Transfacet Approach Research Articles

Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better?

To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes. Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH. A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal. This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01). No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.

The Importance of Planning Ahead: A Three-Dimensional Analysis of the Novel Trans-Facet Corridor for Posterior Lumbar Interbody Fusion Using Segmentation Technology

The rise of minimally invasive lumbar fusions and advanced imaging technologies has facilitated the introduction of novel surgical techniques with the trans-facet approach being one of the newest additions. We aimed to quantify any pathology-driven anatomic changes to the trans-facet corridor, which could thereby alter the ideal laterality of approach to the disc space. In this retrospective cohort study, we measured the areas and maximum permissible cannula diameters of the trans-facet corridor using commercially available software (BrainLab, Munich, Germany). Exiting and traversing nerve roots, thecal sacs, and lumbar vertebrae were manually segmented on T2-SPACE magnetic resonance imaging. Spondylolisthesis, disc protrusions, and disc space heights were recorded. A total of 118 trans-facet corridors were segmented bilaterally in 16 patients (65.6 ± 12.1 years, 43.8% female, BMI 29.2 ± 5.1 kg/m2). The mean areas at L1-L2, L2-L3, L3-L4, and L4-L5 were 89.4 ± 24.9 mm2, 124 ± 39.4 mm2, 123 ± 26.6 mm2, and 159 ± 42.7 mm2, respectively. The mean permissible cannula diameter at the same levels were 7.85 ± 1.43 mm, 8.98 ± 1.72 mm, 8.93 ± 1.26 mm, and 10.2 ± 1.94 mm, respectively. Both parameters increased caudally. Higher degrees for spondylolisthesis were associated with larger areas and maximum cannula diameters on regression analysis (p < 0.001). Our results illustrate that pathology, like spondylolisthesis, can increase the area of the trans-facet corridor. By understanding this effect, surgeons can better decide on the optimal approach to the disc while taking into consideration a patient's unique anatomy.

Using Novel Segmentation Technology to Define Safe Corridors for Minimally Invasive Posterior Lumbar Interbody Fusion.

There has been a rise in minimally invasive methods to access the intervertebral disk space posteriorly given their decreased tissue destruction, lower blood loss, and earlier return to work. Two such options include the percutaneous lumbar interbody fusion through the Kambin triangle and the endoscopic transfacet approach. However, without accurate preoperative visualization, these approaches carry risks of damaging surrounding structures, especially the nerve roots. Using novel segmentation technology, our goal was to analyze the anatomic borders and relative sizes of the safe triangle, trans-Kambin, and the transfacet corridors to assist surgeons in planning a safe approach and determining cannula diameters. The areas of the safe triangle, Kambin, and transfacet corridors were measured using commercially available software (BrainLab, Munich, Germany). For each approach, the exiting nerve root, traversing nerve roots, theca, disk, and vertebrae were manually segmented on 3-dimensional T2-SPACE magnetic resonance imaging using a region-growing algorithm. The triangles' borders were delineated ensuring no overlap between the area and the nerves. A total of 11 patients (65.4 ± 12.5 years, 33.3% female) were retrospectively reviewed. The Kambin, safe, and transfacet corridors were measured bilaterally at the operative level. The mean area (124.1 ± 19.7 mm2 vs 83.0 ± 11.7 mm2 vs 49.5 ± 11.4 mm2) and maximum permissible cannula diameter (9.9 ± 0.7 mm vs 6.8 ± 0.5 mm vs 6.05 ± 0.7 mm) for the transfacet triangles were significantly larger than Kambin and the traditional safe triangles, respectively (P < .001). We identified, in 3-dimensional, the borders for the transfacet corridor: the traversing nerve root extending inferiorly until the caudal pedicle, the theca medially, and the exiting nerve root superiorly. These results illustrate the utility of preoperatively segmenting anatomic landmarks, specifically the nerve roots, to help guide decision-making when selecting the optimal operative approach.

Clinical Outcome of Pedicle-Sparing Transfacet Diskectomy and Fusion with Segmental Instrumentation for Thoracic Disc Herniation.

Thoracic disk herniations (TDHs) are relatively rare compared with their cervical and lumbar counterparts. Posterior approaches allow for a simpler and less invasive surgery than anterior and lateral approaches. A pedicle-sparing transfacet approach was initially described in 1995, and modified in 2010. A few clinical series have reported the outcome of this procedure in patients with TDH. This study aimed to evaluate the outcomes and complications of pedicle-sparing transfacet diskectomy with interbody fusion and segmental instrumentation in patients with TDH. Twenty-one consecutive patients with symptomatic TDH referred to our tertiary care center were included in this retrospective study. All patients underwent a pedicle-sparing transfacet diskectomy with polyetheretherketone (PEEK) cage interbody fusion and short segmental instrumentation. Distribution of TDH, operative duration, blood loss, Visual Analog Scale (VAS) pain scores, Nurick grades, modified Japanese Orthopaedic Association (mJOA) scores, and fusion rate were assessed. All patients had single-level herniations. The most common location was T12-L1 (38.1%), followed by T11-T12 (33.3%). All patients were successfully operated on with no cerebrospinal fluid (CSF) leaks or wrong-level surgery. The VAS scores significantly diminished from 4.9 (preoperatively) to 2 (18 months after surgery). The average mJOA score increased from 4.6 to 8.5, and the average Nurick grade decreased from 3.1 to 1.6. All patients reported significant improvement in quality of life relative to their preoperative status. A modified pedicle-sparing transfacet diskectomy combined with PEEK cage interbody fusion and segmental instrumentation offers a safe and less invasive approach for the treatment of TDHs.

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.

Management of single-level thoracic disc herniation through a modified transfacet approach: A review of 86 patients.

Background: Symptomatic thoracic disc herniation (TDH) is rare and does not typically resolve with conservative management. Traditional surgical management is the transthoracic approach; however, this approach can carry significant risk. Posterolateral approaches are less invasive, but no single approach has proven to be more effective than the other results are often dependent on surgeon experience with a particular approach, as well as the location and characteristics of the disc herniation.Methods: This was retrospective review of a prospectively collected database. Eighty-six patients with TDH treated surgically through the modified transfacet approach were reviewed and evaluated for pain improvement, Nurick grade, and neurological symptoms. Patients were followed for 12 months postoperatively; estimated blood loss, length of hospital stay, hospital course, and postoperative complications were also assessed.Results: All attempts at disc resection were successful. Most patients reported improvement in pain, sensory involvement, and strength. Seventy-nine patients had complete resolution of their symptoms while four patients had unchanged symptoms. Three patients experienced mild neurologic worsening postoperatively, but this resolved back to baseline. One patient experienced myelopathy during the postoperative period that resolved with steroid administration. The procedure was well tolerated with minimal complications.Conclusion: TDH can be managed surgically through a variety of approaches. The selection of approach is dependent on surgeon experience with an approach, the patient’s health, and the location and type of disc. The transfacet approach is safe and efficacious.

Transforaminal Percutaneous Endoscopic Lumbar Discectomy Through a Transfacet Approach: Detailed Surgical Technique

Journal of Minimally Invasive Spine Surgery & Technique (JMISST) is the official journal of the Korean Minimally Invasive Spine Surgery Society (KOMISS) for the publication of research results about minimally invasive spinal surgery (MISS), including studies in spinal endoscopic surgery, minimally invasive procedure for degenerative spine disease, pain intervention, and minimally invasive surgery for spinal fusion or spine trauma, neuroscience, neurology, molecular biology and biomechanics etc. Articles with helpful information for MISS such as reports of rare cases or technical review of special devices or equipment are also available

Impact Factors on Posterior Modified Transfacet Debridement for Thoracic Spinal Tuberculosis Basing on Regression and Classification Analysis

Posterior transfacet approach has been proved to be a safe and effective access to treat thoracic disc herniation. However, the influencing factors of posterior modified transarticular debridement for thoracic tuberculosis have not been reported in the clinical literature. From 2009 to 2014, 37 patients with TST underwent a posterior modified transfacet debridement, interbody fusion following posterior instrumentation, under the cover of 18 months of antituberculosis chemotherapy. The patients were evaluated preoperatively and postoperatively in terms of Frankel Grade, visual analog scale (VAS) pain score, kyphotic Cobb angle, and bone fusion. Blood loss (positive correlation) and focal debridement (positive correlation) could affect operative time. Operative time (positive correlation) could affect blood loss. While, age (positive correlation), PostE (negative correlation), and T_FocalDebridement (positive correlation) could affect bone fusion. The accuracy of naive bayes classifier model is 86.11%. Our preliminary results show that blood loss and focal debridement could affect operative time; operative time could affect blood loss; age, PostE, and T_FocalDebridement could affect bone fusion; the naive Bayes classifier model can predict the KirkaldyWillis accurately.

Symptomatic Lumbar Juxtafacet Cyst Treated by Full Endoscopic Surgery

Juxtafacet cysts (JFCs) include both synovial and ganglion cysts adjacent to a spinal facet joint or arising from the ligamentum flavum of the spinal facet joints. Various treatments have been proposed; however, a surgical approach appears to be most effective. The aim of this study was to review patients with lumbar JFCs treated using a full endoscopic approach and elaborate the details of the surgical routes and techniques and their merits and pitfalls. All patients with lumbar JFCs underwent complete endoscopic cyst removal. Muscle power, visual analog scale score, modified MacNab criteria score, and magnetic resonance imaging were assessed during follow-up. The study enrolled 8 patients. Five patients received an interlaminar approach, 2 patients received a transforaminal approach, and 1 patient received a transfacet approach. Visual analog scale scores decreased from a mean of 7.75 (range, 5-10) before surgery to 0.625 (range, 0-2) after surgery, and modified MacNab criteria score ranged from good to excellent after surgery. No neurologic injuries were observed. JFCs could be effectively treated by full endoscopic surgery. The type of approach should be based on the anatomic site of the lesion and the condition of the patient. The interlaminar approach is appropriate for cysts located in the lower segment with larger interlaminar space. The transforaminal or transfacet approach is preferred for patients for whom general anesthesia is a high risk.

Herniated Disc at the Upper Lumbar Region: Surgical Technique and Clinical Outcomes

Background Data: Upper lumbar disc herniation involving D12/L1, L1/L2, and L2/L3 levels is less prevalent than lower lumbar discs. In terms of clinical characteristics and surgical managements, they are different from those at the lower levels of the lumbar spine. Spinal canals are narrower than those of the lower levels, which may compromise multiple spinal nerve roots or conus medullaris with higher complication rate with surgical intervention. Purpose: To investigate the clinical features and surgical outcomes of patients operated on for upper lumbar disc herniations. Study Design: Retrospective clinical cohort study. Patients and Methods: This study included 20 patients diagnosed with herniated disc at upper levels (T12-L1, L1-L2, and L2-L3). Patients were operated on during the period between June 2015 to March 2017. All patients were operated on via transfacet approach with pedicle screw fixation. Postoperative data including clinical and neurological outcomes and radiographic imaging have been collected. Postoperative follow-up evaluation included immediate postoperative medical records and a postoperative visit to the outpatient clinic until 18 months postoperatively. Patients’ outcomes were assessed using Visual Analogue Scale of radicular and back pain and Oswestry Disability Index (ODI) as functional score. Results: Over a mean follow-up period of 13±2.5 months, there was significant improvement in radicular pain (P = 0.0026) and back pain (P = 0.049) and myelopathy and statistically significant improvement in Oswestry Disability Index (ODI) (P = 0.0032) compared to the preoperative value. No postoperative complications were detected in this series. Conclusion: This approach offers a safe technique for decompression and stabilization at lower thoracic and upper lumbar region. (2019ESJ178)

Microsurgical Experience with Pedicle-Sparing Transfacet Approach for Thoracic Disk Herniation.

Thoracic disk herniation (TDH) is relatively uncommon. The surgical approach differs from lumbar or cervical disk herniations because serious complications are associated with the posterior approach in TDH. Various different approaches have been tried for the surgical removal of TDH, but most of them are cumbersome surgeries such as thoracotomy or thoracoscopic or anterior approaches with or without instrumentation. The requirement for a simplified, familiar, and less morbid surgery has motivated some new approaches. A pedicle-sparing transfacet approach (PSTA) was first described in 1995, but to date no sufficient clinical series has been presented in the literature to report on its feasibility and applicability along with complication and morbidity rates. Our objective was to assess the feasibility of the PSTA under microscopic visualization in a cumulative clinical series. Twenty-eight consecutive patients with no response to medical/physical treatment with and without motor weakness of their lower extremities underwent the surgery for TDH via the PSTA under microscopic visualization by a senior neurosurgeon. Preoperative and postoperative low extremity muscle strength, sensation, reflex status, and visual analog scores (VAS), Nurick grades, and complications were recorded. Postoperative MRI within 24 hours was performed. The median follow-up period was 33 months. The patients consisted of 16 men and 12 women. The disk levels ranged from T8 to T12-L1. All but one patient received one-level surgery. One patient was operated on two levels. A total of 21 patients had paracentral disk herniations; the other 7 had central disk herniations. Postoperative MRI showed satisfactory removal of disk herniation in all but one patient. There was no infection, wrong level surgery, or incidental durotomy. Median VAS levels significantly improved after the operation from 7.4 to 2.3. The Nuric grades decreased from 2.7 to 1.6 after surgery. The microsurgical PSTA is a safe and feasible technique with a significantly shorter surgeon's learning curve. The approach offers a wide surgical window; moreover, it can by increased by tilting the surgical table allowing satisfactory decompression of TDH. After PSTA, segmental instrumentation is not required.

Preliminary experience in treating thoracic spinal tuberculosis via a posterior modified transfacet debridement, instrumentation, and interbody fusion

BackgroundPosterior transfacet approach has been proved to be a safe and effective access to treat thoracic disc herniation. However, the therapeutic effect and safety of modified transfacet approach for treating thoracic spinal tuberculosis (TST) has not been reported in the clinical literature. In this study, the clinical efficacy and safety of a single-stage posterior modified transfacet debridement, posterior instrumentation, and interbody fusion for treating TST were retrospectively evaluated.Patients and methodsFrom 2009 to 2014, 37 patients with TST underwent a posterior modified transfacet debridement, interbody fusion following posterior instrumentation, under the cover of 18 months of antituberculosis chemotherapy. The patients were evaluated preoperatively and postoperatively in terms of Frankel Grade, visual analog scale (VAS) pain score, kyphotic Cobb angle, and bony fusion.ResultsThe follow-up time was 39.8 ± 5.1 months (29–50 months). No postoperative complication or recurrence of spinal tuberculosis was observed. Definitive bony fusion was achieved in all patients. At the final follow-up, 2 cases were rated as Frankel grade D, 35 as grade E. VAS was recovered from 8.4 ± 1.0 cm to 0.4 ± 0.8 cm. The kyphotic angles were corrected from 29.4 ± 10.9° to 17.6 ± 6.3°. Using the Kirkaldy-Willis criteria, functional outcome was excellent in 29 patients, good in 7, and fair in 1.ConclusionsOur preliminary results showed that single-stage posterior modified transfacet debridement, posterior instrumentation, and interbody fusion are effective and safe surgical options for treating TST.

Percutaneous Endoscopic Lumbar Surgery via the Transfacet Approach for Lumbar Synovial Cyst

There are currently no high-quality studies on the optimal therapeutic approach for juxtafacet cyst, as treatment guidelines have not been developed. Herein, a novel technique in which we used an endoscopic transfacet approach to treat a patient with symptomatic lumbar synovial cyst is presented. An 87-year-old man presented with severe dull pain in the right anterior thigh. Lumbar magnetic resonance imaging revealed disc extrusion over the central canal zone at the L2-L3 and L4-L5 levels and an ovoid lesion with a hyperintense center plus a hypointense rim on the T2-weighted image. The lesion was located over the medial side of the right juxtafacet region at the L2-L3 level, causing thecal sac compression. After the operation, the visual analog pain scale improved with a value of 0-1/10, and straight leg raise test was negative. Microscopically, cystic fibrous tissue with focal myxoid degeneration, fibrin exudate, and scant synovial-like lining was observed. These findings were consistent with clinical synovial cyst. Three months later, lumbar magnetic resonance imaging was performed, and no evidence of cyst was disclosed. Lumbar computed tomography revealed the upper part of left L2-L3 facet joint was removed. The patient did not report any radicular pain during the 6-month follow-up period. Percutaneous endoscopic lumbar surgery could be a new option for the management of lumbar synovial cysts, especially when general anesthesia is not appropriate for the patient.

The Clinical Outcomes Of Patients With L1-L2 Disc Herniation Treated By Microsurgical Trans Facet Approach

Background: In comparison to lower lumbar disc herniation, L1-L2 disc herniation has unique characteristics, which cause controversy in selection of surgical approach. The goal of this study was to evaluate the clinical outcomes for treatment of L1-L2 disc herniation by microsurgical transforaminal lumbar interbody fusion (TLIF) technique. Therefore, 37 symptomatic patients of L1-L2 disc herniation who were treated by TLIF, from 2008 to 2016, in three academic hospitals were reviewed retrospectively. Follow-up of these patients should significant clinical improvement following TLIF surgery (p-value <0.001) and acceptable bony union with respect to the results, we concluded that TLIF can be an effective, reproducible and safe technique for surgical treatment of L1-L2 disc herniation.

THORACIC DISC HERNIATION: SURGICAL DECOMPRESSION BY POSTERIOR APPROACH A LA CARTE

ABSTRACT Objectives: To present the clinical and radiographic results of patients with thoracic disc herniation treated by the posterior approach, according to location and type of hernia (à la carte). Methods: We evaluated thirteen patients (14 hernias) treated by the posterior approach. Eight (61.5%) patients were male and the mean age was 53 years (34-81). Clinical evaluation was performed by the Frankel and JOA modified scales. All the patients underwent the posterior approach, which was performed by facetectomy, transpedicular approach, transpedicular + partial body resection, costotransversectomy or costotransversectomy + reconstruction with CAGE. Results: The mean follow-up was 2 years and 6 months (11-77 months). Of the 14 operated hernias, six (43%) were lateral, 2 (14%) paramedian, and 6 (43%) central. Seven were soft (50%) and seven were calcified. The transfacet approach was carried out in 5 cases (36%), transpedicular in 1 case (7%), transpedicular + partial body resection in 4 (29%), costotransversectomy in 3 (21%), and costotransversectomy + CAGE in one case (7%). The majority of patients with lateral hernia (5/6) were subjected to transfacet decompression and in cases of central and paramedian hernias, all patients underwent decompression, which is more extensive. Conclusions: The posterior approach is safe and effective, and the best approach must be chosen based on location and type of the herniation and the surgeon's experience.

Surgical Treatment for Central Calcified Thoracic Disk Herniation: A Novel L-Shaped Osteotome.

Few reports are available on the posterior transfacet approach for the treatment of central calcified thoracic disk herniation (TDH). The objective of this study was to assess outcomes and complications in a consecutive series of patients with TDH who underwent posterior transfacet decompression and diskectomy with segmental instrumentation and fusion. The data for 27 patients (16 males and 11 females) were retrospectively reviewed and analyzed, including clinical presentation, blood loss, operative time, pre- and postoperative complications, visual analog scale, Japanese Orthopedic Association (JOA) score, and Frankel grade. All patients underwent trans-facet decompression and segmental instrumentation with interbody fusion. Mean patient age at surgery was 55.2 years (range, 21-81 years). Average follow-up was 30±19 months (range, 12-50 months). All patients were successfully treated with posterior decompression and segmental instrumentation with interbody fusion. Average operative time was 124±58 minutes (range, 87-180 minutes). Mean blood loss was 439±225 mL (range, 300-1500 mL). Average pre- and postoperative JOA scores were 4.12±0.87 and 8.01±0.97 points, respectively. Overall JOA scores showed a significant postoperative improvement. Overall recovery rates were excellent in 12 patients, good in 6, fair in 5, and unchanged in 1. No patient was classified as worse. The results suggest that the posterior approach using a special L-shaped osteotome is feasible. No major complications occurred while achieving adequate decompression for central calcified TDH.

Thoracic discectomy by posterior pedicle-sparing, transfacet approach with real-time intraoperative ultrasonography: Clinical article.

Symptomatic thoracic disc herniations (TDHs) are relatively uncommon, and the technical challenges of resecting the offending disc are formidable due to the location of spinal cord that has relatively poor perfusion characteristics within a narrow canal. The majority of disc herniations are long-standing calcified discs that can be adherent to the ventral dura. Real-time intraoperative ultrasound (RIOUS) visualization of the spinal cord during the retraction and resection of the disc greatly enhances the safety and efficacy of disc resection. The authors have adopted the posterior laminectomy with pedicle-sparing transfacet approach with real-time ultrasound guidance in their practice, and they present the clinical outcome in their patients to illustrate the safety profile of this technique. Sixteen consecutive patients undergoing operative management of TDHs were identified from the authors' database. All patients underwent microdiscectomy through a posterior transfacet pedicle-sparing approach under RIOUS. Outcomes and complications were retrospectively assessed in this patient series. Clinical records and pre- and postoperative imaging studies were scrutinized to assess levels and types of disc herniation, blood loss, surgical time, pre- and postoperative Nurick grades, Japanese Orthopaedic Association (JOA) scores, and complications. All patients had single-level symptomatic TDHs. The patients presented with symptoms including thoracic myelopathy, axial back pain, urinary symptoms, and thoracic radiculopathy. Thoracic disc herniations involved levels T2-3 to T12-L1. Discs were classified as central or paracentral, and as calcified or noncalcified. All discs were successfully removed with no incidence of neural injury or CSF leak. The mean estimated blood loss was 523 ml, and the mean surgical time was 159 minutes. Nurick grades improved on average from 3.3 to 1.6. The mean JOA scores improved from 5.7 to 8.3 out of 11. The mean Hirabayashi recovery rate of the JOA score was 57%. All patients reported improvement in symptoms compared with preoperative status except for 1 patient with an American Spinal Injury Association Grade A spinal cord injury prior to surgery. The average duration of follow-up was 10.5 months. One patient developed postoperative wound infection that required additional operative debridement and revision of hardware. Thoracic discectomy via a posterior pedicle-sparing transfacet approach is an adequate method of managing herniations at any thoracic level. The safety of the operation is significantly enhanced by the use of realtime intraoperative ultrasonography.

Surgical treatment of thoracic disc herniations using a modified transfacet approach.

Background:Ideal surgical treatment for thoracic disc herniation (TDH) is controversial due to variations in patient presentation, pathology, and possible surgical approach. Althougth discectomy may lead to improvements in neurologic function, it can be complicated by approach related morbidity. Various posterior surgical approaches have been developed to treate TDH, but the gold standard remains transthoracic decompression. Certain patients have comorbidities and herniation that are not optimally treated with an anterior approach. A transfacet pedicle approach was first described in 1995, but outcomes and complications have not been well described. The aim of this work was to evaluate the clinical effect and complications in a consecutive series of patients with symptomatic thoracic disc herniations undergoing thoracic discectomy using a modified transfacet approach.Materials and Methods:33 patients with thoracic disc herniation were included in this study. Duration of the disease was from 12 days to 36 months, with less than 1 month in 13 patients. Of these, 15 patients were diagnosed with simple thoracic disc herniation, 6 were associated with ossified posterior longitudinal ligament, and 12 with ossified or hypertrophied yellow ligament. A total of 45 discs were involved. All the herniated discs and the ossified posterior longitudinal ligaments were excised using a modified transfacet approach. Laminectomy and replantation were performed for patients with ossified or hypertrophied yellow ligament. The screw–rod system was used on both sides in 14 patients and on one side in l9 patients.Results:29 patients were followed up for an average of 37 months (range 12-63 months) and 4 patients were lost to followup. Evaluation was based on Epstein and Schwall criteria.5 15 were classified as excellent and 10 as good, accounting for 86.21% (25/29); 2 patients were classified as improved and 2 as poor. All the patients recovered neurologically after surgery. A total of 25 patients had significantly improved motor function from 3 to 6 months after surgery and 10 patients had slow recovery 6 months after surgery.. Of the three patients with postoperative complications, two had exacerbated preexisting defects and one had implant failure. Postoperative computed tomography or magnetic resonance imaging showed that all patients had well fused replanted lamina and completely decompressed canal.Conclusion:Thoracic discectomy using a modified transfacet approach can significantly improve the clinical outcomes.

Improved outcomes with direct percutaneous CT guided lumbar synovial cyst treatment: advanced approaches and techniques

PurposeTo determine if lumbar synovial cyst rupture in symptomatic patients results in improved clinical outcome when using direct tandem and/or coaxial percutaneous CT guided techniques.Materials and methods20 patients with unilateral...

Approaches in injections for radicular pain: The transforaminal, epidural and transfacet approaches

Spinal injections must be carried out adhering to very strict conditions. However, these procedures have almost come to be seen as everyday and may be practised under quite questionable conditions. The recent reports of new and extremely serious neurological complications have changed the attitudes of those making referrals as well as the attitudes of the interventional radiologists carrying out these procedures. The range of indications for transforaminal injections has shrunk in favour of epidural injections. Where the transforaminal approach is still used, the needle must be positioned extremely accurately. A prior radioopaque contrast medium injection is essential from a safety perspective. The transforaminal epidural injection via the transfacet approach looks to be a promising alternative that is strictly avascular.