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Kweh BTS, Khoo B, Asaid M, Donaldson C, Kam J, Barnett S, Seevanayagam S, Gonzalvo AC. Alexis retractor efficacy in transthoracic thoracoscopically assisted discectomy for thoracic disc herniations. Acta Neurochir (Wien) 2024; 166:135. [PMID: 38472445 DOI: 10.1007/s00701-024-06034-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/15/2024] [Indexed: 03/14/2024]
Abstract
PURPOSE A transthoracic anterior or lateral approach for giant thoracic disc herniations is a complex operation which requires optimal exposure and maximal visualisation. Traditional metal rigid retractors may inflict significant skin trauma especially with prolonged operative use and limit the working angles of endoscopic instrumentation at depth. We pioneer the use of the Alexis retractor in transthoracic thoracoscopically assisted discectomy for the first time. METHODS The authors describe and demonstrate the technical use of the Alexis retractor during operative cases. Patient positioning, clinical rationale and operative nuances are elucidated for readers to gain an appreciation of the transthoracic approach to thoracic disc herniations. RESULTS The advantages of the Alexis retractor include minimally invasive circumferential flexible retraction, facilitation of bimanual instrument use, diminished risk of surgical site infections and reduced rib retraction leading to less postoperative pain. CONCLUSION Use of the flexible and intuitive Alexis retractor maximises operative exposure and is an effective adjunct when performing complex transthoracic approaches for thoracic disc herniations.
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Affiliation(s)
- Barry Ting Sheen Kweh
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia.
- National Trauma Research Institute, Melbourne, VIC, 3004, Australia.
| | - Boyuan Khoo
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Mina Asaid
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
- Department of Neurosurgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Christopher Donaldson
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
| | - Jeremy Kam
- Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Stephen Barnett
- Department of Cardiothoracic Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Siven Seevanayagam
- Department of Cardiothoracic Surgery, Austin Hospital, Melbourne, Victoria, Australia
| | - Augusto Carlos Gonzalvo
- Department of Neurosurgery, Austin Hospital, 145 Studley Road, Heidelberg, Victoria, 3084, Australia
- Department of Surgery, University of Melbourne, Parkville, VIC, 3010, Australia
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Epstein NE, Abulnick MA. Perspective: Transthoracic, posterolateral, or transpedicular approaches to thoracic disks, not laminectomy. Surg Neurol Int 2023; 14:303. [PMID: 37680932 PMCID: PMC10481820 DOI: 10.25259/sni_648_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 08/04/2023] [Indexed: 09/09/2023] Open
Abstract
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.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurosurgery, School of Medicine, State University of NY at Stony Brook, and Editor-in-Chief Surgical Neurology International NY and c/o Dr. Marc Agulnick 1122 Franklin Avenue Suite 106, Garden City, NY 11530, United States
| | - Marc A Abulnick
- Department of Orthopedics, Assistant Clinical Professor of Orthopedics, NYU Langone Hospital, Long Island, Garden City, New York, 1122 Franklin Avenue Suite 106 Garden City, NY 11530, United States
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Hamid S, Moradi F, Bagheri SR, Zarpoosh M, Amirian P, Ghasemi H, Alimohammadi E. Evaluation of clinical outcomes, complication rate, feasibility, and applicability of transfacet pedicle-sparing approach in thoracic disc herniation: a systematic review and meta-analysis. J Orthop Surg Res 2023; 18:516. [PMID: 37475044 PMCID: PMC10360238 DOI: 10.1186/s13018-023-04016-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/14/2023] [Indexed: 07/22/2023] Open
Abstract
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.
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Affiliation(s)
- Shafi Hamid
- School of Medicine, Wayne State University, Detroit, MI, USA
| | - Farid Moradi
- Department of Neurosurgery, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Seyed Reza Bagheri
- Department of Neurosurgery, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mahsa Zarpoosh
- Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Parsa Amirian
- Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Hooman Ghasemi
- School of Nursing and Midwifery, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ehsan Alimohammadi
- Department of Neurosurgery, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Spallone A, Visocchi M, Greco F, Signorelli F, Gladi M, Fasinella R, Belogurov A, Iacoangeli M. Costotransversectomy in the Surgical Treatment of Mediolateral Thoracic Disk Herniations: Long-Term Results and Recent Minimally Invasive Technical Adjuncts. ACTA NEUROCHIRURGICA. SUPPLEMENT 2023; 135:375-383. [PMID: 38153496 DOI: 10.1007/978-3-031-36084-8_57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
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.
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Affiliation(s)
- Aldo Spallone
- Institute of Bioorganic Chemistry, Neuroscience, Russian Academy of Sciences, Moscow, Russia
- NCL-Neurological Center of Latium, Rome, Italy
| | | | - Fabio Greco
- Skull Base Surgery Unit, Campus Bio-Medico University, Rome, Italy
| | - Francesco Signorelli
- Institute of Neurosurgery, Le Marche Polytechnic University and Polyclinic, Ancona, Italy
| | - Maurizio Gladi
- Institute of Bioorganic Chemistry, Neuroscience, Russian Academy of Sciences, Moscow, Russia
- NCL-Neurological Center of Latium, Rome, Italy
| | - Rossella Fasinella
- Institute of Bioorganic Chemistry, Neuroscience, Russian Academy of Sciences, Moscow, Russia
- NCL-Neurological Center of Latium, Rome, Italy
| | - Alexey Belogurov
- Institute of Bioorganic Chemistry, Neuroscience, Russian Academy of Sciences, Moscow, Russia
- NCL-Neurological Center of Latium, Rome, Italy
| | - Maurizio Iacoangeli
- Institute of Bioorganic Chemistry, Neuroscience, Russian Academy of Sciences, Moscow, Russia.
- NCL-Neurological Center of Latium, Rome, Italy.
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Kashyap S, Webb AG, Friis EA, Arnold PM. Management of single-level thoracic disc herniation through a modified transfacet approach: A review of 86 patients. Surg Neurol Int 2021; 12:338. [PMID: 34345479 PMCID: PMC8326068 DOI: 10.25259/sni_94_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Riverside, California, United States
| | - Andrew G Webb
- Department of Clinical Imaging Research, Carle Illinois College of Medicine Beckman Institute of Advanced Science and Technology, Urbana, Illinois, United States
| | - Elizabeth A Friis
- Department of Mechanical Engineering, University of Kansas, Lawrence, Kansas
| | - Paul M Arnold
- Department of Neurosurgery, Carle Neuroscience Institute, Urbana, Illinois, United States
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Radiographic and clinical features of thoracic disk disease associated with myelopathy: a retrospective analysis of 257 cases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:2211-2220. [PMID: 33389202 DOI: 10.1007/s00586-020-06688-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/11/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
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.
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Revision surgery in thoracic disc herniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2019; 29:39-46. [PMID: 31734804 DOI: 10.1007/s00586-019-06212-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgical treatment failures or strategies for the reoperation of residual thoracic disc herniations are sparsely discussed. We investigated factors that led to incomplete disc removal and recommend reoperation strategies. METHODS As a referral centre for thoracic disc disease, we reviewed retrospectively the clinical records and imaging studies before and after the treatment of patients who were sent to us for revision surgery for thoracic disc herniation from 2013 to 2018. RESULTS A total of 456 patients were treated from 2013 to 2018 at our institution. Twenty-one patients had undergone previously thoracic discectomy at an outside facility and harboured residual, incompletely excised and symptomatic herniated thoracic discs. In 12 patients (57%), the initial symptoms that led to their primary operation were improved after the first surgery, but recurred after a mean of 2.8 years. In seven patients (33%) they remained stable, and in two cases they were worse. All patients were treated via all dorsal approaches. In all 21 cases, the initial excision was incomplete regarding medullar decompression. All of the discs were removed completely in a single revision procedure. After mean follow-up of 24 months (range 12-57 months), clinical neurological improvement was demonstrated in seven patients, while three patients suffered a worsening and 11 patients remained stable. CONCLUSION Our data suggest that pure dorsal decompression provides a short relief of the symptoms caused by spinal cord compression. Progressive myelopathy (probably due to mechanical and vascular deficits) and scar formation may cause worsening of symptoms. These slides can be retrieved under Electronic Supplementary Material.
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Vaishnav AS, Othman YA, Virk SS, Gang CH, Qureshi SA. Current state of minimally invasive spine surgery. JOURNAL OF SPINE SURGERY 2019; 5:S2-S10. [PMID: 31380487 DOI: 10.21037/jss.2019.05.02] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Over the past two decades, minimally invasive surgical approaches have become increasingly feasible, efficient and popular for the management of a wide range of spinal disorders, with a growing body of research demonstrating numerous advantages of these techniques over the traditional open approach. In this article, we review the technologies and innovations that are expanding the horizon of minimally invasive spine surgery (MISS), and highlight high-quality peer-reviewed literature in the past year that expands our knowledge and understanding of indications, advantages and limitations of MISS.
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Affiliation(s)
| | - Yahya A Othman
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | | | - Sheeraz A Qureshi
- Hospital for Special Surgery, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
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