Thoracic Discectomy Research Articles

Multilevel anterior thoracic discectomies and anterior interbody fusion using a microsurgical thoracoscopic approach

A video-assisted thoracoscopic microsurgical approach was performed to treat a myelopathic patient with a severe kyphotic deformity caused by chronic nonunion of compression fractures of the T7-9 vertebrae. The kyphotic deformity was treated by combined operative procedures. First, an anterior release was performed using a thoracoscopic technique, sectioning the anterior longitudinal ligament and performing multilevel thoracic discectomies. Next, a posterior reduction and internal fixation of the deformity was achieved using hook-rod instrumentation. Finally, bone graft harvested during the posterior approach was used for interbody fusion via a thoracoscopic approach. Microsurgical thoracoscopic techniques potentially can be used in a variety of spinal surgeries. Compared to transthoracic and posterolateral approaches, this technique presents distinct advantages to treatment of anterior spinal pathology. The small incisions made into the intercostal spaces without retracting the ribs may reduce postoperative pain, shorten the length of hospitalization, and allow early return to activity. The operative techniques used in this case are described in detail. This report demonstrates that thoracoscopic discectomies and interbody fusion are technically feasible and can be effectively performed with acceptable results.

Laparoscopic approaches to the lumbar vertebrae. An anatomic study using a porcine model.

This study described and compared retroperitoneal and transperitoneal laparoscopic approaches to the lumbar vertebrae in pigs. Technical and perioperative complications were evaluated for each approach. The objective of this study was to develop a laparoscopic approach to the lumbar vertebrae that is associated with minimal technical and perioperative complications. Laparoscopic techniques have been used extensively in many surgical fields. Recently, thoracoscopy has been used to perform a number of thoracic spinal procedures, including thoracic discectomy, and anterior osteotomy, release, and fusion. To date, there have been no published reports describing laparoscopic approaches to the lumbar vertebrae. With all pigs positioned in left lateral recumbency, retroperitoneal and transperitoneal laparoscopic approaches to the lumbar vertebrae were performed in three pigs. Placement of the insufflation needles and trocar ports were determined for each approach. Dissection of the lumbar vertebrae were performed, and the technical and perioperative complications recorded. Radio-opaque markers were placed to identify the dissected lumbar intervertebral disc spaces, and intraoperative fluoroscopy was used to confirm marker placement. Gross anatomic dissections were performed after the pigs were killed. Loss of pneumoretroperitoneum resulted in surgical termination in two of three pigs undergoing retroperitoneal laparoscopic approach to the lumbar vertebrae. In the remaining pig, difficulty was encountered in mobilization of the psoas major muscle from the lumbar vertebrae, and significant bleeding occurred. The transperitoneal approach to the lumbar vertebrae resulted in rapid mobilization of the psoas musculature and exposure of the lumbar vertebral bodies and discs of L1-L6/L7. Intraoperative complications included minimal bleeding and difficulty encountered in mobilization of the renal vascular pedicle. The retroperitoneal approach was difficult because of the degree of muscle dissection required for exposure of the lumbar vertebrae. Complications associated with the retroperitoneal approach included loss of pneumoretroperitoneum because of entry into the peritoneal cavity, hemorrhage, and limited exposure of the lumbar vertebrae. The transperitoneal approach was easier technically, allowing identification and access to lumbar vertebral bodies and intervertebral discs from L1-L6/L7. Operative complications associated with the transperitoneal laparoscopic approach were minimal.

The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery. A prospective multicenter study comprising the first 100 consecutive cases.

A prospective multicenter study on 100 consecutive surgical procedures. A prospective multicenter study was performed to evaluate the early perioperative complications in 100 endoscopic spinal procedures--78 video-assisted thoracic surgical procedures and 22 laparoscopic lumbar instrumentation and fusion procedures. Endoscopic procedures have been widely applied in general surgery for appendectomy, cholecystectomy, liver resection, Nissen fundoplication, colon resection, and hernia repairs. Video-assisted thoracic surgery is widely used for pleural biopsy, lung resection, and sympathectomy. This is the first large series to date investigating the safety and potential complications using endoscopic surgery for anterior decompression or fusion of the thoracolumbar spine. Video-assisted thoracic surgical procedures included multilevel anterior thoracic releases for deformity, 27 patients; anterior thoracic discectomies with spinal canal decompression, 41 patients; pyogenic vertebral osteomyelitis decompression, 2 patients; and vertebral corpectomy for neurologic decompression, 8 patients. Mean operative time was 2 hours, 34 minutes (range, 45 minutes to 6 hours), and mean length of stay was 4.97 days (range, 2-21 days). Anterior laparoscopic interbody stabilization and fusion at L4-5 or L5-S1 was performed in 22 patients. The mean operative time was 4 hours, 17 minutes (range, 2 hours, 40 minutes to 9 hours), and the mean length of stay was 5.6 days (range, 1-23 days). The most common video-assisted thoracic surgical complications were transient intercostal neuralgia (six patients) and atelectasis (five patients). The most common laparoscopic complication was bone graft donor site infection (two patients). There were two endoscopic cases that were converted to open procedures, one for extensive pleural adhesions and one for a common iliac vein laceration. The endoscopic spinal approaches proved to be safe operative procedures in 100 consecutive cases. There were no permanent iatrogenic neurologic injuries and no deep spinal infections.

A Technical Report on Video-Assisted Thoracoscopy in Thoracic Spinal Surgery|Preliminary Description

This report is a preliminary description of the efficacy of video-assisted thoracoscopic surgery in thoracic spinal procedures that otherwise require open thoracotomy. This report sought to describe the efficacy of video-assisted thoracoscopic surgery in thoracic spinal procedures that otherwise require open thoracotomy. In a landmark study that compared video-assisted thoracoscopic surgery for peripheral lung lesions with thoracotomy, video-assisted thoracoscopic surgery reduced postoperative pain, improved early shoulder girdle function, and shortened hospital stay. Video-assisted thoracoscopic surgery was performed in 12 thoracic spinal patients (herniated nucleus pulposus, infection, tumor, or spinal deformity) and is described in detail in this report. Video-assisted thoracoscopic surgery in thoracic spinal surgery resulted in little postoperative pain, short intensive care unit and hospital stays, and little or no morbidity. In the short follow-up period, there was no post-thoracotomy pain syndrome nor neurologic sequelae in these patients. Operative time decreased dramatically as experience was gained with the procedure. Given consistently improving surgical skills, a number of thoracic spinal procedures using video-assisted thoracoscopic surgery, including thoracic discectomy, internal rib thoracoplasty, anterior osteotomy, corpectomy, and fusion, can be performed safely with no additional surgical time or risk to the patient.

Posterolateral Arthroscopic Discectomies of the Thoracic and Lumbar Spine

Posterolateral arthroscopic discoscopies were performed on the lumbar and thoracic spine of the cadaver of a 6-foot-tall man. The purpose of this study was to determine the anatomic relationships of the discotomies and to examine the feasibility of the procedure for thoracic discectomies. At most levels in the thoracic spine, the rib neck acted as a guide to the posterolateral disc and as a safeguard against penetration of the pleural cavity. The average distance from the dura to the discotomy was 0.79 cm, with this distance increasing caudally. The thoracic nerve roots were found, in general, to be at less risk of damage because of their initial posterolateral course as they entered the subcostal groove. In the lumbar spine, the average distance from discostomy to the dura was 11.5 mm. Access to the triangular working zone could be gained with angles of insertion ranging from 38 degrees to 65 degrees. At angles less than 35 degrees, there was a significant risk of nerve injury. It is concluded that some thoracic discs can be safely removed through this approach and that the lumbar ventral ramii are very vulnerable to injury because of their proximity to the annulotomy.

Thoracic discectomy using video assisted thoracoscopy.

The applicability of using video assisted thoracoscopic surgery (VATS) to resect thoracic discs was investigated. A laboratory study was conducted using two human cadavers and three live pigs as surgical specimens. A total of nine thoracic levels were decompressed. To study the feasibility of performing thoracic resections using VATS. VATS has been used by thoracic surgeons since 1991 to resect pulmonary lesions. As far as we know, VAT has not yet been used to resect thoracic discs. Surgical resections of nine disc levels were carried out in two human cadavers and three anesthetized pigs. VATS was used to provide the surgeon with visualization of the surgical site. Large thoracotomy incisions were not necessary. Five of seven cadaver disc spaces and two of three porcine disc spaces were adequately evacuated of disc material. One episode of dural violation occurred. One animal died during the procedure from an anesthetic complication. VATS provides a useful means of performing thoracic discectomies using a small thoracotomy incision. The decrease in invasiveness provided by this new technology may reduce operative morbidity, hospitalization time, and costs. More work is needed, especially in the design of instrumentation, before this becomes a viable alternative to current surgical procedures.