A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations

Management of Lumbar Disc Herniation: A Systematic Review

A herniated disc in the spine is a condition during which a nucleus pulposus is displaced from intervertebral space. It is a common cause of back pain. The patients who experience pain related to a herniated disc often remember an inciting event that caused their pain. This activity reviews the evaluation and management of lumbar disc herniation and discusses the role of the healthcare team in evaluating and improving care for patients with this condition. Data sources were PubMed/Medline and Embase. Our review investigated English-language articles (from 2010 to 2023) according to the PRISMA guidelines. Overall, there were seven articles. Surveys and analyses of national databases were the most widely used methods (n=7). The search identified 777 studies; 7 were eligible for inclusion in the analysis. Further understanding of spinal disc herniation and treatment protocols may help improve evaluation and management in the future. Our research covered a range of management options. Disc herniation is a frequent problem for internists, emergency department doctors, nurse practitioners, and primary care physicians. To manage efficiently, an interprofessional team is needed. The first course of treatment is conservative, with paracetamol and anti-inflammatories being frequently used to relieve pain. A chemist must supervise the use of opioid analgesics in certain situations. Although surgery is sometimes the final option, patients frequently have neurological damage and lingering discomfort. In circumstances where physical treatment is not working, MRI interpretation becomes necessary. Primary care physicians or mental health professionals should handle back pain as it is frequently linked to mental health issues. Results can be enhanced by regular exercise and preserving a healthy body weight.

Full-endoscopic discectomy for thoracic disc herniations: a single-arm meta-analysis of safety and efficacy outcomes

INTRODUCTION

Surgical intervention is the treatment of choice in patients with thoracic disc herniation with refractory symptoms and progressive myelopathy. Due to high occurrence of complications from open surgery, minimally invasive approaches are desirable. Nowadays, endoscopic techniques have become increasingly popular and full-endoscopic surgery can be performed in the thoracic spine with low complication rates.

METHODS

Cochrane Central, PubMed, and Embase databases were systematically searched for studies that evaluated patients who underwent full-endoscopic spine thoracic surgery. The outcomes of interest were dural tear, myelopathy, epidural hematoma, recurrent disc herniation, and dysesthesia. In the absence of comparative studies, a single-arm meta-analysis was performed.

RESULTS

We included 13 studies with a total of 285 patients. Follow-up ranged from 6 to 89 months, age from 17 to 82 years, with 56.5% male. The procedure was performed under local anesthesia with sedation in 222 patients (77.9%). A transforaminal approach was used in 88.1% of the cases. There were no cases of infection or death reported. The data showed a pooled incidence of outcomes as follows, with their respective 95% confidence intervals (CI)-dural tear (1.3%; 95% CI 0-2.6%); dysesthesia (4.7%; 95% CI 2.0-7.3%); recurrent disc herniation (2.9%; 95% CI 0.6-5.2%); myelopathy (2.1%; 95% CI 0.4-3.8%); epidural hematoma (1.1%; 95% CI 0.2-2.5%); and reoperation (1.7%; 95% CI 0.1-3.4%).

CONCLUSION

Full-endoscopic discectomy has a low incidence of adverse outcomes in patients with thoracic disc herniations. Controlled studies, ideally randomized, are warranted to establish the comparative efficacy and safety of the endoscopic approach relative to open surgery.

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.

Image-guided transthoracic transpedicular microdiscectomy for a giant thoracic disc herniation: patient series

BACKGROUND

This case series reports on five consecutive patients who underwent image-guided transpedicular transthoracic microdiscectomy. The authors retrospectively reviewed five patients who had undergone Stealth image-guided transpedicular transthoracic microdiscectomy between 2015 and 2021.

OBSERVATIONS

Image guidance with O-arm verified critical anatomical landmarks in the setting of large central calcified and/or soft tissue disc prolapse. This allowed limited rib head resection, pedicle removal, and corpectomy to give adequate access and not require interbody fusion. The authors performed a partial posterior corpectomy anterior to the affected disc prolapse and microsurgical delivery of the affected disc anteriorly into the corpectomy cave away from the thecal sac. Electronic and radiographic records were analyzed at their initial presentation and at follow-up. The median patient age was 51 years (range, 44-56 years), with 80% of the patients being males. Four of five patients had significant improvement of their presenting clinical symptoms. One patient had a complicated postoperative recovery with a pneumothorax and subsequent bilateral pneumonia requiring intensive care. Another patient developed delayed postoperative worsening of paraparesis.

LESSONS

The use of Stealth image guidance with O-arm for transthoracic microdiscectomy for complex calcified thoracic disc herniation is an effective operative technical adjunct to verify anatomical landmarks and limit the microsurgical procedure.

Comparative Analysis of Transforaminal Endoscopic Thoracic Discectomy and Microscopic Discectomy for Symptomatic Thoracic Disc Herniation

OBJECTIVE

To evaluate the clinical outcomes of transforaminal endoscopic thoracic discectomy (TETD) and microscopic discectomy (MD) for the treatment of symptomatic thoracic disc herniation (TDH).

METHODS

Seventy-seven patients (mean, 55.9 years; follow-up, 11.2 months) with symptomatic TDH were retrospectively reviewed (39 TETD and 38 MD). Radiological factors and perioperative outcomes were reviewed. Visual analogue scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association impairment scale were used to evaluate clinical and functional outcomes. Patient satisfaction was evaluated using modified MacNab criteria.

RESULTS

The levels of surgery and the location of hernia were evenly distributed in the both groups. The operative time (70.6 minutes vs. 175.7 minutes), estimated blood loss (3.8 mL vs. 357.4 mL), and length of hospital stay (7.0 days vs. 13.0 days) were significantly different between the TETD and MD groups (p < 0.05). VAS scores for dorsal back pain and ODI scores were significantly improved in both groups (p < 0.05). Patients who underwent TETD tended to be more satisfied with the outcome in terms of the modified MacNab criteria (89.7% vs. 73.0%, p = 0.059). Two patients in the MD group underwent revision surgery, whereas one patient in the TETD group underwent MD because of incomplete decompression.

CONCLUSION

TETD for the symptomatic TDH is a feasible and safe procedure that could be used for a wider range of surgical levels with a shorter operative time and hospital stay and less blood loss. While achieving similar outcomes, TETD achieved better patient satisfaction because of the use of local anesthesia and its minimal invasiveness.

Minimally invasive dorsal approach in the surgery of giant thoracic disc herniation: technical note and clinical case report

Giant thoracic disc herniations are calcified hernias that fill more than 40% of the spinal canal and result in myelopathy with associated neurological symptoms. This is a fairly rare abnormality that requires surgical treatment. Currently, there is no unambiguous opinion about the surgical approach to the treatment this pathology. It is believed that the most effective method is the anterior approach (mini-thoracotomy or thoracoscopic approach), which reduces the risks of spinal cord injury, but is associated with the risks of damage to the lungs, pleura and major vessels. It is also quite large. We describe the case of a 60-year-old female patient with a giant thoracic disc herniation. Complete removal of the hernia through a minimally invasive dorsal approach was performed, followed by stabilization. No complications have been registered after the surgery. In this case, surgery resulted in a curative treatment outcome for the patient.

Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series

BACKGROUND

Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches.

OBSERVATIONS

Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness.

LESSONS

In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.

Five-Year Outcomes After Transforaminal Endoscopic Foraminotomy and Discectomy for Soft and Calcified Thoracic Disc Herniations

BACKGROUND

The aim of this study was to evaluate the safety and long-term clinical outcomes of transforaminal full endoscopic discectomy and foraminotomy performed with manual reamers under local anesthesia on soft and calcified herniated discs in the mid and lower thoracic spine.

METHODS

Postoperative pain relief was self-evaluated by 16 patients using a visual analog scale (VAS) and Oswestry Disability Index (ODI). Patients were scored at 6, 12, 24, and 60 months after surgery.

RESULTS

Significant pain reduction of more than 50% in the VAS score was achieved in 15 out of 16 patients at all review points throughout this study. Similarly, a decrease of more than 50% in ODI scores was achieved in 15 out of 16 patients in all 4 review points. There were no surgical complications. Good postoperative results were achieved in patients regardless of the consistency of the disc herniation.

CONCLUSIONS

Transforaminal full endoscopic discectomy and foraminotomy with manual reamers performed under local anesthesia produces sustained reduction in pain and improves functionality in patients with mid and lower thoracic spine soft and calcified disc herniations. The surgery is safe and straightforward to perform with the correct training.

LEVEL OF EVIDENCE

4.

CLINICAL RELEVANCE

Thoracic transforaminal endoscopic discectomy and foraminotomy, performed in TIVA, may be a useful adjunct for treatment of patients with soft and calcified disc herniations in thoracic spine.

Full endoscopic surgery for thoracic pathology: an assessment of supportive evidence

In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology.

The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis.

An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language.

We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients.

Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection.

Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46–100%) with a complication rate of 8% (range 0–15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing ‘self-neuromonitoring’ by allowing patients to respond to cord and/or nerve stimuli.

Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080

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.

Transforaminal Endoscopic Discectomy for Large, Two Level Calcified, Thoracic Disc Herniations With 5-Year Follow-up

To describe technical details and benefits of transforaminal endoscopic discectomy for treatment of patients with large, dorsomedial, calcified thoracic disc herniations at 2 levels and to report on their clinical outcomes in long follow-up period of 5 years using 4 different outcome tools. We present 2 patients with large, calcified disc herniations at 2 levels in mid and lower thoracic spine treated endoscopically in local anesthesia. Clinical outcomes were analyzed using verbal numeric scale (VNS), Roland-Morris low back pain and disability questionnaire (RMQ), Oswestry Disability Index (ODI), and modified MacNab criteria at 6-, 12-, 24-, 60-month follow-up. After transforaminal endoscopic discectomy, both patients had significant postoperative reduction of back pain using VNS and significant outcome improvement using ODI, RMQ score, and modified MacNab criteria. These results did not change during all 4 follow-up periods. Transforaminal percutaneous full-endoscopic discectomy and hand reamers foraminotomy in local anesthesia is feasible and effective surgical technique for patients with large, calcified thoracic disc herniations at 2 levels even in long follow-up period of 5 years using 4 different outcome measuring tools. All 3 outcome measuring tools correlated well with pain reduction using VNS.

Thoracic Endoscopic Spine Surgery: A Comprehensive Review

BACKGROUND

From the 1990s, there has been growth in the literature demonstrating the feasibility of minimally invasive approaches for treating diverse spinal disorders. There is still much work to be done in circumnavigating the technical challenges and elucidating relative advantages of endoscopic techniques in spine surgery. In this comprehensive literature review, we discuss the history, advantages, disadvantages, approaches, and technology of, and critically examine peer-reviewed studies specifically addressing, endoscopic thoracic spinal surgery.

METHODS

Literature review was conducted with the key words "endoscopic," "minimally invasive," and "thoracic spinal surgery," using PubMed, Web of Science, and Google Scholar.

RESULTS

Review of 241 thorascopic procedures showed a success rate of 98% to 100%, low morbidity, and favorable complication profile. Review of 115 thoracic fixation procedures demonstrated high success rate, and 87% of screw positions were rated "good." Review of 55 full endoscopic uniportal decompressions showed sufficient decompression in most patients. Match pair analysis of 34 patients comparing video-assisted thoracoscopy surgery (VATS) or posterior spinal fusion reported the VATS group had increased operative duration but reduced blood loss.

CONCLUSIONS

Based on our literature review, there is a high rate of positive outcomes with endoscopic thoracic spine surgery, which reduces tissue dissection, intraoperative blood loss, and epidural fibrosis. However, the technical challenge highlights the importance of further training and innovation in this rapidly evolving field.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

There is growing evidence demonstrating the success of endoscopic thoracic spinal surgery. Populations that could be helped include the elderly and immunocompromised, who would benefit from decreased hospital stay and enhanced recovery time.

Transforaminal Endoscopic Thoracic Discectomy: Technical Review to Prevent Complications

For all the spine surgeons, thoracic disc herniations (TDHs) entrust a real challenge in terms of patient diagnosis, proper selection, surgical technique, and potential adverse events. TDHs are relatively uncommon compared to the lumbar and cervical levels. Literature reports a variable prevalence of TDHs around 6% to 40%, but less than 1% of all disk herniations are symptomatic TDHs, evidencing as a relatively unusual condition. Nowadays, transforaminal endoscopic thoracic discectomy (TETD) has been implemented as an alternative to classic open procedures with results that are as good as and, in some situations, better than those in traditional discectomy. However, the surgeon must be familiar with endoscopic lumbar spine surgery before opting to perform a TETD, considering that the learning curve is much harder. We describe all the steps and safety considerations during TETD based on the anatomic differences compared to lumbar endoscopic procedures. TETD is an effective and safe method that yields more benefits, provides a direct route to the lesion with less morbidity, and is performed in a minimally invasive way. Many severe complications related to the thoracic region could be avoided having the proper knowledge, adequate technique, and safety routes and considerations.