instrumented Fusion in Thoracic and Thoracolumbar Tuberculosis

Study Design

Retrospective analysis.

Purpose

We evaluated the functional, neurological, and radiological outcome in patients with thoracic and thoracolumbar tuberculosis operated through the transpedicular approach.

Overview of Literature

For surgical treatment of thoracic and thoracolumbar tuberculosis, the anterior approach has been the most popular because it allows direct access to the infected tissue, thereby providing good decompression. However, anterior fixation is not strong, and graft failure and loss of correction are frequent complications. The transpedicular approach allows circumferential decompression of neural elements along with three-column fixation attained via pedicle screws by the same approach.

Methods

A total of 47 patients were diagnosed with tuberculosis of the thoracic or thoracolumbar region from August 2012 to August 2013. Of these, 28 patients had progressive neurological deterioration or increasing back pain despite conservative measures and underwent transpedicular decompression and pedicle screw fixation with posterior fusion. Antituberculosis therapy was given till signs of radiological healing were evident (9–16 months). Functional outcome (visual analog scale [VAS] score for back pain), neurological recovery (Frankel grading), and radiological improvement were evaluated preoperatively, immediate postoperatively, and at 3 months, 6 months, and 1 year.

Results

Mean VAS score for back pain improved from 8.7 preoperatively to 1.1 at 1 year follow-up. Frankel grading preoperatively was grade B in 7, grade C in 11, and Grade D in 10 patients, which improved to grade D in 6 and grade E in 22 patients at the last follow-up. Radiological healing was evident in the form of reappearance of trabeculae formation, resolution of pus, fatty marrow replacement, and bony fusion in all patients. Mean correction of segmental kyphosis postoperatively was 10.5°. Mean loss of correction at final follow-up was 4.1°.

Conclusions

Transpedicular decompression with instrumented fusion is a safe and effective approach for management of patients with thoracic and thoracolumbar tuberculosis.

Transpedicular endoscopic surgery for lumbar spinal synovial cyst-report of two cases

BACKGROUND

Lumbar facet cysts are a benign, degenerative, and fairly uncommon cause for lumbar radiculopathy. The standard surgical treatment for lumbar facet cysts often requires a laminectomy and medial facetectomy which can further destabilize a pathological motion segment. The authors present here a novel technique for transpedicular endoscopic access to the pathology that obviates the need to violate the lamina or facet.

METHODS

Two patient cases are described where the lumbar 4-5 facet cysts arise medial to the pedicle. Percutaneous access to the cysts was established by drilling through the adjacent pedicle creating a 7-mm corridor to establish access for the endoscopic tubular retractor and the working channel endoscope. Straight and bendable forceps were used to remove the cysts under direct visualization.

RESULTS

Following surgery, the patients' symptoms showed immediate regression with complete relief of one patient's foot drop by 6 months.

CONCLUSIONS

Transpedicular endoscopic access is described as novel minimally invasive surgical option in the awake patient for lumbar facet cysts adjacent to the Lumbar 4 or 5 pedicle.

Transpedicular Lumbar Endoscopic Surgery for Highly Migrated Disk Extrusions: Preliminary Series and Surgical Technique

OBJECTIVE

Endoscopic surgery for highly migrated lumbar disk extrusions is a challenge even for spine surgeons who are familiar with using endoscopic techniques. Because of the anatomic constraints involved in transforaminal access in endoscopic surgery, an incomplete removal of a highly migrated disk extrusion can result in some cases. Here the authors describe a new technique for accessing extruded lumbar disks that have migrated into the canal directly through a transpedicular approach.

METHODS

A technique for the endoscopic treatment of highly migrated lumbar disk extrusions is presented. Retrospectively, we reviewed a series of 21 consecutive patients operated on with lumbar 3-4, lumbar 4-5, and lumbar 5-sacral 1 highly migrated disk extrusions: preoperative and postoperative clinical data with 1-year follow-up.

RESULTS

A preliminary series of 11 male and 10 female patients with an average age of 56.9 years (from 33-78 years old) who underwent transpedicular endoscopic retrieval of an extruded lumbar disk between 2012 and 2015 is presented. Two patients required revision to transforaminal access, 1 at the same sitting and the other 4 weeks later. The mean visual analog scale score for radicular pain improved from an average pain score before surgery of 8.1-1.7 one year after surgery. No pedicle fractures were encountered.

CONCLUSIONS

Transpedicular endoscopic access to highly migrated lumbar herniated disk extrusions is presented as a unique minimally invasive approach to extruded lumbar herniated disks, especially at L3-4, L4-5, and L5-S1.

Single-Stage Posterolateral Transpedicular Approach With 360-Degree Stabilization and Vertebrectomy in Primary and Metastatic Tumors of the Spine

OBJECTIVE

Currently, anterior, posterior, or combined approaches are used in various spinal disorders; however, a single-stage posterolateral transpedicular approach with 360° stabilization and vertebrectomy provides better results for spinal tumors.

METHODS

We evaluated the age, sex distribution, presenting symptoms, neurologic examination findings according to the pre- and postoperative Frankel classification, pre- and postoperative VAS pain scores, preoperatively administered medical therapies, pre- and postoperative corset use, level of the lesion, levels of previous surgical interventions, root ligation (if performed), results of the primary disease, hospitalization duration (after the operation), postoperative complications (if any), postoperative follow-up duration, and postoperative survival duration of 22 patients.

RESULTS

We observed that primary bone tumors were localized in the lumbar (75%) and thoracic regions (25%) and that metastatic tumors were localized in the thoracic (77.78%) and lumbar regions (22.22%). The VAS and Frankel scores of the 22 patients who were included in the study revealed that this surgical treatment modality was associated with statistically significant improvements in test scores (P < 0.001). No ribcage dislocation was observed. In 1 patient (4.54%), a neurologic deficit developed. Two patients (9.09%) required revision because of screw malposition.

CONCLUSIONS

In spinal tumors, 360° fusion performed via a posterolateral approach is a less risky, relatively safe, and less invasive method. This method, which reduces the risks of anesthesia and internal problems and decreases cost, is an essential technique for decreasing hospitalization duration, improving pain levels, and achieving faster mobilization and faster initiation of radiotherapy and chemotherapy.

Percutaneous Drainage of Chronic Destructive Lumbar Osteomyelitis Abscess Via the Use of Bilateral Transpedicular Trocar Access

BACKGROUND

Pyogenic spondylodiskitis is an infection of intervertebral disks and spinal vertebral bodies. Various minimally invasive approaches to the infected disk spaces/abscesses have been described for management of early stages of the infection. Patients with chronic occurrence present with extensive infection, neurologic deficits, and bone destruction. Such patients commonly have substantial medical comorbidities. Despite the increased risks of complications, they often are treated with open surgical approaches without minimally invasive options. We describe a bilateral transpedicular approach to vertebral body abscess in a chronically infected patient with intraoperative contiguous irrigation.

CASE DESCRIPTION

We present 2 cases, a 58-year-old man and a 61-year-old man, both with a diagnosis of vertebral osteomyelitis. Images of lumbar spine showed epidural abscess and adjacent vertebral body destruction. Because of their poor clinical condition and chronicity of disease, these patients underwent percutaneous bilateral transpedicular approach.

CONCLUSION

Patients in poor health and with chronic vertebral osteomyelitis may benefit from minimally invasive percutaneous transpedicular drainage and irrigation of the abscess, representing a minimally invasive and effective treatment alternative for these patients.

[BIOMECHANICAL STUDY ON ADJACENT UPPER AND LOWER AND UNILATERAL FRACTURED VERTEBRAL PEDICLE SCREW FIXATION IN TREATMENT OF THORACOLUMBAR FRACTURE]

OBJECTIVE

To investigate the stability of unilateral fractured vertebral pedicle screw fixation in the treatment of thoracolumbar fracture.

METHODS

Eighteen fresh calf thoracolumbar spine specimens (T₁₁-L₃) were obtained to establish the L₁ burst fracture models with Panjabi's high speed trauma apparatus, and were divided into 3 groups:pedicle fixation for adjacent upper and lower vertebrae of fractured vertebra (4 pedicle screws in group A), combined with pedicle screw fixation for unilateral fractured vertebrae (5 pedicle screws in group B), and three-level 6 pedicle fixation (group C). Under normal, fractured, and reconstructed conditions, the range of motion (ROM) of adjacent upper and lower vertebrae of fractured vertebra were measured in flexion, extension, bilateral bending, and axial rotation. Axial stiffness under flexion-compression was measured on the MTS-858 testing system.

RESULTS

There was no significant difference in ROM and axial stiffness under normal and fractured conditions in all directions among groups (P<0.05), indicating load balance in the groups. ROM of groups B and C were significantly less than that of group A under reconstructed condition in all directions (P<0.05), but no significant difference was found between group B and group C (P>0.05). Biomechanical test showed that group B was significantly higher than group A in the axial stiffness value (P<0.05), but difference was not significant between group B and group C (P>0.05).

CONCLUSIONS

Transpedicular fixation of fractured vertebrae can enhance the stability of the spine. Both unilateral and bilateral fractured vertebral pedicle screw fixations have the same stability.

A Modified Microsurgical Endoscopic-Assisted Transpedicular Corpectomy of the Thoracic Spine Based on Virtual 3-Dimensional Planning

BACKGROUND AND OBJECTIVE

The main difficulties of transpedicular corpectomies are lack of space for vertebral body replacement in the neighborhood of critical structures, the necessity for sacrifice of nerve roots in the thoracic spine. and the extent of hemorrhage due to venous epidural bleeding. We present a modified technique of transpedicular corpectomy by using an endoscopic-assisted microsurgical technique performed through a single posterior approach. A 3-dimensional (3D) preoperative reconstruction could be helpful in the planning for this complex anatomic region.

METHODS

Surface and volume 3D reconstruction were performed by Amira or the Dextroscope. The clinical experience of this study includes 7 cases, 2 with an unstable burst fracture and 5 with metastatic destructive vertebral body disease, all with significant retropulsion and obstruction of the spinal canal. We performed a comparison with a conventional cohort of transpedicular thoracic corpectomies.

RESULTS

Qualitative parameters of the 3D virtual reality planning included degree of bone removal and distance from critical structures such as myelon and implant diameter. Parameters were met in each case, with demonstration of optimal positioning of the implant without neurological complications. In all patients, the endoscope was a significant help in identifying the origins of active bleeding, residual tumor, extent of bone removal, facilitating cage insertion in a minimally invasive way, and helping to avoid root sacrifice on both sides.

CONCLUSIONS

Microsurgical endoscopic-assisted transpedicular corpectomy may prove valuable in enhancing the safety of corpectomy in destructive vertebral body disease. The 3D virtual anatomic model greatly facilitated the preoperative planning.

Percutaneous Transpedicular Fixation: Technical tips and Pitfalls of Sextant and Pathfinder Systems

Study Design

The efficacy of the operative techniques, possible benefits as well as pitfalls and limitations of the techniques are discussed. Potential drawbacks are also detected.

Purpose

This study aims to report indications, techniques, and our experience with the use of the Sextant and PathFinder percutaneous transpedicular screw fixation systems.

Overview of Literature

Percutaneous pedicle screw insertion is a novel technique. Successful percutaneous placement of pedicle screws requires surgical skill and experience because of lack of anatomic surface landmarks. Fluoroscopy-guided percutaneous placement of pedicle screws is effective. Many systems are now available.

Methods

We conducted a prospective operative and postoperative analysis of 40 patients with absolute indication for thoracic or lumbar instability between January 2009 and June 2013. All procedures were performed with the Sextant (group A) and PathFinder (group B) systems under fluoroscopic guidance. Operative techniques are discussed and the results compared.

Results

Percutaneous transpedicular screw fixation minimizes the morbidity associated with open techniques without compromising the quality of fixation. A total of 190 screws were inserted. There was no additional morbidity. Postoperative computed tomography images and plain X-rays were analyzed. Reduction of visual analog scale scores of back pain was evident.

Conclusions

Fluoroscopy-guided percutaneous pedicular screws are feasible and can be safely done. Current systems allow multi-segmental fixation with significantly less difficulties. The described techniques have acceptable intra- and postoperative complication rates, and overall sufficient pain control with early mobilization of patients.

A quantitative analysis of posterolateral approaches to the ventral thoracic spinal canal

BACKGROUND CONTEXT

Various posterolateral approaches exist to access ventral thoracic spinal canal pathologies. Selecting the optimal surgical approach requires sound understanding of the exposure and working angle afforded by each approach.

PURPOSE

The purpose of this study was to quantify exposure of the ventral spinal canal with various posterolateral thoracic spinal approaches and to determine how regional anatomical differences affect measurements.

STUDY DESIGN

This is a quantitative anatomical cadaveric study.

METHODS

Four fresh cadaveric C7-L1 specimens were used with a saline infusion model to mimic in vivo thecal sac dimensions. Using stereotactic navigation, we measured exposure (expressed as percentage of total width) and maximum approach angle of the ventral spinal canal without thecal sac retraction after each surgical condition: laminectomy (L), 50% medial facetectomy (MF), transpedicular (TP), costotransversectomy (CTV), and lateral extracavitary (LE). The thoracic spine was divided into four regions (T1-T2, T3-T6, T7-T10, and T9-T12). A two-sided paired t test was used.

RESULTS

At T1-T2, visualized exposures were 25.8%, 31.5%, 42.3%, 45.1%, and 46.8%, respectively, after each surgical condition. Costotransversectomy and LE did not provide significant increase in exposure compared with the preceding condition. At T3-T6, exposures were 19.1%, 29.6%, 38.7%, 44.4%, and 44.5%, respectively. Only LE did not provide significant increase in exposure compared with the preceding condition. At T7-T10, visualized exposures were 17.9%, 30.6%, 39.9%, 44.9%, and 53.3%, respectively. All successive surgical conditions provided a significant increase in exposure. At T11-T12, visualized exposures were 14.2%, 25.8%, 43.1%, 47.7%, and 52.7%, respectively. Only LE did not provide a significant increase in exposure compared with the preceding condition. Each successive surgical condition provided a significantly increased lateral approach angle compared with the preceding condition, except LE at T1-T2. Maximum approach angle was more favorable at T1-T2 for L, MF, TP, and CTV compared with other thoracic regions.

CONCLUSIONS

Medial facetectomy and TP approaches provide significantly increased exposure of the ventral spinal canal at all thoracic regions. Costotransversectomy provided significantly increased exposure compared with TP at T3-T12. Lateral extracavitary only provided significantly increased exposure compared with CTV at T7-T10. The results of this study can be used preoperatively to determine the optimal approach based on quantitative measurements and region-specific anatomical differences.

Ultrasound-guided posterolateral approach for midline calcified thoracic disc herniation

Objective

Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression.

Methods

We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature.

Results

The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up.

Conclusion

Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.

Transpedicular curettage and drainage of infective lumbar spondylodiscitis: technique and clinical results

Background

Infective spondylodiscitis usually occurs in patients of older age, immunocompromisation, co-morbidity, and individuals suffering from an overall poor general condition unable to undergo reconstructive anterior and posterior surgeries. Therefore, an alternative, less aggressive surgical method is needed for these select cases of infective spondylodiscitis. This retrospective clinical case series reports our novel surgical technique for the treatment of infective spondylodiscitis.

Methods

Between January 2005 and July 2011, among 48 patients who were diagnosed with pyogenic lumbar spondylodiscitis or tuberculosis lumbar spondylodiscitis, 10 patients (7 males and 3 females; 68 years and 48 to 78 years, respectively) underwent transpedicular curettage and drainage. The mean postoperative follow-up period was 29 months (range, 7 to 61 months). The pedicle screws were inserted to the adjacent healthy vertebrae in the usual manner. After insertion of pedicle screws, the drainage pedicle holes were made through pedicles of infected vertebra(e) in order to prevent possible seeding of infective emboli to the healthy vertebra, as the same instruments and utensils are used for both pedicle screws and the drainage holes. A minimum of 15,000 mL of sterilized normal saline was used for continuous irrigation through the pedicular pathways until the drained fluid looked clear.

Results

All patients' symptoms and inflammatory markers significantly improved clinically between postoperative 2 weeks and postoperative 3 months, and they were satisfied with their clinical results. Radiologically, all patients reached the spontaneous fusion between infected vertebrae and 3 patients had the screw pulled-out but they were clinically tolerable.

Conclusions

We suggest that our method of transpedicular curettage and drainage is a useful technique in regards to the treatment of infectious spondylodiscitic patients, who could not tolerate conventional combined anterior and posterior surgery due to multiple co-morbidities, multiple level infectious lesions and poor general condition.