Treatment Of Thoracic Disc Herniation Research Articles

Endoscope-assisted minimally invasive transforaminal thoracic interbody fusion

Surgical treatment of thoracic disc herniation is technically challenging from anterior, lateral or posterior approaches. Because of the deeply located thoracic discs and non-retractable thoracic thecal sac, standard anterior and lateral procedures for discectomy require extensive tissue dissection causing prolonged lengths of stay in hospital. In this video, the authors present a case of calcified disc herniation at the level of T10/11 causing paraplegia and voiding difficulty. The patient was operated on via an endoscope-assisted minimally invasive transforaminal thoracic interbody fusion (EA-TTIF). The herniated disc and calcification were removed through a 26-mm tubular retractor, under microscopes via a unilateral transpedicular approach. The endoscopes were used for direct visualization of the ventral thecal sac and confirmation of complete decompression. After the operation, the patient's neurological function completely recovered. Minimally invasive EA-TTIF is a viable and effective option for the surgical management of thoracic disc herniation. Thoracic interbody fusion can be achieved through a minimally invasive approach from the back. The video can be found here: http://youtu.be/54rRMtvSyCM.

Endoscopic Transforaminal Thoracic Foraminotomy and Discectomy for the Treatment of Thoracic Disc Herniation

Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery.

National Trends in the Treatment of Thoracic Disc Herniation with and without Myelopathy: Analysis of 9,811 Patients

National Trends in the Treatment of Thoracic Disc Herniation with and without Myelopathy: Analysis of 9,811 Patients

Reviewer’s comment concerning “Surgical treatment of thoracic disc herniations via tailored posterior approaches” (doi:10.1007/s00586-011-1821-7 R1 by W. Börm et al.)

This paper reports the idea of the authors on the possibility to find “a posterior-tailored approach” for the surgical treatment of thoracic disc herniations. This possibility is based essentially on the site of pathology; approaches related to localization at different levels of the thoracic spine. The results of the study in terms of local pain reduction, of radicular pain, increased motor strength, sensitivity and myelopathy improvement and JOA score are almost similar to those reported in other series with a higher number of patients [1]. First of all, I congratulate the authors for the effort made to systematize this pathology because only a few centers in the world have great experience and relevant series. I am also really convinced that they made every effort to introduce the reviewers’ tips in their paper, and everyone agrees to cancel the open thoracotomy approaches in this pathology, especially, for the high rate of morbidity. However, we must not forget that today, the surgical approaches to thoracic disc herniations may not only include costo-transversectomy, lateral extracavitary, foraminotomy, transfacet and/or transpedicular, and interlaminar. Today it is mandatory to include and hold onto endoscopic approaches, or at least transpendicular approaches with endoscopic assistance, as key choices for median and or calcified disc herniations [2]. On the other hand, we are completely convinced that the learning curve for this technique is really long, especially given to the low number of cases that the majority of spine departments receive each year. Exactly for this reason, unless in an emergency due to rapid neurological deteriorations, these patients should be treated and sent to the most appropriate reference centers. Finally, I believe that the most important criteria in the decision of a surgical strategy should be a contemporary balance between clinical data, type of hernia, soft or hard, but in particular the place of the same with respect to the spinal canal: median, paramedian, lateral or far lateral. So their results are commendable, but the correlation between these parameters was not considered [3].

Surgical treatment of thoracic disc herniations via tailored posterior approaches

We present clinical findings, radiological characteristics and surgical modalities of various posterior approaches to thoracic disc herniations and report the clinical results in 27 consecutive patients. Within an 8-year period 27 consecutive patients (17 female, 10 male) aged 30-83 years (mean 53 years.) were surgically treated for 28 symptomatic herniated thoracic discs in our department. Six of these lesions (21%) were calcified. In all cases surgery was performed via individually tailored posterior approaches. We evaluated the pre- and postoperative clinical status and the complication rate in a retrospective study. Nearly one half of the lesions (46.4%) were located at the three lowest thoracic segments. Clinical symptoms included back pain or radicular pain (77.8%), altered sensitivity (77.8%), weakness (40.7%), impaired gait (51.9%) or bladder dysfunction (22%). Costotransversectomy was performed in 8 patients, 1 lateral extracavitary approach, 2 foraminotomies, 15 transfacet and/or transpedicular approaches and 2 interlaminar approaches were used for removing the pathologies. After a mean follow-up of 38.6 months (3-100 months), complete normalization or reduction of local pain was recorded in 87% of the patients and of radicular pain in 70% of the cases, increased motor strength could be achieved in 55%, sensitivity improved in 76.2% and improvement of myelopathy was noted in 71.4%. Two patients suffered from postoperative impairment of sensory deficits, which in one case was discrete. The overall recovery rate within the modified JOA score was 39.5%. In 1 patient, two revisions were required because of instability and a persisting osteophyte, respectively. The rate of major complications was 7.1% (2/28). Surgical treatment of thoracic disc herniations via posterior approaches tailored to the individual patient produces satisfying results referring to clinical outcome. Posterior approaches remain a viable alternative for a large proportion of patients with symptomatic thoracic disc herniations.

Video-Assisted Thoracoscopic Surgery Combined With a Tubular Retractor System for Minimally Invasive Thoracic Discectomy

Several approaches have been proposed for the treatment of thoracic disc herniations. Posterior approaches include transpedicular, costotransversectomy, and lateral extracavitary; anterior approaches include retropleural and transpleural thoracotomy and thoracoscopy. We present a novel minimally invasive approach to thoracic discectomies, combining thoracoscopy and a tubular retractor system. We discuss the utility and safety of this technique. The patient is placed in a lateral decubitus position, with a double-lumen endotracheal tube for single-lung ventilation. With use of thoracoscopic techniques, the disc space is identified; approximately 2 cm of the head and neck of the rib is removed to expose the pedicle of the lower vertebral body. The tubular retractor is deployed with continuous thoracoscopic visualization and a trough is created anterior to the canal by drilling the adjacent vertebral bodies straddling the disc space. The operative microscope is utilized to dissect the disc, pulling it anteriorly into the trough. There were 5 patients in the past 9 months who were candidates for anterior thoracic discectomy. Disc herniations from T3-4 to T10-11 were treated without any significant complications. Patients were followed up clinically and radiographically. Combining thoracoscopy with the tubular retractors allows continuous monitoring of the lung, aorta, and vena cava during the placement of the retractors. Additionally, use of the tubular retractors, as opposed to a complete thoracoscopic discectomy reduces the working distance and allows the use of the microscope with 3- dimensional visualization, thus enhancing the safety of this approach.

The diagnosis and treatment of thoracic disc herniation

Objective To study the clinical manifestation,diagnosis and surgical results of thoracic disc herniation. Methods The clinical appearances from 15 cases with thoracic herniation were analyzed, to study their clinical feature and imaging data,instruct operative methods. Results The thoracic disc protrusion of 3 cases were resected with laminectomy through posterolateral approach. 8 cases were removed transversoarthropediculectomy through posterolateral or costotransversectomy through anterolateral approach and 4 cases were resected with laminactomy and transversoarthropediculectomy. Results The following up period were from 1 to 4 years, excellent and good results were obtained in 80% of the patients. Conclusions Systematic examination, CT or MRI is valuable for the diagnosis of thoracic disc protrusion. Operative treatment is an effective safe way with posterolateral or anterolateral approach and both laminectomy and transversoarthropediculectomy for thoracic disc protrusion. Key words: Thoracic disc protrusion; Diagnosis; Surgical treatment

Transthoracic Surgical Treatment for Centrally Located Thoracic Disc Herniations Presenting With Myelopathy

Retrospective review. Review clinical outcomes for myelopathic patients undergoing transthoracic discectomies for central calcified herniations. Ideal surgical treatment for thoracic disc herniation is controversial due to variations in patient presentation, pathology, and possible surgical approach. Although discectomy may lead to improvements in neurologic function, it can be complicated by approach-related morbidity, especially for ventral calcified disc herniations. Review of clinical outcomes for myelopathic patients undergoing transthoracic discectomies for central calcified herniations was completed, paying special attention to neurologic status and procedure-related complications. Between 2002 and 2007, 27 myelopathic patients were treated with 28 transthoracic surgeries for centrally located symptomatic calcified thoracic disc herniations over the last 5 years at a single institution. Demographic data, details of surgery, preoperative and postoperative Nurick and American Spinal Injury Association scores, length of stay, complications, and follow-up data were collected in all patients. A total of 27 patients, 8 male (30%) and 19 female (70%) with an average age of 52.3 years (range: 19 to 72) underwent 28 thoracotomies. All had myelopathy whereas 6/27 also had radicular pain syndromes. Fourteen patients had anterior instrumentation alone, 3 had anterior and posterior instrumentation, and 1 had posterior instrumentation alone. Average Nurick grade was 2.5 preoperatively and 1.4 postoperatively. Of note, American Spinal Injury Association scores improved postoperatively in 12/27 patients (10D to 10E; 2C to 2D), remained unchanged in 13/27 (11E to 11E, 2D to 2D), and worsened in 2/27 (2D to 2C). Average length of stay was 7 days (range: 3 to 15). All patients required chest tube placement with average duration of 4 days (range: 1 to 7). Major complications occurred in 6 cases (21.4%) over an average follow-up of 12 months (range: 1 to 40 mo). Thoracotomy for treatment of centrally located thoracic disc herniations is associated with improvement in or stabilization of myelopathic symptoms in the majority of patients with an acceptable rate of complications. Interestingly, most patients with weakness improved in strength (12/16, 75%), no patients with normal strength developed new weakness (10/10, 100%), and only 2 patients had new weakness noted postoperatively (7.4%).

Lateral extracavitar approach application to the surgical treatment of thoracic disc herniation, treatment results

Lateral extracavitar approach application to the surgical treatment of thoracic disc herniation, treatment results

Symptom and surgical treatment of thoracic disc herniation

Symptom and surgical treatment of thoracic disc herniation

Neuroendoscopy for spinal disorders: a brief review

Neuroendoscopy has grown rapidly in the last 20 years as a therapeutic modality for treating a variety of spinal disorders. Spinal endoscopy has been widely used to treat patients with cervical, thoracic, and lumbosacral disorders safely and effectively. Although it is most commonly used with minimally invasive lumbar spine surgery, endoscopy has gained widespread acceptance for the treatment of thoracic disc herniations and for anterior release and rod implantation in the correction of thoracic spinal deformity. The authors review the use of endoscopy in spine surgery and in the treatment of spinal disorders as well as in the treatment of intrathoracic nonspinal lesions. Endoscopy has some significant advantages over open or other minimally invasive techniques in that it can allow for better visualization of the lesion, smaller incision sizes with reduced morbidity and mortality, reduced hospital stays, and ultimately lower cost. In addition, spinal endoscopy allows observers and operating room staff to be more involved in each case and fosters education. Spinal endoscopy, like any novel modality, carries with it additional risks and the surgeon must always be prepared to convert to an open procedure. The learning curve for spinal endoscopy is steep and the procedure should not be attempted alone by a novice surgeon. Nevertheless, with training and experience, the spine surgeon can achieve better outcomes, reduced morbidity, and better cosmesis with spinal endoscopy, and the operating times are comparable to open procedures. As technology evolves and more experience is obtained, neuroendoscopy will likely achieve further roles as a mainstay in spine surgery.

Thoracic Microendoscopic Discectomy

Feasibility analysis of percutaneous posterolateral thoracic microendoscopic discectomy in a human cadaver model. To describe a new, minimally invasive, posterolateral approach to the thoracic spine for the treatment of disc herniations. Thoracoscopic discectomy offers surgeons direct ventral access to thoracic disc herniations but requires entry into the chest. Many surgeons favor a posterolateral approach to the thoracic spine, thereby avoiding morbidity associated with entry into the thoracic cavity. By adapting minimal access surgical techniques to the thoracic spine, effective treatment of thoracic disc herniations should be possible and may help expedite recovery. Two cadaveric human torsos were used. Using simple adaptations of our standard lumbar microendoscopic discectomy technique, endoscopic discectomies were performed throughout the mid and lower thoracic spine. Operative time was recorded. The extent of the discectomy as well as the extent of bony removal was evaluated using computed tomography myelography. Nine discectomies were performed in two cadaveric specimens, from T5-T6-T9-T10. Operative times ranged from 46 to 77 minutes (mean 60 minutes). The procedure required removing 3.4 mm (+/-1.9 mm) of the ipsilateral facet, which amounted to 35.4% (+/-17.5%) of the facet complex. Canal decompression averaged 73.5% (+/-7.9%). Thoracic microendoscopic discectomy allows for a posterolateral approach to thoracic disc herniation without entry into the chest cavity that consistently gives access to the majority of the canal while requiring only a minimal amount of bone removal. This technique provides an approach angle similar to that obtained with other posterolateral discectomy techniques while limiting the morbidity associated with exposure.

Thoracic microendoscopic discectomy

Various approaches exist for the treatment of thoracic disc herniation. Anterior approaches facilitate ventral exposure but place the intrathoracic contents at risk. Posterolateral approaches require extensive muscle dissection that adds to the risk of postoperative morbidity. The authors have developed a novel posterolateral, minimally invasive thoracic microendoscopic discectomy (TMED) technique that provides an approach to the thoracic spine which is associated with less morbidity. Seven patients 23 to 54 years old with nine disc herniations underwent TMED. All lesions were soft lateral or midline thoracic disc herniations. Under fluoroscopic guidance with the patient positioned prone, the authors used a muscle dilation approach and the procedure was performed with endoscopic visualization through a tubular retractor. Based on a modified Prolo Scale, five patients experienced excellent results, one good, and one fair. No case required conversion to an open procedure. The mean operative time was 1.7 hours per level, and estimated blood loss was 111 ml per level. Hospital stays were short, and no complications occurred. The TMED is safe, effective, and provides a minimally invasive posterolateral alternative for treatment of thoracic disc herniation without the morbidity associated with traditional approaches.

Treatment for thoracic disc herniation with postero-lateral approach

Treatment for thoracic disc herniation with postero-lateral approach

Transpedicular approach for thoracic disc herniations

Patients with symptomatic herniated thoracic discs may require operation for intractable radiculopathy or functionally disabling myelopathy. In the past, laminectomy was the procedure of choice for the treatment of thoracic herniations, but it was found that the approach was associated with an unacceptably high rate of neurological morbidity. Several strategies have been developed to excise the disc without manipulating the spinal cord. The focus of this paper is the transpedicular approach. The author retrospectively reviewed the cases of 20 consecutive patients presenting with herniated thoracic discs in whom surgery was performed via a transpedicular approach. Fourteen patients presented with acute myelopathy and six with radiculopathy. Of those with myelopathy six of six regained ambulation and six of seven regained normal bladder function. No patient with myelopathy experienced neurological worsening. In four patients presenting with radiculopathy postoperative pain resolved, and in two it remained unchanged. Three minor complications (15%) occurred. No patient suffered postoperative spinal instability-related pain or delayed kyphosis. As experience accumulates in the use of multiple approaches for the treatment of thoracic disc herniations, the role of each is becoming more clearly defined. The transpedicular approach is most applicable to lateral or centrolateral calcified or soft discs. The more anterior (transthoracic or thoracoscopic) and lateral (costotransversectomy or lateral extracavitary) approaches may be more useful for excision of central calcified discs.

Treatment of thoracic disc herniation: evolution toward the minimally invasive thoracoscopic technique

Thoracic disc herniation has always carried with it the potential for serious adverse neurological consequences if not treated appropriately. The authors review the historical evolution of treatment for thoracic disc herniation from the early surgical series using dorsal approaches (which were known to involve a significant risk of paraplegia) to later surgical series in which lateral and then ventral approaches to the disc were increasingly emphasized, with significant improvement in patient outcome. The evolution of minimally invasive thoracoscopic techniques is discussed, together with the results of several surgical series demonstrating significant reductions in morbidity compared with more traditional methods. The technique of thoracoscopic discectomy is presented in detail.

Anterior decompression to spinal cord through a posterior approach for the treatment of thoracic disc herniation

Anterior decompression to spinal cord through a posterior approach for the treatment of thoracic disc herniation

Anterior decompression and fusion via the extrapleural approach for thoracic disc herniation causing myelopathy.

Anterior decompression and fusion via an extrapleural approach was performed for 33 patients with myelopathy arising from thoracic disc herniation and the clinical usefulness and problems related to this procedure were assessed on the basis of surgical results and complications. The severity of the myelopathy was evaluated by the Japanese Orthopaedic Association score, and the surgical results were based on the recovery rate. The upper-level limit of decompression and fusion via the extrapleural approach was T4-5. The recovery rate for the mean postoperative follow-up period of 41 months was 66.7%. An age of 60 years or more, long duration of illness and severe preoperative myelopathy were indicators of a poor prognosis. Two patients suffered from a postoperative transient pulmonary complication due to hemothorax. X-ray examinations revealed good bone union in all the patients. The present study indicates that anterior decompression and fusion via the extrapleural approach is a useful technique which can be used to achieve a high success rate in the surgical treatment of thoracic disc herniation, if intervention is early.

Surgical treatment of thoracic disc herniation: A reappraisal of Larson's lateral extracavitary approach

Twenty patients with thoracic disc herniations underwent removal of the transverse process, articular facet, pedicle, and rib—a procedure described by Larson as the lateral extracavitary approach. Eleven patients presented with myelopathy: five mild, nine moderate, and four severe. Fifteen patients showed significant neurologic improvement after the operation and five patients none. Postoperative follow-up ranged from 1 to 8 years. The pros and cons of each of the surgical approaches to this type of lesion are considered with reference to the published data.

Thoracic disc herniation: Improved diagnosis with computed tomographic scanning and a review of the literature

Thoracic disc herniation is uncommon. One of the main problems in the treatment of thoracic disc herniation has been the lack of accuracy of diagnostic tests. Now, with the use of computed tomographic scanning with and without metrizamide in the subarachnoid space, this accuracy has greatly improved. Computed tomography scanning can demonstrate the type and level of the lesion even when the myelographic study is negative. We have reviewed 280 cases; a peak incidence was noted in the fourth decade with 75% of the protruded discs occurring below T-8. Back pain was the most common presenting symptom followed by sensory disturbances. By the time of diagnosis, 70% of the patients had signs of spinal cord compression. A small group of patients could be identified that invariably had a good prognosis. They had a history of trauma, symptoms lasting less than a month, and soft disc herniation. Regarding the results of surgical treatment, there was a success rate ranging from 57% for decompressive laminectomy to over 80% for the posterolateral, lateral, and transthoracic approaches.