Transthoracic removal of midline thoracic disc protrusions causing spinal cord compression

Stable Regional and Global Alignment in Patients Treated With Minimally Invasive Lateral Retropleural Thoracic Diskectomy Without Fixation

BACKGROUND AND OBJECTIVES

Thoracic disk herniations are challenging to treat, and open transthoracic or minimally invasive thoracoscopic approaches are associated with significant morbidity, substantial costs, and steep learning curves. The minimally invasive lateral retropleural thoracic diskectomy (MIS-LRP-TD) approach is straightforward and is associated with lower perioperative morbidity. With MIS-LRP-TD, the overlying rib, ipsilateral pedicle, ligamentum flavum, posterior longitudinal ligament, and posterior third of the adjacent vertebral bodies are resected. Adjunct fixation is typically not performed, eliminating hardware-related complications and costs. This radiographic study investigates long-term global and thoracic spine alignment after MIS-LRP-TD without fixation.

METHODS

This study was a single-institution, retrospective evaluation of all patients who underwent MIS-LRP-TD without fixation between November 7, 2017 and July 19, 2022. Preoperative and the most recent postoperative radiographs were used to determine the C7 plumb line to central sacral vertical line, thoracic Cobb angle (TCA), segmental Cobb angle, C7 to sagittal vertical axis, thoracic kyphosis, and segmental kyphosis.

RESULTS

In total, 22 patients with 24 disk herniations underwent MIS-LRP-TD without fixation. The mean (SD) radiographic follow-up was 12.9 (11.2) months. Overall, no significant differences were seen in C7 plumb line to central sacral vertical line (P = .65), C7 to sagittal vertical axis (P = .99), thoracic kyphosis (P = .30), TCA (P = .28), segmental kyphosis (P = .27), or segmental Cobb angle (P = .56) at follow-up. One patient demonstrated a >5° change in TCA but remained asymptomatic.

CONCLUSION

Despite requiring extensive resection of the middle column and ipsilateral costovertebral joint at the index level, MIS-LRP-TD without adjunct fixation does not lead to significant global, regional, or segmental deformity. Thus, MIS-LRP-TD appears to be a safe, effective treatment approach for challenging thoracic disk herniations.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Phanor L. Perot Jr.: South Carolina's father of academic neurosurgery

Phanor Leonidas Perot Jr., MD, PhD (1928-2011), was a gifted educator and pioneer of academic neurosurgery in South Carolina. As neurosurgical resident and then as a junior faculty member at the Montreal Neurological Institute, he advanced understandings of both epilepsy and spinal cord injury under Wilder Penfield, William Cone, and Theodore Rasmussen. In 1968, he moved to Charleston to lead neurosurgery. From his time spent with master physicians such as Isidor Ravdin and Wilder Penfield, Perot himself became "the ultimate teacher." His research spanned the fields of epilepsy to torticollis to spinal trauma, focusing the most on the basic pathophysiology of spinal cord damage elucidated through somatosensory evoked potentials. His research was distinguished by generous grant funding. By the time he stepped down as chairman in 1997, the division of neurosurgery had become a department and he had served as president of the American Academy of Neurological Surgery and the Society of Neurological Surgeons. Perot taught prolifically at the bedside, and considered the residency program at the Medical University of South Carolina his greatest achievement. Although Dr. Perot never fully retired, he also enjoyed active hobbies of fly-fishing, traveling, and hunting, until his death on February 2, 2011. He influenced many and earned his role in history as the father of academic neurosurgery in South Carolina.

Use of Cannulated Reamers to Facilitate Thoracic Diskectomy Using a Minimally Invasive Retropleural Thoracotomy Approach-Surgical Technique

BACKGROUND

The surgical treatment of symptomatic thoracic disk herniations is technically challenging. In the past decade, a minimally invasive retropleural thoracotomy approach has become more popular to treat this pathology. However, efficient bone removal to safely perform the diskectomy and spinal cord decompression is difficult with this technique because of the small incision size and long working distance in the thoracic cavity and the proximity of the compressed thoracic cord.

OBJECTIVE

To describe a novel surgical technique for performing a thoracic diskectomy using a minimally invasive lateral approach using cannulated reamers to facilitate bone removal.

METHODS

This technique was used in 7 consecutive patients who presented with thoracic myelopathy from a thoracic disk herniation. First, a standard lateral minimally invasive retropleural approach to the thoracic spine was performed. Partially threaded guide wires were placed in the posterior aspect of the vertebral bodies adjacent to the affected disk space, and sequential cannulated reamers were passed over the guidewires to perform partial corpectomies. The posterior annulus, posterior longitudinal ligament, and herniated disk material were then resected using Penfield dissectors and Kerrison rongeurs to complete the decompression.

RESULTS

All 7 patients who underwent thoracic diskectomy using this approach had stable or improved neurologic function postoperatively. There were no complications related to the use of the cannulated reamer technique.

CONCLUSION

The use of cannulated reamers provides a simple and efficient method for safe bone removal to facilitate minimally invasive thoracic diskectomy using a lateral approach. This is an easily reproducible technique using commonly available equipment.

Minimally Invasive Retropleural Thoracic Diskectomy: Step-by-Step Operative Planning, Execution, and Results

BACKGROUND

Thoracic disk herniation is rare and difficult to treat. The minimally invasive lateral retropleural approach to the thoracic spine enables the surgeon to decompress the neural elements and minimize thecal sac manipulation through direct visualization with less exposure-related morbidity.

OBJECTIVE

To provide a detailed step-by-step overview of the minimally invasive retropleural approach for thoracic diskectomies, including preoperative planning through postoperative care as practiced at our institution.

METHODS

Lateral retropleural thoracic diskectomies performed at a single institution from July 1, 2017, to June 30, 2020, were reviewed. Clinical and outcome data were collected and analyzed. The retropleural approach was divided into several components: relevant anatomy, indications and contraindications, preoperative setup, exposure and approach, diskectomy, and closure and postoperative care.

RESULTS

Twelve patients were treated during the study interval. Their average (SD) age was 44.2 (9.5) years; 10 of 12 were men. Eleven patients presented with thoracic myelopathy. The level treated ranged from T6-7 to T12-L1. Disk herniations were calcified in 10 of 12 patients. These lesions were approached from the left side in 7 of 12 patients. Six patients had complications, none of which were neurological. Chest tubes were placed for pleural violation, pneumothorax, or hemothorax in 3 patients. Two patients experienced postoperative abdominal pseudohernia. Neurological symptoms were stable or improved in all patients. The median (IQR) Nurick scale improved from 3.0 (2.0-3.0) preoperatively to 1.0 (0-3.0) ( P = .026) postoperatively.

CONCLUSION

Lateral retropleural diskectomy enables safe, efficient resection of most thoracic disks while minimizing patient morbidity.

Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance

OBJECTIVE

Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs.

METHODS

A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores.

RESULTS

A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade.

CONCLUSIONS

The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon's arsenal for the confident tackling of all TDHs.

Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation.

METHODS

This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described.

RESULTS

Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation.

CONCLUSION

This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.

Video-assisted thoracoscopic image-guided spine surgery: evolution of 19 years of experience, from endoscopy to fully integrated 3D navigation

OBJECTIVE

The purpose of this study was to describe the evolution of thoracoscopic spine surgery from basic endoscopic procedures using fluoroscopy and anatomical localization through developmental iterations to the current technology use in which endoscopy and image-guided surgery are merged with intraoperative CT scanning.

METHODS

The authors provided detailed explanations of their thoracoscopic spine surgery techniques, beginning with their early-generation endoscopy with fluoroscopic localization, which was followed with point surface matching techniques and early image guidance. The authors supplanted this with the modern era of image guidance, thoracoscopic spine surgery, and seamless integration that has reached its current level of refinement.

RESULTS

A retrospective review of single-institution thoracoscopic procedures performed by the senior author over the course of 19 years yielded a total of 160 patients, including 73 women and 87 men. The mean patient age was 55 years, and the range included patients 16-94 years of age. There were no patients with worsened neurological function. One hundred sixteen patients underwent surgery for thoracic disc herniation, 18 for underlying neoplasms with spinal cord compression, 14 for osteomyelitis and discitis, 12 for thoracic deformity with neurological changes, and 8 for traumatic etiologies.

CONCLUSIONS

More than 19 years of experience has revealed the benefits of integrating thoracoscopic spine surgery with intraoperative CT scanning and image-guided surgery, including direct decompression without manipulation of neural elements, superior 3D spatial orientation, and localization of complex spinal anatomy. With the exponential growth of machine learning, robotics, artificial intelligence, and advances in imaging techniques and endoscopic imaging, there may be further refinements of this technique on the horizon.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

PURPOSE

The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches.

METHODS

Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12-79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions.

RESULTS

Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X² 4.13 P:0.042). Severe post-operative neuralgia (VAS 7-10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X² 7.07 p 0.0078).

CONCLUSIONS

MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

A Novel, Minimally Invasive Hybrid Technique to Approach Intracanal Herniated Thoracic Discs

BACKGROUND

Multiple options exist for thoracic disc herniation (TDH). However, when a specific technique is chosen, the goal is to avoid the manipulation of the spinal cord, which is already compressed.

OBJECTIVE

To describe a hybrid endoscopic technique for intracanal TDH by combining an oblique paraspinal approach (OPA) and transforaminal full-endoscopic discectomy.

METHODS

We describe the step-by-step operative technique and present the clinical and radiological outcomes of a case series of hybrid endoscopic thoracic discectomy.

RESULTS

A total of 3 patients were treated. We observed the usefulness of an OPA to enlarge the intervertebral foramen through the rigid tubular retractor and the feasibility of a full-endoscopic transforaminal approach to reach intracanal TDHs.

CONCLUSION

Early experience with the hybrid endoscopic technique for TDHs demonstrated acceptable clinical and radiological outcomes in the 3 patients treated; however, a larger sample size and a methodologically advantageous study to compare this procedure with conventional options are necessary to probe the full benefits of the hybrid technique.

Percutaneous endoscopic decompression for calcified thoracic disc herniation using a novel T rigid bendable burr

BACKGROUND

The basic endoscopic instruments are not suitable for removing calcified or hard discs in patients with thoracic disc herniations (TDH). We describe a percutaneous endoscopic technique for the treatment of calcified TDH using an endoscopic drill system with a T rigid bendable burr.

METHODS

Eleven patients (8 males, mean age 42.1 years) with single-segmental calcified TDH were treated with percutaneous endoscopic surgeries.

RESULTS

Our technique using this endoscopic drill system with a T rigid bendable burr is safe and effective for the treatment of calcified TDH.

CONCLUSIONS

Percutaneous endoscopic decompression using the T rigid bendable burr is a safe and reproducible surgical procedure for the treatment of calcified TDH.

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

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

Non-neurological outcomes of anterior and posterolateral approaches in the surgical treatment of thoracic disc disease: a retrospective study

Background

Symptomatic thoracic disc herniation (TDH) is rare, and for those patients that fail conservative treatment, two main categories of surgical approaches exist-anterior and posterolateral. In many cases either approach would be considered equally appropriate. Recommendations in support of either anterior or posterolateral approaches are currently based on case series and expert opinion. Here, we utilize National Surgical Quality Improvement Program (NSQIP) database to determine and compare the rates of complication associated with anterior or posterolateral approaches in the treatment of TDH.

Methods

An analysis of NSQIP data from 2005 to 2014 was conducted. Patients were included based on a combination of a postoperative diagnosis of TDH. Patients were then grouped according to anterior or posterior approaches on the basis of Current Procedural Terminology (CPT) codes. Propensity score matching was performed to account for baseline demographics [sex, race, age, obesity, diabetes, smoking, history of chronic obstructive pulmonary disease (COPD), history of CHF, and American Society of Anesthesiologists (ASA) class]. The 30-day outcome measures of these patients were analyzed.

Results

A total of 432 patients were identified, 80.3% underwent posterolateral and 19.7% anterior interventions. There were no significant differences in 30-day outcome measures between the anterior or posterior intervention groups. Within the matched group of 170 patients, the anterior group had significantly longer lengths of stay (5.49±3.96 vs. 4.01±4.81, P<0.0001), but there were no observed significant differences in the rate of occurrences of UTIs, pneumonias, sepsis, bleeding, intubation, or death.

Conclusions

Posterolateral and anterior approaches carry an equal non-neurological perioperative complication profile. Posterolateral approaches may carry shorter hospital stays compared to anterior interventions.

Mini-open Lateral Retropleural Approach for Symptomatic Thoracic Disk Herniations

BACKGROUND

Surgeries for symptomatic thoracic disk herniations (TDH) remain challenging.

OBJECTIVE

A mini-open lateral retropleural approach is described and the clinical outcomes are reported.

MATERIALS AND METHODS

A total of 23 patients underwent mini-open lateral retropleural diskectomy. Patients were placed in a lateral position. A 5-cm lateral incision was made followed by resection of the rib after careful dissection of its undersurface from the endothoracic fascia. The fascia was incised and separated from parietal pleura to widen the retropleural space. The rib head was removed followed by a pedicle resection below the TDH to expose the dura. A posterior partial corpectomy above and below the disk was performed to create a space ventral to the TDH, which was later dissected away from the dura and removed.

RESULTS

Fourteen males and 9 females comprised the clinical cohort. Five presented with axial back pain, 7 with radicular pain and 11 with myelopathy. All but 2 disks were successfully removed. The mean blood loss was 214cc and the mean hospital stay was 5.3 days. There was no mortality or new neurological deficits. The mean follow-up was 15.4 months.

CONCLUSIONS

Mini-open lateral retropleural approach is safe and effective to remove symptomatic TDH with minimal morbidities and fast patient recovery.

Surgical Approaches for the Treatment of Thoracic Disk Herniation: Results of a Decision Analysis

STUDY DESIGN

A decision analysis.

OBJECTIVE

To perform a decision analysis utilizing postoperative complication data, in conjunction with health-related quality of life (HRQoL) utility scores, to rank order the average health utility associated with various surgical approaches used to treat symptomatic thoracic disk herniation (TDH).

SUMMARY OF BACKGROUND DATA

Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been developed for its treatment, which may be classified into 4 major categories: open anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benefit profiles, but there is still no set algorithm for choosing an approach in cases with multiple surgical options.

METHODS

We searched Medline, EMBASE, and the Cochrane Library for relevant articles on surgical approaches for TDHs published between 1990 and August 2014. Pooled complication data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to determine which surgical approach resulted in the highest average HRQoL.

RESULTS

Posterior surgical approaches resulted in the highest average HRQoL, followed by thoracoscopic, lateral, and finally open anterolateral transthoracic procedures. The higher average HRQoL associated with posterior approaches over all others was highly significant (P<0.001); conversely, the open anterolateral approach resulted in a lower average postoperative utility compared with all other approaches (P<0.001).

CONCLUSIONS

The results of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs, which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical trials, are necessary to ascertain whether novel surgical strategies have risk/benefit profiles that ultimately supersede those of traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.

Transpedicular Approach to Thoracic Disc Herniaton Guided by 3D Navigation System

BACKGROUND

The choice of surgical approach for thoracic disc herniation should consider the location on the axial plane and the consistency of the herniated disc. Calcified midline disc herniations are difficult to remove with a transpedicular approach because of limitations due to blind spots; so they are usually treated via a transthoracic approach, although this entails a high risk of thoracopulmonary injuries.

METHODS

In this work we present two cases of calcified midline thoracic disc herniations treated with a transpedicular approach, improved by using a three-dimensional (3D) neuronavigation system to verify the extent of removal on the blind side.

RESULTS

Postoperative computed tomography (CT) scans demonstrated that this original technical innovation, in the two present cases, allowed us to reach the side opposite the disc herniation and to assess the extent of resection at the end of the procedure.

CONCLUSIONS

The employment of a neuronavigation system in the transpedicular approach allowed safe and effective removal of calcified midline thoracic disc herniations. We did not observe any postoperative neurological worsening, onset of spinal instability, or other adverse events.

Treatment of symptomatic thoracic disc herniations with lateral interbody fusion

BACKGROUND

Symptomatic thoracic herniated discs have historically been treated using open exposures (i.e., thoracotomy), posing a clinical challenge given the approach related morbidity. Lateral interbody fusion (LIF) is one modern minimally disruptive alternative to thoracotomy. The direct lateral technique for lumbar pathologies has seen a sharp increase in procedural numbers; however application of this technique in thoracic pathologies has not been widely reported.

METHODS

This study presents the results of three cases where LIF was used to treat symptomatic thoracic disc herniations. Indications for surgery included thoracic myelopathy, radiculopathy and discogenic pain. Patients were treated with LIF, without supplemental internal fixation, and followed for 24 months postoperatively.

RESULTS

Average length of hospital stay was 5 days. One patient experienced mild persistent neuropathic thoracic pain, which was managed medically. At 3 months postoperative all patients had returned to work and by 12 months all patients were fused. From preoperative to 24-month follow-up there were mean improvements of 83.3% in visual analogue scale (VAS), 75.3% in Oswestry Disability Index (ODI), and 79.2% and 17.4% in SF-36 physical (PCS) and mental component scores (MCS), respectively.

CONCLUSIONS

LIF is a viable minimally invasive alternative to conventional approaches in treating symptomatic thoracic pathology without an access surgeon, rib resection, or lung deflation.

Management of Giant Calcified Thoracic Disks and Description of the Trench Vertebrectomy Technique

STUDY DESIGN

Case series and review of the literature.

OBJECTIVE

To review the management of giant calcified disks in our large cohort and compare with the existing literature. We discuss our surgical technique.

METHODS

Twenty-nine cases of herniated thoracic disk between 2000 and 2013 were reviewed. Eighteen patients were identified as having giant calcified thoracic disks, defined as diffusely calcified disks occupying at least 40% of the spinal canal. Demographic data was collected in addition to presentation, imaging findings, operative details, and outcomes using the modified Japanese Orthopaedic Association (mJOA) scale.

RESULTS

Giant calcified thoracic disks (GCTDs) are unique clinical entities that require special neurosurgical consideration owing to significant (≥40%) involvement of the spinal canal and compression of the spinal cord, often leading to myelopathy. The median age at diagnosis was 51.2 years (range 37 to 70) with the mean duration of presenting symptoms being 9.9 months (range 2 weeks to 3 years). Seventeen (94.4%) patients presented with at least one sign of myelopathy (hyperreflexia, hypertonia, bladder or bowel dysfunction) with the remaining 1 (5.6%) patient presenting with symptoms in keeping with radiculopathy. Thoracotomy was performed on 17 (94.4%) patients, and 1 (5.6%) patient had a costotransverse approach. Mean follow-up was 19.8 months (range 7 months to 2 years). mJOA score improved in 15 (83.3%) patients. mJOA scores in the other patients remained stable.

CONCLUSIONS

GCTDs are difficult neurosurgical challenges owing to their size, degree of spinal cord compression, and consistency. We recommend a trench vertebrectomy via a thoracotomy in their surgical management. This procedure safely allows the identification of normal dura on either side of the compressed segment prior to performing a diskectomy. Excellent fusion rates were achieved with insertion of rib head autograft in the trench.

Indications and Techniques for Spinal Instrumentation in Thoracic Disk Surgery

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To identify the indications, techniques, and outcomes for instrumented fusion during thoracic discectomy.

SUMMARY OF BACKGROUND DATA

Thoracic discectomy may require extensive bone removal to avoid spinal cord manipulation, but the indications and techniques for instrumented fusion during thoracic discectomy remain poorly delineated.

METHODS

The authors identified 220 consecutive patients who underwent thoracic discectomy between 1992 and 2012. Clinical and radiographic variables were compared between patients who underwent instrumented fusion and patients without instrumentation, and among surgical approaches utilized for discectomy.

RESULTS

Patient age for the entire cohort averaged 49±13.01 years, and mean clinical follow-up was 45 months (range, 1-218 mo). Patients underwent 226 thoracic discectomy procedures, including 48 thoracotomy, 136 thoracoscopy, and 42 posterolateral approaches. Seventy-eight patients required instrumented fusion and, compared with patients without instrumentation, were more likely to present with myelopathy (P<0.0001) and harbor giant (P=0.0012), calcified (P=0.019), or transdural (P=0.0004) herniated disks. Surgery with instrumentation resulted in greater blood loss (P<0.0001), longer hospital stay (P<0.0001), and a higher complication rate (22% vs. 9.9%), yet patients in both cohorts had similar rates of symptom resolution postoperatively. Of the patients who underwent thoracic discectomy without instrumentation, 3 (2.1%) developed delayed deformity or instability and required subsequent surgery for fixation and fusion at an average 6.3 months postoperatively (range, 4-8 mo). Patients who underwent instrumented fusion exhibited no nonunions or delayed deformity.

CONCLUSIONS

Thoracic discectomy without fixation is a reasonable clinical option in carefully selected patients, but instrumented fusion is safe and effective in other patients. Indications for fixation and fusion are thus proposed.

Thoracic disc disorders with myelopathy: treatment trends, patient characteristics, and complications

STUDY DESIGN

Retrospective review.

OBJECTIVE

To analyze trends in the use of 3 surgical treatments (anterior/anterolateral decompression and spinal fusion [ASF], posterior/posterolateral decompression and spinal fusion [PSF], and disc decompression/excision without fusion [DDE]) for patients with thoracic disc disorders with myelopathy (TDM), and how the treatments differ in terms of patient and hospital characteristics, complications, mortality, and resource utilization.

SUMMARY OF BACKGROUND DATA

Various approaches have been described in the literature, but the preferred method is not well established.

METHODS

Using the Nationwide Inpatient Sample database, we identified 13,837 patients with TDM who underwent spine surgery from 2000 through 2010. Analyses were performed using linear regression for trends, χ test for categorical variables, and analysis of variance test for discrete variables (significance, P < 0.05).

RESULTS

Over the study period, the preferred treatment of TDM shifted substantially from DDE being performed in two-thirds of the patients in 2000 to PSF being performed in almost half of all patients by 2010. Patients undergoing ASF were significantly younger and had significantly higher rates of private insurance than those in the other groups. DDE was performed significantly more frequently at nonteaching hospitals. Patients undergoing ASF had the highest complication rate (24.2%), especially pulmonary and cardiac complications. They also had a 2.8-fold and 2.0-fold mortality compared with DDE and PSF, respectively. Patients undergoing DDE had significantly shorter length of stay and lower total hospitalization charges than the other groups.

CONCLUSION

Over the last decade, there has been a significant increase in PSF use in the surgical treatment of TDM. Postoperative complication and mortality rates were highest with ASF; DDE approach was associated with significantly fewer complications, shorter length of stay, and lower hospitalization charges than other groups.

LEVEL OF EVIDENCE

4.

Transforaminal approach in thoracal disc pathologies: transforaminal microdiscectomy technique

Objective. Many surgical approaches have been defined and implemented in the last few decades for thoracic disc herniations. The endoscopic foraminal approach in foraminal, lateral, and far lateral disc hernias is a contemporary minimal invasive approach. This study was performed to show that the approach is possible using the microscope without an endoscope, and even the intervention on the discs within the spinal canal is possible by having access through the foramen. Methods. Forty-two cases with disc hernias in the medial of the pedicle were included in this study; surgeries were performed with transforaminal approach and microsurgically. Extraforaminal disc hernias were not included in the study. Access was made through the Kambin triangle, foramen was enlarged, and spinal canal was entered. Results. The procedure took 65 minutes in the average, and the mean bleeding amount was about 100cc. They were mobilized within the same day postoperatively. No complications were seen. Follow-up periods range between 5 and 84 months, and the mean follow-up period is 30.2 months. Conclusion. Transforaminal microdiscectomy is a method that can be performed in any clinic with standard spinal surgery equipment. It does not require additional equipment or high costs.

Surgical treatment for thoracic disc herniation: an update

STUDY DESIGN

Retrospective review of the literature.

OBJECTIVE

To update recent trends in the surgical treatment for thoracic disc herniation (TDH).

SUMMARY OF BACKGROUND DATA

TDH is rare; however, it is usually accompanied by myelopathy and is indicated for surgical treatment. A variety of surgical approaches have been described to reach these anatomically challenging lesions.

METHODS

Review of the literature.

RESULTS

Recently, minimally invasive techniques for TDH have gained popularity. These include thoracoscopic and mini-open anterolateral retropleural approaches, as well as microscopic and endoscopic surgery. In addition, this article updates important aspects of surgical treatment for TDH such as definition of surgical level, treatment of calcified and/or giant disc, multilevel lesions, and fusion requirements.

CONCLUSION

Definition of surgical level is imperative in the surgical treatment for TDH. Outcomes of minimum invasive surgery are satisfactory. Type of disc herniation and biomechanical stability are the important factors for surgical planning.

Lateral extracavitary, costotransversectomy, and transthoracic thoracotomy approaches to the thoracic spine: review of techniques and complications

STUDY DESIGN

Systematic review.

OBJECTIVE

The authors review complications, as reported in the literature, associated with ventral and posterolateral approaches to the thoracic spine.

SUMMARY OF BACKGROUND

The lateral extracavitary, costotransversectomy, and transthoracic thoracotomy techniques allow surgeons to access the ventral thoracic spine for a wide range of spinal disorders including tumor, degeneration, trauma, and infection. Although the transthoracic thoracotomy has been used traditionally to reach the ventral thoracic spine when access to the vertebral body is required, modifications to the various dorsal approaches have enabled surgeons to achieve goals of decompression, reconstruction, and stabilization through a single approach.

METHODS

A systematic Medline search from 1991 to 2011 was performed to identify series reporting clinical data related to these surgical approaches. The morbidity associated with each approach is reviewed and strategies for complications avoidance are discussed.

RESULTS

Four thousand six hundred seventy-seven articles that assessed outcomes of the approaches to the thoracic spine were identified; of these 31 studies that consisted of 774 patients were selected for inclusion. A mean complication rate of 39%, 17%, and 15% for thoracotomy, lateral extracavitary, and costotransversectomy, respectively, was determined. The thoracotomy approach had the highest reoperation (3.5%) and mortality rates (1.5%). The specific complications and neurological outcomes were categorized.

CONCLUSIONS

Outcomes of the surgical approaches to the thoracic spine have been reported with great detail in the literature. There are limited studies comparing the respective advantages and disadvantages and the differences in technique and outcome between these approaches. The present review suggests that in contrast to the historical experience of the laminectomy for thoracic spine disorders, these alternative approaches are safe and rarely associated with neurological deterioration. The differences between these approaches are based on their complication profiles. A thorough understanding of the regional anatomy will help avoid approach-related complications.

Surgical management and clinical outcomes of multiple-level symptomatic herniated thoracic discs

Object

Symptomatic herniated thoracic discs (HTDs) are rare, and patients infrequently require treatment of 2 or more disc levels. The authors assess the surgical management and outcomes of patients with multiple-level symptomatic HTDs.

Methods

A retrospective review of a prospectively maintained database was performed of 220 consecutive patients treated surgically for symptomatic HTDs. Clinical and surgical results were compared between patients with single-level disease and patients with multiple-level disease and also among the different approaches used for surgical decompression.

Results

Between 1992 and 2012, 56 patients (mean age 48 years; 26 male, 30 female) underwent 62 procedures for 130 HTDs. Forty-six patients (82%) had myelopathy, and 36 (64%) had thoracic radiculopathy; 24 patients had both conditions in varying degree. Symptom duration averaged 28 months. The surgical approach was dictated by disc size, consistency, and location. Twenty-three thoracotomy, 26 thoracoscopy, and 13 posterolateral procedures were performed. Five patients required a combination of approaches. Patients underwent 2-level (n = 44), 3-level (n = 7), 4-level (n = 4), or 5-level (n = 1) discectomies. Instrumented fusion was performed in 36 patients (64%). Thirteen patients harbored 19 additional discs, which were deemed asymptomatic/nonoperative.

The mean hospital stay was 6.5 days. Complete disc resection was verified with postoperative imaging in every patient. The procedural complication rate was 23%, and the nature of complications differed based on approach. No patients had surgery-related spinal cord injury or new myelopathy.

At a mean follow-up of 48 months, myelopathy and radiculopathy had resolved or improved at a rate of 85% and 92%, respectively. Using a general linear model, preoperative symptom duration (p = 0.037) and perioperative hospital length of stay (p = 0.004) emerged as negative predictors of myelopathy improvement. Most patients (96%) were satisfied with the surgical results.

Compared with 164 patients who underwent single-level HTD decompression, patients requiring surgery for multiple-level HTDs were more often myelopathic (p = 0.012). Surgery for multiple-level HTDs was more likely to require a thoracotomy approach (p = 0.00055) and instrumented fusion (p < 0.0001) and resulted in greater blood loss (p = 0.0036) and higher complication rates (p = 0.0069). The rates of resolution for myelopathy (p = 0.24) and radiculopathy (p = 1.0), however, were similar between the 2 patient groups.

Conclusions

The management of multiple-level symptomatic HTDs is complex, requiring individualized clinical decision making. The surgical approaches must be selected to minimize manipulation of the compressed thoracic spinal cord, and a patient may require a combination of approaches. Excellent surgical results can be achieved in this unique and challenging patient population.

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69 %), 31 had radiculopathy (94 %), and 31 had axial pain (94 %). Among patients with myelopathy, 14 (42.4 %) had bladder and/or bowel dysfunction. In the last eight cases (24 %), the approach was retropleural instead of transpleural. Patients were followed up for 18.2 months on average. The mean length of hospital stay was 5 days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91 %) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1 %), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.

Mini-open retropleural transthoracic approach for the treatment of giant thoracic disc herniation

STUDY DESIGN

We report on all patients treated for giant thoracic disc herniation in the past 10 years.

OBJECTIVE

To specifically discuss our management of thoracic discs that occupy more than 40% of the canal and are thus defined as "giant" and to compare our surgical approach and technique with the previously published case series.

SUMMARY OF BACKGROUND DATA

Giant herniated thoracic discs (HTDs) are recognized as a particular subset of thoracic disc pathology that require unique surgical consideration given their large volume, their often calcified nature, and the fact that the vast majority of patients have an already compromised spinal cord. It has been recommended that for successful resection of these discs an open thoracotomy, followed by a 2-level corpectomy and instrumentation, be performed. In the past decade, our institution has managed giant HTDs differently, using a mini-open retropleural thoracotomy, without the need for vertebrectomy or instrumentation in any case.

METHODS

Seventeen cases of surgically treated giant HTDs were included in this study. Frankel grading system, 36-Item Short Form Health Survey, and Oswestry Disability Index assessed functional outcomes. RESULTS.: Seventeen patients underwent resection of a giant HTD between 2001 and 2010. The median postoperative length of stay was 5.5 days. All patients were myelopathic on presentation, Frankel scores ranged from B to D preoperatively. On long-term follow-up, 13 patients had improvement of their neurological status by 1 or 2 grades, 3 patients had no change in grade, and 1 patient died 38 days postoperation from pneumonia. No patient had neurological deterioration on long-term follow-up.

CONCLUSION

Anterior exposure of the thoracic spine using a mini-open thoracotomy and retropleural approach coupled with a limited bony resection surrounding the giant disc, without corpectomy or instrumentation, represents an effective, safe, and appropriate surgical treatment for the resection of giant thoracic discs.

Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations

STUDY DESIGN

A retrospective review of a case series.

OBJECTIVES

Giant thoracic disc herniations remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less-invasive approaches. With the current study, we describe a surgical technique to treat giant thoracic disc herniations while minimizing approach-related morbidity.

METHODS

Demographic and radiographic data; clinical outcome and perioperative complications were retrospectively analysed for patients with single-level giant thoracic disc herniations who underwent mini-thoracotomy and selective microsurgical anterior spinal cord decompression without instrumented fusion.

RESULTS

Between 2007 and 2012, 7 consecutive patients with giant thoracic disc herniations were treated (average age of 53 years; range 45-66 years). The average canal encroachment was 73.2 % (range 40-92 %) with 5 grossly calcified discs of which 3 had transdural components. All patients had gradual myelopathic progression. The average Nurick grade was 3.5 (range 2-5). All patients were successfully treated with anterior microsurgical decompression without instrumentation. Uninstrumented fusion with rib graft was performed only in one patient with advanced degenerative changes. Average time of surgery was 337.8 min (range 220-450 min). The average length of hospital stay was 7.4 days (range 6-11 days). The average neurological status at follow-up (average 23.5 months; range 9-36 months) using the modified Nurick grading scale was 1.28. No vertebral collapse or loss of spinal alignment developed. There were no neurological complications. One patient developed an acute headache and diplopia, 10 days after surgery, following sneezing associated with a post-operative thoracic cerebrospinal fluid leakage requiring revision. Two patients suffered an approach-related complication in form of intercostal neuralgia; one was persistent.

CONCLUSIONS

Anterior decompression using a mini-transthoracic approach provides sufficient exposure for microsurgical decompression of giant thoracic disc herniations without disrupting the stability of the spine. Microsurgical decompression without instrumentation does not appear to lead to vertebral collapse or spinal malalignment.

Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience

OBJECT

Symptomatic herniated thoracic discs remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less invasive approaches. Many of these techniques, such as thoracoscopy, have not been widely adopted due to technical difficulties. The current study was performed to examine the safety and early results of a minimally invasive lateral approach for symptomatic thoracic herniated intervertebral discs.

METHODS

Sixty patients from 5 institutions were treated using a mini-open lateral approach for 75 symptomatic thoracic herniated discs with or without calcification. The mean age was 57.9 years (range 23-80 years), and 53.3% of the patients were male. Treatment levels ranged from T4-5 to T11-12, with 1-3 levels being treated (mean 1.3 levels). The most common levels treated were T11-12 (14 cases [18.7%]), T7-8 (12 cases [16%]), and T8-9 (12 cases [16%]). Symptoms included myelopathy in 70% of cases, radiculopathy in 51.7%, axial back pain in 76.7%, and bladder and/or bowel dysfunction in 26.7%. Instrumentation included an interbody spacer in all but 6 cases (10%). Supplemental internal fixation included anterolateral plating in 33.3% of cases and pedicle screws in 10%; there was no supplemental internal fixation in 56.7% of cases. Follow-up ranged from 0.5 to 24 months (mean 11.0 months).

RESULTS

The median operating time, estimated blood loss, and length of stay were 182 minutes, 290 ml, and 5.0 days, respectively. Four major complications occurred (6.7%): pneumonia in 1 patient (1.7%); extrapleural free air in 1 patient (1.7%), treated with chest tube placement; new lower-extremity weakness in 1 patient (1.7%); and wound infection in posterior instrumentation in 1 patient (1.7%). Reoperations occurred in 3 cases (5%): one for posterior reexploration, one for infection in posterior instrumentation, and one for removal of symptomatic residual disc material. Back pain, measured using the visual analog scale, improved 60% from the preoperative score to the last follow-up, that is, from 7.8 to 3.1. Excellent or good overall outcomes were achieved in 80% of the patients, a fair or unchanged outcome resulted in 15%, and a poor outcome occurred in 5%. Moreover, myelopathy, radiculopathy, axial back pain, and bladder and/or bowel dysfunction improved in 83.3%, 87.0%, 91.1%, and 87.5% of cases, respectively.

CONCLUSIONS

The authors' early experience with a large multicenter series suggested that the minimally invasive lateral approach is a safe, reproducible, and efficacious procedure for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional surgical techniques and without the use of endoscopes. Symptom resolution was achieved at similar rates using this approach as compared with the most efficacious techniques in the literature, and with fewer complications in most circumstances.

History and current state of neurosurgery at the Medical University of South Carolina

We review the development of neurosurgery at the Medical University of South Carolina (MUSC) and the emergence of MUSC as a leading academic neurosurgical center in South Carolina. Historical records from the Waring Historical Library were studied, former and current faculty members were interviewed, and the personal records of Dr Phanor J Perot were examined. Dr Frederick E Kredel was the first to perform cerebral revascularization in stroke patients using omental flaps and the first to culture glioma cells in artificial media. The MUSC Neurosurgery residency program was established in 1964 by its first formally trained neurosurgeon, Julian Youmans, MD. The first graduate of the program, Dr Russell Travis, went on to become the President of the American Association of Neurological Surgeons. In 1968, the longest serving chairman, Dr Perot, joined the department and conducted significant research in spinal cord injury, receiving a continuous, 20-year award from the National Institute of Neurological Disorders and Stroke. A major change in the neurosurgery program occurred in 2004 when Dr Sunil Patel accepted the chairmanship. He integrated neurosurgery, neurology, and basic neuroscience departments into a comprehensive Department of Neurosciences to provide integrated clinical care. This department now ranks second in the country in National Institutes of Health research funding. Recently, the Center for Global Health and Global Neurosurgery was established with a vision of caring for patients beyond national borders. Neurosurgery at MUSC has been influenced by Drs Kredel and Perot and the current leadership is moving forward with a uniquely integrated department with novel areas such as global neurosurgery.

Minimally invasive extracavitary approach for thoracic discectomy and interbody fusion: 1-year clinical and radiographic outcomes in 13 patients compared with a cohort of traditional anterior transthoracic approaches

Object

Open transthoracic approaches, considered the standard in treating thoracic disc herniation (TDH), are associated with significant comorbidities. The authors describe a minimally invasive lateral extracavitary tubular approach for discectomy and fusion (MIECTDF) to treat TDH.

Methods

In 13 patients (5 men, 8 women; mean age 51.8 years) with myelopathy and 15 noncalcified TDHs, the authors achieved a far-lateral trajectory by dilating percutaneously to a 20-mm working portal docked at the transverse process–facet junction, which then provided a corridor for a near-total discectomy, bilateral laminotomies, and interbody arthrodesis requiring minimal cord retraction. A cohort of 11 demographically comparable patients treated via transthoracic approaches was used as control.

Results

Preoperative Frankel grades were B in 1 patient, C in 4, D in 5, and E in 3, whereas at mean of 10 months, 11 had Grade E function and 2 had Grade D function. Mean surgical metrics were operating room time 93.75 minutes, blood loss 33 ml, and hospital stay 3.1 days. Complications included 4 transient paresthesias, 1 CSF leak, 1 abdominal wall weakness, and 3 nonwound infections. One-year follow-up MR imaging revealed full decompression in all cases and no cage migration. Mean visual analog scales scores preoperative, at 6 weeks, 3 months, and 1 year were 5.6, 4.5, 3.2, and 1.2, respectively. No differences existed in preoperative clinical and radiographic profile of the study and control groups. Compared with controls, the MIECTDF group achieved superior scores in all metrics (p < 0.01) except for equivalent 1-year neurological outcomes.

Conclusions

Compared with transthoracic procedures, MIECTDF effectively decompressed the spinal canal, yielding identical 1-year radiographic and clinical outcomes to those seen in controls, while producing superior clinical scores in the interim. Thus, MIECTDF is the authors' treatment of choice for TDH.

Standard fenestration approach to thoracic disc herniation

The objective was to present the safety and efficacy of discectomy in thoracic disc herniation through posterior fenestration. This approach was used to remove six thoracic disc herniations (between T8-H12) in five patients. The follow-up period ranged from 6 months to 3 years. Three patients with spastic paraparesis demonstrated dramatic improvement. Paraparesis improved significantly in one patient, but has recurred 8 months later. Four patients experiencing axial pain reported excellent improvement after operation. This technique appears to be safe, effective and less destructive to the vertebrae. It could be applied easily without instrumentation for stabilization.

Transvertebral herniotomy for T2/3 disc herniation--a case report

STUDY DESIGN

A case report of a 51-year-old man with acute myelopathy owing to T2/3 disc herniation that was treated with transvertebral herniotomy.

OBJECTIVES

To report surgical advantages of the transvertebral approach in the upper thoracic spine.

SUMMARY OF BACKGROUND DATA

Various surgical approaches to the upper thoracic spine have been reported because the approach is difficult owing to the specific anatomical structure. However, a lack of consensus still remains regarding the choice of operative procedure because of some problems for each approach.

METHODS

A 51-year-old man presented acute paraparesis of lower extremities and bladder paralysis owing to T2/3 disc herniation. The herniated disc was removed microscopically by the anterior approach through a 10-mm-diameter hole made in the T2 vertebral body without sternum splitting.

RESULTS

Satisfactory decompression was performed. After operation, the patient had full clinical motor and sensory recovery.

CONCLUSIONS

Transvertebral approach, which has been recently performed for cervical disc lesion, was also less invasive and safer than the conventional approaches, such as sternum splitting, transthoracic or posterolateral approaches, for our patient with T2/3 disc herniation.

Anterior approach to thoracic and lumbar spine lesions: results in 145 consecutive cases

Object

The authors report on a series of 145 consecutive patients with different types of spine lesions surgically treated via an anterior approach (AA) at the thoracic and lumbar levels during the past 10 years. Indications, techniques, and surgical results are described.

Methods

This series included 92 patients with fractures, 30 with neoplasms, 13 with thoracic disc hernias, and 10 with spinal infections. Based on the lesion to be addressed, the AA was used for lesion excision, corpectomy, vertebral body reconstruction with cages, realignment, and/or plating or screwing. The approach was extracavitary in 55 patients and intracavitary in 90. In 126 patients (86.8%), neural decompression and spine stabilization were achieved via a stand-alone AA (SA-AA), whereas 19 patients (13.1%) were treated using a 2-stage anteroposterior approach. This circumferential approach was reserved for select cases of severe traumatic dislocation, particular types of tumors, or specific anatomical locations. The authors developed a simple neuronavigation-based method of identifying the severely injured patients who were eligible for the SA-AA by evaluating the angle of lateral dislocation.

Results

There were no deaths and no instances of major surgery-related morbidity. Minor morbidity was almost always transitory and was reported in 13 patients (8.9%). Neurological improvement was reported in 20% of injured patients with a preoperative incomplete lesion. Postoperatively, all patients were able to stand or at least sit without load pain. During the follow-up (mean ± standard deviation 3.8 ± 2.4 years), there were no cases of failure, fracture, dislocation, or bending of the anterior instrumentation, and the rate of pseudarthrosis was 0%.

Conclusion

The anterior route provides direct access to most spine diseases and allows optimal neural decompression and the possibility of adequate realignment and strong reconstruction/fixation. Stability of the vertebral column is achieved, resolution of clinical pain is rapid and almost complete, and the rate of surgical complications is very low. The authors assert that the SA-AA offers so many advantages and has such good results that the 2-stage anteroposterior approach can be reserved for a minority of select cases and that the time for using the posterior approach alone is over.

Techniques for the operative management of thoracic disc herniation: minimally invasive thoracic microdiscectomy

Thoracic disc herniations are uncommon lesions that are asymptomatic in most patients; however, for individuals who present with persistent radiculopathy that is nonresponsive to conservative treatment or with myelopathic symptoms with or without radiculopathy attributed to a thoracic disc herniation, operative intervention of the thoracic spine is sought. Various procedures and approaches for the treatment of thoracic disc herniations have been reported, but they have been associated with numerous intraoperative complications and postoperative morbidities. This article discusses a novel minimally invasive procedure for the surgical treatment of thoracic disc herniations referred to as a minimally invasive thoracic microdiscectomy. It uses a series of muscle dilators, a tubular retractor, and microscopic visualization by way of a posterolateral approach in an effort to minimize many of the complications that are associated with the more traditional approaches.

Endoscopic thoracic microdiscectomy

Object. The purpose of this clinical study was to evaluate prospectively surgical and neurological outcomes after endoscopic thoracic disc surgery.

Methods. The authors assessed the following quantifiable outcome data in 46 patients: operative time, blood loss, duration of chest tube insertion, narcotic use, hospital length of stay (LOS), and long-term follow-up neurological function and pain-related symptoms.

In patients who presented with myelopathy there was a postoperative improvement of two Frankel grades. Pain related to radiculopathy was improved by 75% and in one patient it worsened postoperatively. The authors also present operative data, surgical outcomes, and complications.

Conclusions. Thoracoscopic discectomy can be used to achieve acceptable results. It has several distinct advantages such as reduced postoperative pain, morbidity, and LOS compared with traditional open procedures.

Surgical management of giant herniated thoracic discs: analysis of 20 cases

Object. The authors evaluated the clinical and surgical outcomes obtained in patients with giant herniated thoracic discs (HTDs), defined as occupying more than 40% of the spinal canal. Surgery-related considerations and functional outcomes in patients with small- and medium-sized HTDs were compared.

Methods. The authors reviewed 140 cases of surgically treated HTDs, 20 (14%) of which were giant. Before and after surgery, all patients underwent computerized tomography myelography, magnetic resonance imaging, or both. Functional outcomes were assessed using the Frankel grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The results observed in patients with giant HTDs were compared with those with small- and medium-sized HTDs. The mean overall follow-up period was 2.6 years.

Sixty-six patients (47%) presented with myelopathy, including 19 (95%) with a giant HTD. Of the latter, 16 (80%) underwent anterior, eight thoracoscopic, and eight open thoracotomy approaches. Four patients (20%) with laterally oriented giant HTDs within the spinal canal underwent surgery via a posterolateral approach.

Based on analysis of long-term follow-up data, 53% of patients with giant HTDs improved neurologically by one Frankel grade. Progression of myelopathy was arrested in 42%, and in 5% the Frankel grade worsened by one. In patients with small- and medium-sized HTDs, the Frankel grade improved by one in 77%, stabilized in 23%, and worsened in 0%. Patients with giant HTDs who underwent thoracoscopic surgery had worse short- and long-term functional outcomes than those in whom open thoracotomy was performed.

Conclusions. Patients with giant HTDs presented more frequently with myelopathy and experienced worse functional outcomes than those with smaller HTDs. Based on their experience, the authors recommend open thoracotomy rather than thoracoscopy for the treatment of midline giant HTDs.

Transthoracic discectomy without interbody fusion

BACKGROUND

Transthoracic discectomy is an established surgical procedure for the treatment of thoracic disk disease. Most authors advocate interbody fusion after transthoracic discectomy. The purpose of this study was to determine if there were any adverse consequences in foregoing interbody fusion after transthoracic discectomy.

METHODS

Eighteen consecutive patients underwent transthoracic discectomy without fusion between 1996 and 2002 at Mayo Clinic (Rochester, MN). There were 11 women and 7 men with the mean age of 54 years (range, 28-84 years). Surgical indications were radiculopathy in 1 patient and myelopathy in 17. Follow-up data were obtained from the clinic visits and telephone surveys. We used the available pre- and postoperative radiographs for 16 patients at the last follow-up to establish the incidence of postoperative kyphosis and/or scoliosis at the operated level. Mean duration of the radiographic follow-up was 22 +/- 24 (SD) months.

RESULTS

None of the patients reported the onset of a new axial spine pain postoperatively. No patient developed segmental kyphosis or scoliosis at the operated level during the follow-up period. Fifteen of 18 (83%) patients had significant improvement in their neurological symptoms and signs. Two patients remained unchanged. An 83-year-old patient had a slight worsening of her gait after surgery. Specifically, the only 3 nonambulatory patients regained ambulation after discectomy. There were 4 complications: 1 wound infection, 1 pleural effusion requiring pleurodesis, 1 cerebrospinal fluid leak, and 1 case of disabling intercostal neuralgia.

CONCLUSIONS

These results indicate that interbody fusion may not be necessary for selected patients undergoing transthoracic discectomy. Further long-term follow-up is needed to evaluate the development of late spinal instability and resultant deformity after this procedure.

Thoracic microendoscopic discectomy: a human cadaver study

STUDY DESIGN

Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model.

OBJECTIVE

To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations.

SUMMARY OF BACKGROUND

Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery.

METHODS

Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography.

RESULTS

Nine discectomies were performed in two cadaveric specimens, from T5-T6-T9-T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (+/-1.9 mm) of the ipsilateral facet, which amounted to 35.4% (+/-17.5%) of the facet complex. Canal decompression averaged 73.5% (+/-7.9%).

CONCLUSIONS

Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.

Anterior decompression and fusion for multiple thoracic disc herniation

Multiple thoracic disc herniations are rare and there are few reports in the literature. Between December 1998 and July 2002, we operated on 12 patients with multiple thoracic disc herniations. All underwent an anterior decompression and fusion through a transthoracic approach. The clinical outcomes were assessed using the Frankel neurological classification and the Japanese Orthopaedic Association (JOA) score. Under the Frankel classification, two patients improved by two grades (C to E), one patient improved by one grade (C to D), while nine patients who had been classified as grade D did not change. The JOA scores improved significantly after surgery with a mean recovery rate of 44.8% +/- 24.5%. Overall, clinical outcomes were excellent in two patients, good in two, fair in six and unchanged in two. Our results indicate that anterior decompression and fusion for multiple thoracic disc herniations through a transthoracic approach can provide satisfactory results.

Endoscopic thoracic microdiscectomy

Object

The purpose of this investigation was to evaluate surgical and neurological outcomes in thoracic disc surgery in a prospective fashion.

Methods

Quantifiable outcome data such as operating time, blood loss, duration of chest tube drainage, narcotic drug use, length of hospital stay (LOS), and long-term follow up of neurological function and pain-related symptoms were collected prospectively.

In patients with myelopathy there was an improvement of two Frankel grades in the thoracoscopic discectomy group and one Frankel grade in the patients treated with thoracotomy; however, patients in the thoracotomy group were significantly worse preoperatively. None of the patients experienced worsened pain, and pain related to radiculopathy was improved by 75% in the thoracoscopic group.

Conclusions

Thoracoscopic discectomy yields acceptable surgical results and has several distinct advantages, with reduced postoperative pain, morbidity, and LOS.

The endoscopically assisted simultaneous posteroanterior reconstruction of the thoracolumbar spine in prone position

BACKGROUND CONTEXT

The reconstruction of the anterior column of the thoracolumbar spine has become more common in the last few years, due largely to the unfavorable results of exclusively posterior surgical treatment, which has been associated with a lack of about 10 degrees of kyphosis correction after removal of the instrumentation. The minimally invasive anterior techniques have reduced the morbidity of the anterior approach significantly.

PURPOSE

A minimally invasive technique for anterior stabilization of the spine may reduce the morbidity of the open approach. Irrespective of an anterior open or an endoscopic approach, the posteroanterior instrumentation of thoracolumbar fractures requires time-consuming intraoperative maneuvers to change the patient position from prone to lateral. We describe here a standardized anterior endoscopically assisted approach for the segments T4 to L4. This approach allows the patient to remain in prone position. A 4- to 5-cm incision combined with a retractor system is used.

STUDY DESIGN/SETTING

In a prospective study, all patients of our clinic who underwent surgery of the thoracolumbar spine between July 1999 and May 2001 were registered. Study criteria were duration of surgery, duration of anesthesia, intra- and postoperative complications.

PATIENT SAMPLE

Between July 1999 and May 2001, 42 patients (25 male, 17 female, average age of 41.9 years), who presented with 55 injured spinal levels and underwent surgery of the thoracolumbar spine in prone position, were included.

OUTCOME MEASURES

Duration of surgery (posterior/anterior/total), duration of anesthesia, method of instrumentation, intra- and postoperative complications, postoperative hospital stay and radiographs were evaluated.

METHODS

Surgery was performed in prone position. A thoracic approach was used for instrumentation of T9 to L2. A retroperitoneal approach was used for stabilization of L1 to L5. Both procedures were endoscopically assisted with a new retractor system (Synframe; Synthes GmbH, Umkirch, Germany). In this manner, only an incision 4 to 5 cm long and a stab incision for the endoscope were required. The whole procedure was performed in prone position without a change of position during surgery.

RESULTS

A total of 42 patients underwent surgery following this technique: 14 isolated anterior procedures (median duration of surgery, 181 minutes); 13 simultaneous one-stage procedures (median duration of surgery: 210 minutes) and 15 combined two-stage procedures (median duration of surgery: 90 minutes posterior, 120 minutes anterior, 240 minutes posterior+anterior). In the simultaneous posteroanterior procedures, the anterior instrumentation was performed 20 times using one rod, twice using two rods and in six patients simply by bone grafting. No intraoperative complications were observed. In the postoperative course, one case of pneumothorax, one case of hemothorax and one case of transient intercostal neuralgia occurred.

CONCLUSION

The approach to the anterior spine in prone position is feasible by using a self-holding retractor system for the region between T4 and L4. The duration of anesthesia for the one-stage simultaneous procedure was reduced by about 40 minutes, because changing the position of the patient is no longer necessary. The minimal incision, in combination with the retractor system, significantly reduces cost by allowing the use of less expensive instruments and implants. The advantages of the open and the endoscopic techniques are combined, while their disadvantages are minimized. The main advantage of the prone position is the opportunity to access the anterior and posterior spine simultaneously, which is especially helpful in reduction maneuvers.

Thoracic microendoscopic discectomy

OBJECT

Various approaches exist for the treatment of thoracic disc herniation. Anterior approaches facilitate ventral exposure but place the intrathoracic contents at risk. Posterolateral approaches require extensive muscle dissection that adds to the risk of postoperative morbidity. The authors have developed a novel posterolateral, minimally invasive thoracic microendoscopic discectomy (TMED) technique that provides an approach to the thoracic spine which is associated with less morbidity.

METHODS

Seven patients 23 to 54 years old with nine disc herniations underwent TMED. All lesions were soft lateral or midline thoracic disc herniations. Under fluoroscopic guidance with the patient positioned prone, the authors used a muscle dilation approach and the procedure was performed with endoscopic visualization through a tubular retractor. Based on a modified Prolo Scale, five patients experienced excellent results, one good, and one fair. No case required conversion to an open procedure. The mean operative time was 1.7 hours per level, and estimated blood loss was 111 ml per level. Hospital stays were short, and no complications occurred.

CONCLUSIONS

The TMED is safe, effective, and provides a minimally invasive posterolateral alternative for treatment of thoracic disc herniation without the morbidity associated with traditional approaches.

Necessity of rib head resection for anterior discectomy in the thoracic spine

STUDY DESIGN

The relation between the rib head and the thoracic disc was investigated anatomically.

OBJECTIVES

To clarify the necessity of rib head resection in thoracoscopic discectomy using the anterior approach.

SUMMARY OF BACKGROUND DATA

When using the transthoracic anterior approach, the rib head must often be resected. However, there are no reports in which the relation between the rib head and the interspinal disc has been investigated.

METHODS

The distance between the inferior margin of the superior vertebral body and the superior margin proximal to the rib (hereafter, "rib index") was measured.

RESULTS

The rib index shows negative value in T2-T9 levels, while zero in Tl0 level and positive value T11-T12. The rib index of the fifth to ninth ribs in men was significantly smaller than those in women.

CONCLUSIONS

The surgeon should anticipate full removal of the rib head if operating at T9 and only partial resection below that level.

History of spinal surgery: one neurosurgeon's perspective

Spinal surgery has advanced from decompression procedures to complex spinal reconstruction and internal stabilization within the last 25 years, as a result of a broad-based technological boom that began in the 1970s with the advent of spinal computerized tomography and magnetic resonance imaging. These technological advances have coincided with, and developed as a result of, the concomitant rise of a complex, economically driven consortium of innovative surgeons and researchers, academic institutions, government agencies, and private industry, to form a Medical–Industrial Complex (MeIC). A major growth industry has formed, resulting in an overall societal benefit. Nevertheless, it has impacted graduate medical education and has significantly increased the cost of treating spinal disorders. Back pain and spinal disorders are a major societal health problem that is associated with a high demand for treatment services. There is a potential for abuse as well as a benefit in offering these services. The MeIC has contributed to the overall rise in the cost of health care insurance and in the migration of manufacturing jobs abroad as a solution for lowering production costs. The increased cost has had a negative impact on local and regional economies.

The Efficacy of Anterior Spine Exposure by An Orthopedic Surgeon

This retrospective study was designed to document the incidence and types of perioperative complications that occurred with anterior spinal fusion surgery performed solely by an orthopedic spine surgeon. This study is contrasted to previous studies that document complications from anterior approaches performed by an orthopedic surgeon with the assistance of a general or a vascular surgeon. Specifically, the procedures included thoracotomies, thoracolumbar retroperitoneal, and lumbosacral approaches. Our sample consisted of 450 patients who underwent anterior spinal fusion between levels T1 and S1, from 1985 to 1997. Patient and surgery characteristics included age, sex, diagnosis, levels of fusion, blood loss, operative time, hospitalization time, complications, American Society of Anesthesiologists state, assessment of risk factors, previous surgery, and surgical approach used. Average follow-up was 41.69 months, with a minimum of 12 months and a maximum of 132 months. Our results indicated that anterior procedures performed solely by our senior orthopedic surgeon had a lower incidence of complications, less blood loss, and shorter operative time than anterior procedures performed by an orthopedic surgeon and a vascular or a general surgeon. Our findings suggest that the anterior spinal exposure is a safe approach that may be performed solely by a spinal surgeon who is knowledgeable and experienced.