Thoracic Disc Disease Research Articles

The relationship between intervertebral disc pathologies and the use of digital devices and lack of physical activity in adolescents

Background/Aim: Existing research on herniated discs in adolescents primarily focuses on surgical interventions and outcomes, with fewer studies investigating the effectiveness of non-surgical therapies. The correlation between obesity, facet tropism, lumbosacral transitional vertebrae, trauma, certain sports activities, and herniated discs in adolescents is well-documented. Comparable to adults, a sedentary lifestyle in adolescents potentially carries a significant risk of developing disc degeneration and herniation. Consequently, this study aims to examine the relationship between increased digital device usage, decreased physical activity, and the onset of disc pathologies in adolescents. Methods: The study group included 94 patients aged between 10 and 16 years diagnosed with cervical (CDH), thoracic (TDH), and lumbar (LDH) disc disease. For each participant, the individual daily usage time spent on desktop computers, tablets, laptops, and mobile phones and the total time spent on all digital devices were evaluated. Their level of physical activity was also assessed using the International Physical Activity Questionnaire – Short Form (IPAQ-SF). The study eliminated causes such as listhesis, facet tropism, lumbosacral transitional vertebra, trauma, and sports injuries that could prompt the development of these spinal pathologies. Additionally, other conditions that might cause spinal pain, such as scoliosis, rheumatological diseases with spinal involvement, tumors, and myofascial pain, were also ruled out. Results: The average age of all patients was 13.44 (2.07) years. A majority were women (n=55), comprising 58.50% of the sample. Of the patients, 60.64% had CDH, 12.77% had TDH, and 75.53% had LDH. The amount of physical activity and time spent on digital devices were similar across both genders (P=0.194 and P=0.770). A significant correlation was found between CDH and the time spent on tablets, laptops, and mobile phones (P<0.001). Again, a significant correlation was observed between LDH, usage of desktop computers, total time spent on all digital devices, and the IPAQ-SF score for low physical activity (P<0.001). Conclusion: The prevalence and duration of digital device use among adolescents are increasing, while physical activity is decreasing. Our study indicates that this situation may be linked to the development of disc degeneration and hernias. Understanding this association can help reduce treatment and rehabilitation costs and prevent the potential loss of workability and quality of life resulting from a herniated disc. Consequently, additional comparative research on this topic is crucial.

Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR).

Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10-11 level, two patients Th 7-8, one patient Th 9-10, one patient Th 11-12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions.

Endoscopic decompression of the spinal canal in symptomatic thoracic disc disease. A case report

The risk of disc herniation in the thoracic spine is much less common than in cervical and lumbar segments. It occurs in about 0.25 to 0.75% of reported cases [1]. Osteoarthritis of the intervertebral disc is most common between 30 and 50 years of age. Unlike in the case of disc herniation of the cervical spine, classic anterior access to the spinal canal is not possible due to the vascular structures of the thorax. A modified posterior approach similar to procedures applied in the area of the lumbar spine, is used to decompress discopathy i.e., a hernia located laterally. An important problem, however, is hernias that compress the spinal cord anteriorly. We present a case report of endoscopic decompression of the thoracic spine in the course of central disc herniation from the posterior approach using the unilateral bi-portal technique (UBE).

Clinical and radiographic features of adult calcified thoracic disc herniation: a retrospective analysis of 31 cases.

To analyze the clinical and radiographic characteristics of calcified thoracic disc herniation (CTDH) and explore the possible pathogeneses. This is a retrospective clinical review of prospectively collected imaging data based at a single institute from 2004 to 2021. Clinical and radiographic parameters of CTDH patients were retrospectively collected and analyzed. All 31 patients included presented thoracic myelopathy with a 17.05-month preoperative disease duration. Three (9.7%) patients had a history of trauma, and the rest had insidious onset. The average spinal canal ventral-occupying ratio was 74.90 ± 15.16%. The most prominent radiographic feature was the calcification of the nucleus pulposus in the intervertebral disc and the calcified lesion contiguous with the disc space protruding into the spinal canal. Three main imaging forms of CTDH were found: calcium-ringed lesion (5), heterogeneous calcification lesion (19), and homogeneous calcification lesion (7). The radiographic manifestations, intraoperative findings, and postoperative pathologies of the three subtypes were different. The calcium-ringed lesion type was younger and had a shorter preoperative duration and significantly lower mJOA score. A special case was observed conservatively for five years, which suggested that a heterogeneous lesion could progress to a homogeneous lesion. Adult CTDH is a special thoracic disc disease with insidious onset, a long course, and a high spinal canal-occupying ratio. Calcium deposits in the spinal canal originate from the nucleus pulposus. The intraoperative findings and postoperative pathology of subtypes are different, which might indicate different pathological mechanisms.

Surgical treatment of calcified thoracic herniated disc disease via transthoracic approach with use of intraoperative computed tomography (ICT) and microscope-based augmented reality (AR)

Surgical treatment of calcified thoracic herniated disc disease via transthoracic approach with use of intraoperative computed tomography (ICT) and microscope-based augmented reality (AR)

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.

Thoracic intramedullary neurosarcoidosis with thoracic disc herniation: Diagnostic importance of intramedullary contrast enhancement

Background: Thoracic intramedullary neurosarcoidosis is an uncommon but serious manifestation of spinal cord disease. Its concomitant occurrence with thoracic disc herniation can mislead the physician into attributing neurologic and radiographic findings in the spinal cord to disc pathology rather than inflammatory disorder. Here, we present such a rare case of concomitant thoracic disc and spinal neurosarcoidosis.Case Description: A 37-year-old male presented with progressive right lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the thoracic spinal cord revealed a T6-T7 paracentral disc eccentric to the right with T2 signal change extending from T2 to T10 level. This prompted acquiring a contrasted MRI that also depicted intramedullary enhancement around the T6-T7 disc bulge. Computed tomography scan of the chest showed mediastinal lymphadenopathy concerning for sarcoidosis. Lymph node biopsy confirmed the diagnosis of sarcoidosis, and high-dose steroid treatment was initiated. The patient had significant symptomatic improvement with steroids with full neurological recovery and improvement of his symptoms.Conclusion: While stenosis from thoracic disc disease could potentially suggest a mechanical etiology for the patient’s symptoms, attention must be paid to the imaging findings as well as the degree and extent of cord signal change and intramedullary contrast enhancement. Appropriate and timely diagnosis is essential to avoid unnecessary invasive procedures.

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

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

Revision surgery in thoracic disc herniation

PurposeSurgical treatment failures or strategies for the reoperation of residual thoracic disc herniations are sparsely discussed. We investigated factors that led to incomplete disc removal and recommend reoperation strategies.MethodsAs a referral centre for thoracic disc disease, we reviewed retrospectively the clinical records and imaging studies before and after the treatment of patients who were sent to us for revision surgery for thoracic disc herniation from 2013 to 2018.ResultsA total of 456 patients were treated from 2013 to 2018 at our institution. Twenty-one patients had undergone previously thoracic discectomy at an outside facility and harboured residual, incompletely excised and symptomatic herniated thoracic discs. In 12 patients (57%), the initial symptoms that led to their primary operation were improved after the first surgery, but recurred after a mean of 2.8 years. In seven patients (33%) they remained stable, and in two cases they were worse. All patients were treated via all dorsal approaches. In all 21 cases, the initial excision was incomplete regarding medullar decompression. All of the discs were removed completely in a single revision procedure. After mean follow-up of 24 months (range 12–57 months), clinical neurological improvement was demonstrated in seven patients, while three patients suffered a worsening and 11 patients remained stable.ConclusionOur data suggest that pure dorsal decompression provides a short relief of the symptoms caused by spinal cord compression. Progressive myelopathy (probably due to mechanical and vascular deficits) and scar formation may cause worsening of symptoms.Graphic abstractThese slides can be retrieved under Electronic Supplementary Material.

Effectiveness of Percutaneous Intradiscal Decompression Therapy in Thoracic Disc Herniation

Aims:Although there have been many studies about lumbar and cervical ablation procedures, few studies have been performed in the thoracic region. To evaluate the clinical results of a percutaneous disc decompression device in patients with radicular symptoms and/or dorsal pain due to thoracic disc herniation.Methods:Eleven patients with thoracic disc herniation and/or degenerative discs (all in T10-T11, or T11-T12 levels) who did not respond to conservative treatments were undergoing ablation and compression procedures. Pain and radicular symptoms consistent with the thoracolumbar region were confirmed via abnormal magnetic resonance imaging findings after detailed anamnesis and physical examination. All patients were evaluated before and 1, 3, 6, and 12 months after treatment using the visual analog scale score. The patient satisfaction scale was used to evaluate the level of patient satisfaction at the end of the treatment at 12 months.Results:The median visual analog scale score was 7.00±0.45 points before treatment and 2.73±0.65 points at 12 months post-procedure and were statistically significant (p<0.001). The results of pairwise comparisons using the Bonferroni Corrected Wilcoxon Signed-Rank test showed that there were statistically significant differences. The mean visual analog scale score at the beginning (7.00±0.45) was significantly higher than the mean score of other months. Postoperative improvement was significant with a 99% confidence interval. No complications that may cause permanent damage occurred.Conclusion:Percutaneous disc decompression is an effective and safe procedure to treat pain caused by lower thoracic intervertebral disc disease, which did not respond to conservative treatments.

Effectiveness of Percutaneous Intradiscal Decompression Therapy in Thoracic Disc Herniation

Aims: Although there have been many studies about lumbar and cervical ablation procedures, few studies have been performed in the thoracic region. To evaluate the clinical results of a percutaneous disc decompression device in patients with radicular symptoms and/or dorsal pain due to thoracic disc herniation.Methods: Eleven patients with thoracic disc herniation and/or degenerative discs (all in T10-T11, or T11-T12 levels) who did not respond to conservative treatments were undergoing ablation and compression procedures. Pain and radicular symptoms consistent with the thoracolumbar region were confirmed via abnormal magnetic resonance imaging findings after detailed anamnesis and physical examination. All patients were evaluated before and 1, 3, 6, and 12 months after treatment using the visual analog scale score. The patient satisfaction scale was used to evaluate the level of patient satisfaction at the end of the treatment at 12 months. Results: The median visual analog scale score was 7.00&plusmn;0.45 points before treatment and 2.73&plusmn;0.65 points at 12 months post-procedure and were statistically significant (p&lt;0.001). The results of pairwise comparisons using the Bonferroni Corrected Wilcoxon Signed-Rank test showed that there were statistically significant differences. The mean visual analog scale score at the beginning (7.00&plusmn;0.45) was significantly higher than the mean score of other months. Postoperative improvement was significant with a 99% confidence interval. No complications that may cause permanent damage occurred.Conclusion: Percutaneous disc decompression is an effective and safe procedure to treat pain caused by lower thoracic intervertebral disc disease, which did not respond to conservative treatments.

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

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

Transforaminal Endoscopic Foraminoplasty and Discectomy for the Treatment of a Thoracic Disc Herniation

Transforaminal endoscopic spine surgery has emerged internationally as a minimally invasive technique that can be performed in an awake patient in the outpatient setting. Advances in high-definition endoscopic camera technologies as well as the availability of specialty graspers, reamers, drills, and other instruments that can be used down a working channel endoscope have made a myriad of spine diseases accessible to the minimally invasive spine surgeon. The major challenge inherent in the surgical treatment of thoracic disc disease is that the disc herniation is often ventral to the spinal cord. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc disease.

Cystic Angiomatosis: A Rare Cause of Thoracic Radiculopathy: A Case Report.

Thoracic radiculopathy is a rare condition that is most frequently attributed to thoracic disc disease and diabetes mellitus. It typically presents as pain, paresthesias, dysesthesias, and loss of sensation in a dermatomal distribution across the chest, thorax, and/or abdomen. Neoplasms, skeletal deformities (e.g., scoliosis, kyphosis, and compression fractures), and other skeletal and extraskeletal diseases encompass some of the numerous disease etiologies1-4. Cystic angiomatosis (CA), a disease characterized by cystic skeletal lesions with or without extraskeletal involvement, represents an even rarer cause of thoracic radiculopathy. CA is histologically described as cystic lesions of hemangiomatous, lymphangiomatous, or mixed origin. It typically presents in the first three decades of life4-6 with no sex preference7, and has an estimated incidence rate of between 0.1 and 1.0 in 1,000,0008. It most frequently presents with skeletal and extraskeletal lesions, but it also may present with isolated skeletal lesions5,9,10. The skull, ribs, vertebrae (cervical vertebrae most frequently)7, pelvis, femora, and humeri10,11 are the skeletal structures that are most commonly involved. The spleen, liver, kidneys, pleurae, and lungs represent the most commonly affected extraskeletal structures5,9,12. Skeletal lesions are most commonly located within the medullary cavity; however, cortical involvement has been noted13. CA tends to be diagnosed in asymptomatic individuals after routine radiographs reveal diffuse cystic skeletal lesions. Symptomatic patients may present with bone pain with or without pathological fractures, localized swelling and tenderness, dyspnea, hemoptysis, ascites, and even organ failure. While the lesions may spontaneously remit, patients are at risk for permanent deformity, loss of function, and even death—especially in patients with splenic14,15 or pleural involvement12,16 or infected angiomatic lesions11. …

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 18.2months on average. The mean length of hospital stay was 5days. 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.

Thoracic Radiculopathy

Thoracic radiculopathy is much less common than lumbar or cervical radiculopathy. Degenerative disk disease and trauma are the most common etiologies of thoracic radiculopathy. Fortunately, most symptomatic thoracic disk disease in the absence of neurological signs improves with conservative treatment. There are a broad range of etiologies of thoracic radiculopathy. The optimal treatment, including conservative, interventional, or surgical options for thoracic radiculopathy, is usually related to the specific etiology. To our knowledge and after literature review, there have been no large, multicentered trials on treatment efficacy for thoracic radiculopathy.

Thoracoscopic treatment for single level symptomatic thoracic disc herniation: a prospective followed cohort study in a group of 167 consecutive cases

Thoracic disc disease with radicular pain and myelopathic symptoms can have serious neurological sequelae. The authors present a relevant treatment option. Data of patients with single level symptomatic thoracic disc herniation treated with thoracoscopic microdiscectomy were prospectively collected over a period of 10years. Data collection included the preoperative status and the follow-up status was 6, 12 and 24months after surgery for every patient. A total of 167 single level thorascoscopic discectomies without previous surgery on the level of the procedure were included in this study. The average preoperative duration of pain symptoms was 14.3months, myelopathic symptoms were present for an average of 16.7months before surgery. After the procedure pain scores measured with visual analog scale (VAS) decreased by 4.4 points and the muscle strength improved by a mean of 4.6 points (American Spinal Injury Association ASIA motor score). After 2years, 79% of the patients reported a excellent or good outcome for pain and 80% of the patients reported a excellent or good outcome for motor function. The overall complication rate was 15.6%. Thoracoscopic microdiscectomy for single level symptomatic disc herniation is a highly effective and reliable technique, it can be performed safely with low complication rate.

Anterior approach to the thoracic spine

An anterior approach affords the spine surgeon excellent visualization and access to the anterior thoracic spine, the vertebral bodies, intervertebral disks, spinal canal, and nerve roots. This approach is currently used in the surgical treatment of thoracic disk disease, vertebral osteomyelitis or discitis, fractures and tumors of the vertebral bodies, allowing for proper decompression of neural elements and spine stabilization. Over a 10-year period in a single institution, a total of 142 patients with a mean age of 49.6 years underwent anterior thoracic exposure of the spine. The indication for surgery was trauma fracture in 20 patients, malignancy in 35, degenerative disease in 29 and correction of scoliosis in 58. Surgical approaches were determined based on the location and length of spinal involvement, including cervico-thoracic approach (15) thoracotomic approach (85) video-assisted thoracoscopy (10) and thoracolumbar exposure (32). Mean operative time was 334 min (range from 256 to 410 min). There was no perioperative mortality. Thirty-one patients (21.8%) developed postoperative complications. The anterior approach to the thoracic spine is safe and effective and even the presence of complications can be appropriately managed. An adequate preoperative evaluation stratifying the risk and instituting measures to reduce it, accurate surgical planning and careful surgical technique are key to yielding a good outcome and to reduce the risk of complications.

Percutaneous laser disc decompression for thoracic disc disease: report of 10 cases

Discogenic pain or herniation causing neural impingement of the thoracic vertebrae is less common than that in the cervical or lumbar regions. Treatment of thoracic discogenic pain usually involves conservative measures. If this fails, conventional fusion or discectomy can be considered, but these procedures carry significant risk. To assess the efficacy and safety of percutaneous laser disc decompression (PLDD) for the treatment of thoracic disc disease. Ten patients with thoracic discogenic pain who were unresponsive to conservative intervention underwent the PLDD procedure. Thoracic pain was assessed using the Visual Analog Scale (VAS) scores preoperatively and at 6-month intervals with a minimum of 18-months follow-up. Patients were diagnosed and chosen for enrollment based on abnormal MRI findings and positive provocative discograms. Patients with gross herniations were not included. Length of follow-up ranged from 18 to 31 months (mean: 24.2 mo). Median pretreatment thoracic VAS score was 8.5 (range: 5-10) and median VAS score at final follow-up was 3.8 (range: 0-9). Postoperative improvement was significant with a 99% confidence interval. Of interest, patients generally fell into two groups, those with significant pain reduction and those with little to no improvement. Although complications such as pneumothorax, discitis, or nerve damage were possible, no adverse events occurred during the procedures. The study is limited by its small size and lack of a sham group. Larger controlled studies are warranted. With further clinical evidence, PLDD could be considered a viable option with a low risk of complication for the treatment of thoracic discogenic pain that does not resolve with conservative treatment.

Emerging Endoscopic Minimal Invasive Laser Spinal Surgery (lumbar, cervical and thoracic)

Introduction: Laser Minimally Invasive Spine Surgery (MISS) was thought to be impossible and impractical not long ago, but has rapidly come of age1,2,3,4,5, due to much improved endoscopic and micro spinal surgical instruments the explosive development of bio-computer technology, digital video imaging, ultra fast virtual spino scan, and tissue modulation technology6,7. A significant percentage of spinal surgeries will be modified or replaced with laser MISS8. Therefore a new algorithm in the treatment of degenerative spinal disease is urgently needed (Table 1). Purpose: To identify and demonstrate the laser MISS surgical techniques and treatment for herniated cervical, thoracic and lumbar discs, and degenerative spine disease; to demonstrate the current and future laser MISS related technology, and to describe potential surgical complications and their avoidance. Material and Methods: Recent innovative endoscopic laser MISS instruments, various spinal endoscopes, 3 intra-operative digital x-ray fluoroscopy, digital video photography, various laser application, newer endoscopy for better visualization, and thermodiskoplasty (i.e. the use of the laser at low energy levels, to shrink and tighten disc material) 6,7 are described. Endoscopic laser MISS surgical techniques are demonstrated for lumbar, cervical, and thoracic spinal operations. 6,7,9,10,11 On the horizon, many digital computer aided innovations1 including surgical robotics, image guided technology and other surgical systems are also described. A well designed digital Institutional Information System (IIS) including a Picture Archiving and Communication System (PACS),1,12and a digital 3-D imaging virtual reality system in a surgical planning laboratory1 provides precise diagnosis and pre-operative surgical planning in order to facilitate MISS process, and to provide intramural and extramural connectivity. Digital video game technology, heptic technology and surgical simulator are on the horizon13 to facilitate and to improve education, research, development, and endoscopic laser surgical training 12,13,14,15,16,17 in addition to better patient care. Results and discussion: Laser minimally invasive spine surgery outcome has improved the overall success rate to above 91% or Emerging Endoscopic Minimal Invasive Laser Spinal Surgery (lumbar, cervical and thoracic) 2 of 4 more (94% for one level) with less than 1% of morbidity and zero mortality as demonstrated in a recent multicenter study16. Also potential laser MISS complications and avoidance are fully discussed. The rapid progress in endoscopic laser MISS has been facilitated by modern bio technology. There is a definite correlation between clinical findings, digital radiology, neuropsychological studies, MRI, CT, 3D virtual imaging, virtual spinal endoscopy, surgical findings and positive surgical results. Digital video game technology, heptic technology and surgical simulation will assist in the training of the minimally invasive spine surgeons13, and to shorten the learning curve. Surgical robotics and image guided technology1 for MISS are on the horizon. Conclusion: Endoscopic laser MISS has rapidly become of age and has many obvious advantages.7,10,11,16 Digital technology assists in the advancement, development, the training, and the practice of endoscopic laser MISS for treatment of degenerative disc disease, with preservation of segmental spinal motion. This minimally invasive, less traumatic, outpatient endoscopic laser MISS treatment for cervical, lumbar and thoracic disc disease leads to excellent results, faster recovery, and significant economic savings. In the near future with the assistance of digital technology, endoscopic laser MISS applications will further provide an excellent and effective access or platform for spine arthroplasty, spinal disk replacement, artificial disk, vertebralplasty, spinal fixation/fusion, disc re-growth technology and perhaps genome therapy.