Thoracic Discectomy Research Articles

Intraoperative Intercostal Nerve Block for Pain Management After Retropleural Thoracic Discectomy: Anatomy and Technique

Thoracic discectomy procedures require early and adequate pain control to alleviate patient discomfort after surgery. The intraoperative placement of a nerve block after intercostal nerve violation can offer early pain management after thoracic discectomy. The anatomy and technique of placing an intercostal nerve block after retropleural thoracic discectomy are described. Patient data were collected for patients who underwent this technique. This approach is presented with an illustrative figure and a review of relevant anatomical landmarks to describe the technique and ensure its reproducibility. Data for 93 patients (57 [61%] women; 36 [39%] men; mean [SD] age, 54.1 [14.1] years) who underwent the procedure are provided to assess the reliability of this technique CONCLUSIONS: Intercostal nerve blockage offers a valuable addition to postoperative pain management and may be considered as an available pain relief option for patients undergoing thoracic discectomy.

Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis.

Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH. PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term "thoracic disc herniation" up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy. We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23). The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.

Incidence of radiographic and clinically significant pneumothorax or hemothorax after thoracic discectomy via mini-open lateral retropleural approach without prophylactic chest tube placement.

The mini-open lateral retropleural (MO-LRP) approach is an effective option for surgically treating thoracic disc herniations, but the approach raises concerns for pneumothorax (PTX). However, chest tube placement causes insertion site tenderness, necessitates consultation services, increases radiation exposure (requires multiple radiographs), delays the progression of care, and increases narcotic requirements. This study examined the incidence of radiographic and clinically significant PTX and hemothorax (HTX) after the MO-LRP approach, without the placement of a prophylactic chest tube, for thoracic disc herniation. This study was a single-institution retrospective evaluation of consecutive cases from 2017 to 2022. Electronic medical records were reviewed, including postoperative chest radiographs, radiology and operative reports, and postoperative notes. The presence of PTX or HTX was determined on chest radiographs obtained in all patients immediately after surgery, with interval radiographs if either was present. The size was categorized as large (≥ 3 cm) or small (< 3 cm) based on guidelines of the American College of Chest Physicians. PTX or HTX was considered clinically significant if it required intervention. Thirty patients underwent thoracic discectomy via the MO-LRP approach. All patients were included. Twenty patients were men (67%), and 10 (33%) were women. The patients ranged in age from 25 to 74 years. The most commonly treated level was T11-12 (n = 11, 37%). Intraoperative violation of parietal pleura occurred in 5 patients (17%). No patient had prophylactic chest tube placement. Fifteen patients (50%) had PTX on postoperative chest radiographs; 2 patients had large PTXs, and 13 had small PTXs. Both patients with large PTXs had expansion on repeat radiographs and were treated with chest tube insertion. Of the 13 patients with a small PTX, 1 required 100% oxygen using a nonrebreather mask; the remainder were asymptomatic. One patient, who had no abnormal findings on the immediate postoperative chest radiograph, developed an incidental HTX on postoperative day 6 and was treated with chest tube insertion. Thus, 3 patients (10%) required a chest tube: 2 for expanding PTX and 1 for delayed HTX. Most patients who undergo thoracic discectomy via the MO-LRP approach do not develop clinically significant PTX or HTX. PTX and HTX in this patient population should be treated with a chest tube only when there are postoperative clinical and radiographic indications.

Surgical options in thoracic disc herniation: Evaluating long-term outcomes of 21 cases based on a single-center 10-year experience.

Symptomatic thoracic disc herniation (TDH) is a rare pathology that is addressed with relatively challenging surgical approaches, the choice and technical execution of which have been well described in the literature. Interestingly, long-term outcomes, including surgical site pain-related disability, the need for instrumentation, and commonly occurring complications such as cerebrospinal fluid (CSF)-pleural fistula have not been widely addressed. Here, we address the complication profiles and long-term outcomes of different surgical approaches for TDH. We conducted a retrospective review of 21 consecutive patients who underwent surgery for TDH between 2000 and 2010. We assessed post-operative complications such as CSF-pleural fistulas, as well as long-term outcomes using Frankel grades, the EQ-5D-3L, and the Visual Analog Scale. We also looked at the need for instrumentation postoperatively. 21 consecutive patients (13 females, 8 males) with a mean age of 55.3 years (Standard deviation 8.1) underwent thoracic discectomy for symptomatic TDH. Surgical approaches included posterolateral thoracotomy (52%, n = 11), costotransversectomy (43%, n = 9), and transpedicular (5%, n = 1). Herniations were classified as soft (38%, n = 8), calcified (38%, n = 8), or calcified-transdural (24%, n = 5). Postoperatively, all patients with calcifiedtransdural herniations undergoing posterolateral thoracotomy (100%, n = 5) developed CSF-pleural fistulas, which resolved spontaneously without the need for surgical re-exploration. 89% (n = 16) of patients exhibited sustained improvement in Frankel scores. Persistent wound site pain was reported by 50% (n = 7) of patients. Despite favorable neurological outcomes, patients with symptomatic TDHs can experience long-term surgical site pain, and therefore, a move toward minimally invasive exposure in such cases should be considered. Postoperative complications such as CSF-pleural fistulas are unlikely to require surgical intervention and thus can be managed conservatively.

Real-Time Ultrasound-Guided Posterolateral Thoracic Discectomy: 2-Dimensional Operative Video.

Symptomatic thoracic disk herniations can be challenging to treat. Various surgical approaches have been reported in the literature, but the ideal approach is still a topic of controversy. We present a step-by-step surgical video highlighting the utilization of continuous, real-time intraoperative ultrasound (IOUS) guidance for thoracic discectomy through a posterolateral approach. The background and rationale for the procedure and a detailed presentation of the sequence of surgical steps are detailed in the operative video. We believe that real-time IOUS can be used not only to gain an understanding of the ventral anatomy and to verify decompression after discectomy but it can also be used in a real-time fashion to guide the maneuvers for discectomy itself. Advantages of using real-time IOUS include real-time monitoring of the spinal cord during mobilization of the disk-osteophyte complex and direct visualization of the dura-disk herniation interface, which may enhance the safety of surgery. The patient consented to the procedure and the publication of her image.

Clinical Outcomes of Full Endoscopic Thoracic Discectomy in Acute Disc Herniation: A Case Report from Khyber Pakhtunkhwa

Objectives: Thoracic disc herniations are rare relative to lumber and cervical spine herniations and account for 0.25% to 0.75% of cases in the general population. This case report presents a rare case of a 65-year-old male diagnosed with thoracic disc herniation and managed through full endoscopic thoracic discectomy. Clinical Presentation: A 65-year-old wheelchair-bound male presented to OPD with complaints of paresthesia and sensory symptoms along with motor weakness from the past 2 weeks. No Symptoms of bowel and bladder dysfunction were present. Diagnosis/Intervention: Sagittal and axial MRI findings revealed disc herniation at the T11 – T12 level. Full endoscopic thoracic discectomy through a transforaminal approach was performed to decompress the spinal cord. Conclusion: Acute thoracic disc herniations although rare, can present with variable clinical manifestations. Full endoscopic thoracic discectomy through a transforaminal approach is a safe and effective surgical procedure associated with improved patient outcomes, increased satisfaction scores, and decreased chances of complications. Keywords: Acute thoracic disc herniation, endoscopic discectomy, full endoscopic thoracic discectomy.

Transforaminal endoscopic thoracic discectomy: surgical technique.

The major challenge inherent to the surgical treatment of thoracic disc herniations is that the disc herniation is often ventral to the spinal cord. Posterior approaches are difficult and dangerous due to the morbidity associated with retraction of the thoracic spinal cord. A ventral approach is not feasible due to the thoracic viscera. A lateral transcavitary approach is the standard for treating ventral thoracic disc pathology but is also quite morbid. Transforaminal endoscopic spine surgery has emerged as a minimally invasive technique for treating thoracic disc pathology and it can be performed in the outpatient setting even with the patient awake. Advances in endoscopic camera technologies as well as the availability of specialty instruments that can be used down a working channel endoscope has now made a myriad of spine pathologies accessible to the minimally invasive spine surgeon. The transforaminal approach and the angled endoscopic camera are an ideal combination for creating a technical advantage to accessing thoracic disc pathology in a minimally invasive fashion. The principal challenges to the approach are needle targeting and understanding the endoscopic visual anatomy. Many surgeons interested in pursuing this technique are often deterred by the burden of the cost and time it takes to become adept and performing the technique. Detailed here are the authors' step-by-step technique and illustrative video that demonstrate transforaminal endoscopic thoracic discectomy (TETD).

Uniportal, Transforaminal Endoscopic Thoracic Discectomy: Review and Technical Note.

Symptomatic thoracic disc herniations are a rare entity and their operative treatment is challenging. Open approaches, despite providing excellent access, are associated with significant access morbidity from thoracotomy, and this has led to an increased interest in minimally invasive techniques such as mini-open approach, thoracoscopic approach and the endoscopic approach. In this article, we describe the technical points for performing a transforaminal endoscopic thoracic discectomy and summarize its literature outcomes in the context of other minimally invasive approaches.

Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video.

Technical Report. Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. The patient had complete resolution of his preoperative symptoms after primary repair. In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.

Identification of the Magna Radicular Artery Entry Foramen and Adamkiewicz System: Patient Selection for Open versus Full-Endoscopic Thoracic Spinal Decompression Surgery.

Casually cauterizing the radicular magna during routine thoracic discectomy may have dire consequences. We performed a retrospective observational cohort study on patients scheduled for decompression of symptomatic thoracic herniated discs and spinal stenosis who underwent a preoperative computed tomography angiography (CTA) to assess the surgical risks by anatomically defining the foraminal entry level of the magna radicularis artery into the thoracic spinal cord and its relationship to the surgical level. Fifteen patients aged 58.53 ± 19.57, ranging from 31 to 89 years, with an average follow-up of 30.13 ± 13.42 months, were enrolled in this observational cohort study. The mean preoperative VAS for axial back pain was VAS of 8.53 ± 2.06 and reduced to a postoperative VAS of 1.60 ± 0.92 (p < 0.0001) at the final follow-up. The Adamkiewicz was most frequently found at T10/11 (15.4%), T11/12 (23.1%), and T9/10 (30.8%). There were eight patients where the painful pathology was found far from the AKA foraminal entry-level (type 1), three patients with near location (type 2), and another four patients needing decompression at the foraminal (type 3) entry-level. In five of the fifteen patients, the magna radicularis entered the spinal canal on the ventral surface of the exiting nerve root through the neuroforamen at the surgical level requiring a change of surgical strategy to prevent injury to this important contributor to the spinal cord's blood supply. The authors recommend stratifying patients according to the proximity of the magna radicularis artery to the compressive pathology with CTA to assess the surgical risk with targeted thoracic discectomy methods.

Transdural Thoracic Discectomy and Dorsal Arachnoid Web Fenestration: 2-Dimensional Operative Video.

*Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA; ‡The Ohio State University College of Medicine, Columbus, Ohio, USA; §Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas, USA Correspondence: David S. Xu, MD, Department of Neurological Surgery, The Ohio State University College of Medicine, 410 West 10th Ave, Columbus, OH43210, USA. Email: [email protected]

Minimally Invasive Thoracic Discectomy Instructional Video: 2-Dimensional Operative Video.

Department of Neurosurgery, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA Correspondence: Paul Marcet, MD, PGY-4, 1 Medical Center Blvd, Winston-Salem, NC27157, USA. Email: [email protected]

Evaluation of surgical characteristics and clinical outcome of 11 patients with thoracic discectomy through transfacet approach

Background: In thoracal disc herniation (TDH) requiring surgery, the size, level, anatomic location, and calcification of the disc are extremely important in the selection of the technique to be applied. Since the thoracic region does not allow spinal cord manipulation, the surgery is difficult and requires experience. A consecutive series of patients who underwent thoracic discectomy through a posterior transfacet approach is presented in this study. Methods: Eleven patients (6 men, and 5 women) underwent surgery at 12 disc levels. The mean age was 53.54 years (range 28-72 years). Patients presented with myelopathy (n = 8, 73%), radiculopathy (n = 7, 64%), back pain (n =10, 91%), and urinary dysfunction (n = 6, 55%). Seven (58%) lateral, 3 (25%) calcified, and 4 (33%) large disc herniations were revealed by preoperative imaging. The mean follow-up period was 21.02 ± 8.04 months (range 6 – 43 months). Results: A posterior transfacet approach was used for all eleven patients with TDH. Thoracic discectomy was performed at T11- 12 (36%) level for 4 patients, and equally at T10- 11 (36%) level for the other 4 patients. A bilateral approach with laminotomy was performed in one patient, and a two-level discectomy was performed in another patient. Unilateral partial laminectomy was added for 3 patients. The average operating time was 146.85 minutes (range 125-220 minutes). The average hospital stay was 4.2 days (range, 2- 13 days) while no neurological functional deterioration was observed in any of the patients after surgery. Postoperative 1-month and 6-month ODI scores were found significantly different from preoperative ODI scores in all patients. Conclusions: Thoracal discectomy through the posterior transfacet approach route is a safe and effective technique to achieve adequate decompression without requiring instrumented fusion.

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

ObjectiveTo evaluate the clinical outcomes of transforaminal endoscopic thoracic discectomy (TETD) and microscopic discectomy (MD) for the treatment of symptomatic thoracic disc herniation (TDH). MethodsSeventy-seven patients (mean, 55.9 years; follow-up, 11.2 months) with symptomatic TDH were retrospectively reviewed (39 TETD and 38 MD). Radiological factors and perioperative outcomes were reviewed. Visual analogue scale (VAS), Oswestry Disability Index (ODI), and American Spinal Injury Association impairment scale were used to evaluate clinical and functional outcomes. Patient satisfaction was evaluated using modified MacNab criteria. ResultsThe levels of surgery and the location of hernia were evenly distributed in the both groups. The operative time (70.6 minutes vs. 175.7 minutes), estimated blood loss (3.8 mL vs. 357.4 mL), and length of hospital stay (7.0 days vs. 13.0 days) were significantly different between the TETD and MD groups (p<0.05). VAS scores for dorsal back pain and ODI scores were significantly improved in both groups (p<0.05). Patients who underwent TETD tended to be more satisfied with the outcome in terms of the modified MacNab criteria (89.7% vs. 73.0%, p=0.059). Two patients in the MD group underwent revision surgery, whereas one patient in the TETD group underwent MD because of incomplete decompression. ConclusionTETD for the symptomatic TDH is a feasible and safe procedure that could be used for a wider range of surgical levels with a shorter operative time and hospital stay and less blood loss. While achieving similar outcomes, TETD achieved better patient satisfaction because of the use of local anesthesia and its minimal invasiveness.

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.

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. 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. 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. 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.

Intracranial hypotension due to ventral thoracic dural tear secondary to osteophyte complex: resolution after transdural thoracic microdiscectomy with dural repair. Illustrative case.

BACKGROUNDIntracranial hypotension (IH) manifests with orthostatic headaches secondary to cerebrospinal fluid (CSF) hypovolemia. Common iatrogenic etiologies include lumbar punctures and spinal surgery. Although much rarer, structural defects such as osteophytes and herniated calcified discs can violate dural integrity, resulting in CSF leak.OBSERVATIONSThe authors reported the case of a 32-year-old woman who presented with progressively worsening orthostatic headaches. During an extensive examination, magnetic resonance imaging of her thoracic spine revealed a cervicothoracic ventral epidural collection of CSF, prompting a dynamic computed tomography myelogram, which not only helped to confirm severe cerebral hypotension but also suggested underlying pathology of a dorsally projecting disc osteophyte complex at T2–3. Conservative and medical management failed to alleviate symptoms, and a permanent surgical cure was eventually sought. The patient underwent a transdural thoracic discectomy with dural repair, which resulted in resolution of her symptoms.LESSONSClear guidelines regarding the management strategy of IH secondary to disc osteophyte complexes are yet to be established. A thorough literature review noted only 24 reported cases between 1998 and 2019, in which 13 patients received surgery. There is a 46% symptom resolution rate with conservative management, lower than that for iatrogenic etiologies. For patients in whom conservative management failed, surgical intervention proved effective in resolving symptoms, with a success rate of 92.3%.

444 Partial Transpedicular Thoracic Discectomy With Ultrasonic Aspiration and Ultrasound Guidance for Every Thoracic Disc Herniation: A 43-Patient Case Series and Technical Note Demonstrating Safety and Efficacy

INTRODUCTION: Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. METHODS: A retrospective review was performed of patients who underwent a thoracic discectomy through the partial transpedicular approach between January 2014 and 2020 by a single surgeon. Variables reviewed included demographics, peri-operative imaging, and functional outcome scores. RESULTS: 43 patients (53% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 9 ± 8.86 months. 23 (42.5%) of discs were fully calcified on imaging and 18 (33.3%) were partially calcified. 33 (61.1%) were giant TDH (&gt;40% canal compromise). Average operative time was 197 ± 77.1 minutes with an average blood loss of 238 ± 250 cc. 6 patients required ICU stays. Hospital length of stay was 4.37± 3.42 days. Of patients with follow-up MRI, 38 of 40 disc-levels (95%) demonstrated &lt;20% residual disc. Post-operative Frankel scores (&gt;3 months) were maintained or improved for all patients with 28 (65.1%) patients having an increase of 1 or greater on their Frankel score. 6 (14%) patients required repeat surgery, 2 of which were due to re-herniation, 2 were from adjacent level herniation and 2 others from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intra-operative neuromonitoring was associated with a greater improvement in Frankel grade. CONCLUSION: Here we demonstrate a minimally invasive, posterior approach that utilizes intraoperative ultrasound and ultrasonic aspiration with great outcomes and a complication profile similar or better than other reported case series. This posterior approach is a great complement to the spine surgeon’s arsenal for the confident tackling of all TDHs.

Transpedicular or Transthoracic Approach: An Outcome Comparison Study on Patients with Neurological Manifestation

Background: Approach to lower-thoracic spine for discectomy remains controversial. In this study, we compare primary and secondary outcomes of transpedicular (TP) and transthoracic (TT) approach for discectomy at lower thoracic levels in patients with neurological manifestations. Methods: In this retrospective study, 12 patients with TP or TT approach for lower thoracic discectomy with neurological manifestation, mainly foot drop, were included. During TP approach, cord manipulation was kept at minimum. Posterior fusion was performed in all patients. TT approach was performed by intended level thoracotomy, anterio-lateral fusion was achieved in this group. The postoperative primary and secondary outcomes of the approach were compared in these patients. SPSS software version 20 was used for analysis, and a P-value &lt; 0.005 was considered significant. Results: Twelve patients with neurological manifestation were operated using either of the approaches. Six patients in TP group and four in TT group attained complete neurological recovery after 10.2 and 7.6 weeks, respectively. The mean operative time was 50% more in TT approach. Blood loss in TP approach was less than half, and patients were mobilized earlier with decreased hospital stay. All patients with TT approach needed postoperative intensive care unit (ICU) admission, two of them developed pulmonary complications and postsurgical intercostal neuralgia, and one had cerebrospinal fluid (CSF) leak and readmission within 30 days of discharge. Conclusions: Although TT approach offers excellent exposure for discs in lower thoracic levels, it is associated with increased morbidity and higher complication rates. On the other hand, TP approach offers ample exposure with reduced operative time and blood loss, as well as early mobilization and discharge.

690 Intracranial Hypotension Due to CSF Leak Secondary to Ventral Thoracic Osteophyte Complex: Resolution After Transdural Thoracic Discectomy and Dural Repair

Abstract The hallmark symptom of spontaneous intracranial hypotension (SIH) is orthostatic headaches which manifests secondary to cerebrospinal fluid (CSF) hypovolaemia. Well-recognised aetiologies include trauma which includes procedures such as lumbar punctures and spinal surgery. More recently, structural defects such as bony osteophytes and calcified or herniated discs have been attributed to mechanically compromising dural integrity consequently resulting in CSF leak and symptom manifestation. A thorough literature review noted only a handful of such cases. We report the case of a thirty-two-year-old Asian female who presented with a one-month history of new-onset progressively worsening orthostatic headaches. Workup included MRI of the thoracic spine which revealed an epidural collection of CSF consequently prompting a dynamic CT-myelogram of the spine which not only helped to confirm severe cerebral hypotension but also suggested the underlying cause as being a dorsally projecting osteophyte-complex at level T2-3. Conservative and medical management including bed rest, analgesia, mechanical compression, and epidural blood patches failed to alleviate symptoms and a permanent surgical cure was eventually sought. The surgery involved T2-T3 laminectomy and osteophytectomy and at a 3-month follow-up, complete resolution of symptoms was noted.

Per Pedicel-Ligament Flavum Tunnel Outside-In Foraminoplasty for T10 -T12 Discectomy under a Percutaneous Endoscope.

ObjectiveTo describe the effectiveness of T10–T12 discectomy and per pedicel‐ligament flavum tunnel outside‐in foraminoplasty protocols under percutaneous endoscope.MethodsThis retrospective study from September 2017 to June 2019 comprised 10 patients (mean age was 64.7 years, with 7 men and 3 women) with symptomatic thoracic disc herniation. Patients who had 12 months of follow‐up and no cervical and lumbar spine surgery or trauma during the follow up period were included in the study. Patients underwent surgery at different levels: 3 patients for T10–T11 and 7 patients for T11–T12. Percutaneous endoscopic thoracic discectomy was performed following under‐vision foraminoplasty, which was based on lower pedicel‐ligament flavum tunnel detection. Patients who presented with symptomatic soft disc herniation of the thoracic spine and did not respond to conservative treatments were included. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament were excluded. The surgery involves four steps: (i) facet joint reaching procedures; (ii) sliding the working sleeve caudally to attach the pedicel, rotating the scope to detect the lower border of the superior articular process, the pedicel, and the lower pedicel‐ligamentum flavum tunnel (PEFT) under vision, respectively; (iii) milling the superior articular process under vision; and (iv) finding and removing the disc protrusion after the posterior longitudinal ligament is resected. Patient outcomes were evaluated using vision analog scale scores, Oswestry disability index scores, and Japanese Orthopaedic Association scores. The VAS scores, Oswestry disability index scores, and Japanese Orthopaedic Association scores before and after the operation were compared by t‐test for statistical analysis. MRI, CT, and plain X‐rays were performed in of all the patients before and after surgery.ResultsThe patient was usually able to stand and walk approximately 2 h after the surgery. During the 12‐month follow‐up, all patients showed a significant improvement in pain. Postoperative thoracic MRI examination of all patients showed full decompression of the spinal cord and no residual pressure. Postoperative back pain and nerve root pain were significantly alleviated in all patients, and spinal cord function was significantly restored. The mean visual analog scale scores of patients postoperation were significantly better than those of patients preoperation (6.10 ± 1.37 vs 1.80 ± 0.79, P < 0.05). The mean ODI scores of patients postoperation were better than those of patients preoperation (13% ± 2.36% vs 55% ± 9.20%, P < 0.05). The mean JOA scores increased from 3.2 ± 0.75 to 9.3 ± 0.64. The JOA improvement rate was 79.6% ± 5.1%. There was 1 patient who had transient intercostal neuralgia.ConclusionFollowing pedicel‐ligament flavum tunnel outside‐in foraminoplasty protocols, T10–T12 discectomy is relatively safe when conducted under percutaneous endoscope.