Treatment Of Thoracic Disc Herniation Research Articles

Dynamics of outcomes of thoracoscopic microdiscectomy

Object of the study. Thoracoscopic microdiscectomy (TM) is used for surgical treatment of thoracic disc herniations (TDH). The purpose of this study was to analyze the factors influencing the dynamics of outcomes in the early and late postoperative period Materials and methods/ The study had a retrospective, single-center, observational cohort design. The series included all patients without exception who underwent TM from January 2018 to December 2022. Outcomes were assessed according to the Macnab scale adapted for the thoracic spine. Postoperative complications were classified according to the Clavien-Dindo Classification. Statistical univariate analysis of the data was carried out using the Fisher»s method and the Mann-Whitney U test. Multivariate analysis was performed using multiple linear regression with stepwise elimination. Results/ A total of 36 patients were operated on using the TM technique. These included 22 (61 %) women and 14 (39 %) men. The median age was 45±15 years. Early outcomes were assessed 2 months after the patients» surgery. The median duration of long-term outcomes was 22±12 months. The statistical analysis of early outcomes revealed a connection between the localization of a disc herniation in the lower thoracic spine (Th8 — Th12) with simultaneous surgery at two levels and less favorable outcomes. The analysis of long-term outcomes showed that the only prognostic factor was the patient»s condition when assessing the early outcome. Thus, complete recovery was registered at the first control in 13 out of 15 (86 %) patients and at the last control in 13 out of 16 (81 %) patients (p <0.001). Conclusions. The analysis of early and long-term outcomes made it possible to identify factors that determine the dynamics of recovery after thoracoscopic microdiscectomy. The data obtained can be used in planning postoperative management of this group of patients.

Curative Effect of Lateral Transforaminal Endoscopy on the Treatment of Thoracic Disc Herniation

Curative Effect of Lateral Transforaminal Endoscopy on the Treatment of Thoracic Disc Herniation

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).

Resolution of Thoracic Syringomyelia following Treatment of Thoracic Disc Herniation.

Resolution of Thoracic Syringomyelia following Treatment of Thoracic Disc Herniation.

Sleep apnea and unilateral upper and lower extremity allodynia as a result of a large thoracic disc herniation: a case report

BackgroundClinically significant disc herniations in the thoracic spine are rare accounting for approximately 1% of all disc herniations. In patients with significant spinal cord compression, presenting symptoms typically include ambulatory dysfunction, lower extremity weakness, lower extremity sensory changes, as well as bowl, bladder, or sexual dysfunction. Thoracic disc herniations can also present with thoracic radiculopathy including midback pain and radiating pain wrapping around the chest or abdomen. The association between thoracic disc herniation with cord compression and sleep apnea is not well described.Case presentationThe following is a case of a young male patient with high grade spinal cord compression at T7-8, as a result of a large thoracic disc herniation. The patient presented with complaints of upper and lower extremity unilateral allodynia and sleep apnea. Diagnosis was only made once the patient manifested more common symptoms of thoracic stenosis including left lower extremity weakness and sexual dysfunction. Following decompression and fusion the patient’s allodynia and sleep apnea quickly resolved.ConclusionsThoracic disc herniations can present atypically with sleep apnea. We recommend taking into consideration that sleep symptoms may resolve when planning treatment for thoracic disc herniation.

Transforaminal endoscopic thoracic discectomy with foraminoplasty for the treatment of thoracic disc herniation.

Symptomatic thoracic disc herniation (TDH) is a rare clinical entity and surgical intervention for it is even more uncommon. Despite several surgical techniques being described for thoracic discectomy, considering the unique surgical challenges, none of them have been accepted universally. Minimally invasive techniques have brought in a paradigm shift in the management of cervical/lumbar spinal disorders and similar techniques have been extrapolated to the thoracic region too. The purpose of this paper is to describe our technique, surgical experience, and the clinical results of transforaminal endoscopic thoracic discectomy (TETD). Consecutive patients who underwent TETD (2001-2018) were reviewed. Patients who had a minimum of 6 months of follow-up, and without cervical and lumbar spine surgery or trauma during the follow-up period were included in the study. TETD was performed in patients who presented with symptomatic disc herniation of the thoracic spine and did not respond to conservative treatments. Patients with calcified disc herniation or concomitant ossification of the posterior longitudinal ligament (OPLL) were excluded. Under local anesthesia and intravenous sedation, a 4.7-mm endoscope (TESSYS, Joimax GmbH, Germany) was introduced via transforaminal approach with foraminoplasty using reamer. Patient outcome was evaluated using visual analogue scale (VAS) and Oswestry disability index (ODI) scores. Patient satisfaction was measured using Macnab's criteria. Ninety-two consecutive patients (mean age was 48.9 years, 57 males) who underwent TETD from 2001 to 2018 met the inclusion criteria. Patients underwent surgery at different levels: 16 patients for T2-3 to T5-6 level, 41 cases for T6-7 to T8-9, and 35 patients for T9-10 to T12-L1. During follow-up for an average of 38.4 months, all patients showed a significant improvement of pain (7.6 to 1.6 in VAS and 68.2 vs. 13.2 for ODI, P<0.05 for both). There was one patient who had transient motor weakness. TETD for soft, paramedian or lateral symptomatic TDH is a feasible and effective minimally invasive treatment option with favorable clinical results.

Transforaminal Endoscope for the Treatment of Thoracic Disc Herniation

Objective: Transforaminal endoscope was used in the treatment of thoracic disc herniation and the therapeutic effect was discussed. Methods: Sixteen patients with thoracic disc herniation admitted to our hospital from October 2018 to May 2019 were divided into control group and observation group according to the random number table method, with 8 patients in each group. The control group was treated with posterior laminectomy approach, and the observation group was treated with transforaminal endoscope. The surgery-related conditions (intraoperative blood loss, surgery time, and postoperative drainage volume), VAS score, JOA score and postoperative complications were compared and analyzed. Results: There was no statistically significant difference between the two groups in the total effective rate and preoperative VAS score (P &gt; 0.05). Compared with the control group, the observation group had shorter surgery time and incision length, less postoperative drainage volume, and higher VAS score 3 days after surgery, JOA score on day 7 after surgery, and JOA score 3 months after surgery, showing statistically significant differences (P &lt; 0.05). There was no significant difference in the complications between the two groups (X2=1.067, P=0.833). Conclusions: Transforaminal endoscope had a good clinical effect with small incision and injury in the treatment of patients with thoracic disc herniation.&#x0D;

Surgical treatment of thoracic disc herniation: an overview.

Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord. Literature review. Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Non-anterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications. Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Analysis of the learning curve of the surgical procedure for the treatment of thoracic disc herniation using anterolateral transthoracic approach with the aid of image-guided system.

In surgery, the learning process represents one of the critical topics in the development of a young surgeon where there is often no standardized learning program. The learning curve is defined by plotting proficiency as a function of time, or the number of repetitions. In this study, we analyzed the learning process for a rare and surgically demanding pathology such as thoracic disc herniations (TDHs) treated with an antero-lateral trans-thoracic approach. We analyzed a consecutive series of patients admitted with a diagnosis of TDHs. All patients underwent surgery using a standard antero-lateral trans-thoracic approach, assisted by navigation system based on intraoperative 3D imaging performed with O-Arm™ (Medtronic; Dublin, Ireland) system. Twenty-one patients underwent surgery from January 2012 to June 2017. The time analysis shows a progressive reduction in time from the first to the last case with continued improvement in operating time but progressively less dramatic, this is explicable considering the classic learning curve model. Predictably, a slow learning curve was charted - typical for a technically demanding procedure associated with a rare incidence of pathology. A learning curve is an easy and efficient way to gauge the growth of a surgeon. After 21 cases we obtained an intermediate profile of learning curve between steep and shallow. Despite different alternatives for speeding up the learning process it is not always possible to standardize and reflect them in a learning process. Today, the use of technology is often considered in this but does not always affect the process itself.

Management of Thoracic Disc Herniations via Posterior Unilateral Modified Transfacet Pedicle-Sparing Decompression With Segmental Instrumentation and Interbody Fusion.

Study Design:Retrospective consecutive case series.Objective:The objective of this case series was to demonstrate the safety of a modified transfacet pedicle–sparing decompression and instrumented fusion in patients with thoracic disc herniations (TDHs).Methods:Consecutive patients undergoing operative management of TDH from July 2007 to December 2011 using a posterior unilateral modified transfacet pedicle–sparing approach were identified. All patients underwent open or minimally invasive modified transfacet pedicle–sparing discectomy and segmental instrumentation with interbody fusion, performed by four different surgeons. Pre- and postoperative visual analog scale (VAS) pain scores, Nurick grade, and American Spinal Injury Association Impairment Scale (AIS) were analyzed from a retrospective chart review. Estimated blood loss and complications were also obtained.Results:Fifty-one patients were included that had operations for TDH. Thirty-nine patients had single level decompression and 12 had multilevel decompression. The total number of levels operated on was 64. Five patients were treated with minimally invasive surgery. A herniated disc level of T11-12 (n = 17) was treated most often. One major complication of epidural hematoma occurred. Minor complications such as malpositioned hardware, postoperative hematoma, wound infection, pseudoarthrosis, and pulmonary complications occurred in a few patients. Follow-up ranged from 1 to 46 months with 1 patient lost to follow-up. From preoperative to final postoperative: mean VAS scores improved from 8.31 to 4.05, AIS in all patients remained stable or improved, and Nurick scores improved from 3 to 2.6 on average. No intraoperative or permanent neurological deficit occurred.Conclusion:In our surgical series, 51 consecutive patients underwent modified transfacet pedicle–sparing approach to TDHs and experienced improvement of functional status as well as improvement of objective pain scales with no neurological complications. The posterior unilateral modified transfacet pedicle–sparing decompression and instrumented fusion approach to the thoracic spine is a safe and reproducible procedure for the treatment of TDHs.

Treatment of thoracic disc herniation. Case report

Abstract Background Herniated thoracic intervertebral disc is a rare cause of spinal cord compression. Its frequency varies from 0.15% to 1.7% of all disc herniations, and produces symptoms in 0.5–0.8%. Clinical cases Case 1. A 50-year-old woman, with pain and burning sensation in left hemithorax of four months of onset. It was treated as a herpetic syndrome, with no improvement. She was seen after thirteen days of exacerbation of clinical symptoms. The physical examination showed asymmetric paraparesis, lower left pelvic limb 1/5, and right pelvic limb 3/5, sensory level T8, with left Babinski positive. A thoracic disc herniation in space T8–T9 was diagnosed. Case 2. A 55-year-old patient with a history of presenting pain in lumbar area of 5 years onset. She also had radicular pain that radiated to the right pelvic limb, with intensity 10/10 on a Visual Analogue Scale. Her physical examination showed muscle strength 5/5, with normal sensitivity in all dermatomes and tendon reflexes, and a positive right Babinski. Thoracic disc herniation T7–T8 level was diagnosed. Discussion Due to anatomical conditions that define this type of hernia, the extracavitary posterolateral approach should be the recommended surgical procedure when the simultaneously performed anterior decompression and fixation with posterior instrumentation are the treatments proposed. Conclusion Despite the different anatomical structures of this special area, it was possible to obtain satisfactory results for both clinical cases.

Comparison of In-Hospital Morbidity and Mortality between Anterior and Non-Anterior Approach Procedures for Thoracic Disc Herniation

Surgical treatment for thoracic disc herniation can be largely divided into anterior and non-anterior approach procedures. An anterior approach necessitates invasion of the thoracic cavity, which may subject the patient to increased risk of certain complications. Large sample studies comparing anterior and non-anterior procedures in terms of morbidity and mortality are lacking.

Comparison of In-hospital Morbidity and Mortality Rates Between Anterior and Nonanterior Approach Procedures for Thoracic Disc Herniation

Analysis of population-based national hospital discharge data collected for the Nationwide Inpatient Sample. To compare in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation at national level. Surgical treatment for thoracic disc herniation can be largely divided into anterior and nonanterior approach procedures. An anterior approach necessitates invasion of the thoracic cavity, which may subject the patient to increased risk of certain complications. Large sample studies comparing anterior and nonanterior procedures in terms of morbidity and mortality are lacking. The Nationwide Inpatient Sample was used to identify patients who underwent surgical treatment for thoracic disc herniation from 2000 to 2009 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9) codes. Patients were then divided into those who underwent anterior approach procedures and those who received nonanterior approach procedures using the appropriate ICD-9 codes. Patient- and health care system-related demographic data were retrieved and analyzed. There were 25,413 patients included in this study. Anterior approach procedures were associated with a significantly higher overall in-hospital complication rate (26.8% vs. 9.6%) and mortality rate (0.7% vs. 0.2%), as well as a longer hospital stay (7.6 vs. 4.8 d) and increased hospital charges ($84,199 vs. $46,837) compared with nonanterior approach procedures. Risk factors for mortality in surgical treatment for thoracic disc herniation included age 85 years or more, female sex, and the presence of complications (respiratory, cardiac, and urinary and renal). Anterior approach procedures for thoracic disc herniation were associated with increased in-hospital morbidity and mortality rates, as well as increased health care burden, compared with nonanterior approach procedures. If thoracic disc herniation can be adequately excised by either approach, a nonanterior approach procedure may be a better option.

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.

Surgical Treatment for Thoracic Disc Herniation

Retrospective review of the literature. To update recent trends in the surgical treatment for thoracic disc herniation (TDH). TDH is rare; however, it is usually accompanied by myelopathy and is indicated for surgical treatment. A variety of surgical approaches have been described to reach these anatomically challenging lesions. Review of the literature. Recently, minimally invasive techniques for TDH have gained popularity. These include thoracoscopic and mini-open anterolateral retropleural approaches, as well as microscopic and endoscopic surgery. In addition, this article updates important aspects of surgical treatment for TDH such as definition of surgical level, treatment of calcified and/or giant disc, multilevel lesions, and fusion requirements. Definition of surgical level is imperative in the surgical treatment for TDH. Outcomes of minimum invasive surgery are satisfactory. Type of disc herniation and biomechanical stability are the important factors for surgical planning.

Anterior or posterior approach of thoracic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies

Background contextThe optimal surgical treatment of thoracic disc herniations remains controversial and depends on the consistency of the herniation and its location related to the spinal cord. PurposeTo compare the outcomes of patients with symptomatic thoracic disc herniations treated with anterolateral mini-transthoracic approach (TTA) versus posterior transpedicular discectomy. Study designThis is a prospective comparative cohort study. Patient sampleOne hundred consecutive patients with symptomatic thoracic herniated discs were operated by mini-TTA (56 patients) or transpedicular discectomy (44 patients). Outcome measuresNeurologic assessment by American Spinal Injury Association (ASIA) Impairment Scale and patients' self reported perceived recovery and complications. MethodsThe consistency and location of the herniated disc in relation to the spinal cord was evaluated by preoperative computed tomography and magnetic resonance imaging. Patients were assessed neurologically before surgery and at regular outpatient controls at 2 months or later. Long-term follow-up was achieved by questionnaires sent by mail. ResultsIn both groups, most patients had symptoms of myelopathy and radicular pain; patients who underwent mini-TTA, more frequently suffered from spasticity. Fifty-eight percent of the herniated discs were calcified and 77% were larger than one-third of the spinal canal. All patients presented with ASIA Grade C or D (64%) or ASIA Grade E (36%). Postoperatively, 50% of the patients treated with mini-TTA and 37% of the transpedicular group improved at least one grade on the ASIA scale (p=.19). The duration of surgery, blood loss, hospital stay, and complication rate were significantly higher in patients treated with mini-TTA and were mainly related to the magnitude and consistency of the herniated disc. At long-term follow-up, 72% of the mini-TTA patients reported good outcome versus 76% of the transpedicular discectomy group (p=.80). ConclusionsSurgical treatment of a symptomatic herniated disc contributed to a clinical improvement in most cases. The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc. Medially located large calcified discs should be operated through an anterolateral approach, whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers.

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].