Fig. 2. Pre (a, c, e)- and respective post (b, d, f )-operative images showing decompression of the spinal cord following a three-level (T6, 7; T8, 9, and T9, 10) TMED.

Fig. 3. Postoperative scar after three-level TMED procedure. Of note, no fusion was required nor entry into the thoracic cavity for performing a multilevel thoracic discectomy.

posterior muscle dissection. As a result, patient stays are brief with the majority of patients being discharge the following morning.

Illustrative Case

A 45-year-old female presented with polyradiculopathy and myelopathy from three thoracic disc herniations one at T6, 7, another at T8, 9 and another at T9, 10. The patient underwent a right-sided T6, 7 TMED and a left-sided T8, 9 and T9, 10 TMED. Pre- and postoperative sagittal and axial MRI images show the extent of disc removal (fig. 2c-f) with final decompression of the spinal cord. The patient went on to make a full recovery with minimal postoperative wound scar (fig. 3) and returned to work. In a series of 5 patients treated in this manner, aged 23-54 years, operative times averaged 1.8 h per level and blood loss was approximately 113 ml per level. No cases required conversion to an open procedure and all patients showed improvement in functional outcome as measured by visual pain analog, Oswestry scores, and SF-36.


The natural history of thoracic disc herniation is not well delineated. Currently, the only absolute indication for surgery is myelopathy. Surgery for thoracic disc herniation for controlling radicular thoracic pain is controversial as is the role of fusion. A number of approaches currently exist for the treatment of this condition including the posterior (laminectomy, transpedicular, trans-facet pedicle-sparing), anterolateral (transthroacic, thoracoscopic), anterior (transsternal), and lateral (costotransversectomy, lateral rachiotomy, lateral extracavitary). Though many of these approaches are effective, they require significant dissection and retraction of normal anatomic structures, which can increase patient morbidity. The novel approach described above which uses a series of muscle dilators, tubular retractor, and endoscopic visualization can reduce much of the morbidity associated with this procedure and avoids the need for fusion and entrance into the thoracic cavity. By using a tubular retractor and endoscope, less muscle, rib and transverse process resection is required. The 30° angle endoscope allows for visualization under the dural sack to reduce any spinal cord manipulation during the procedure and facilitate removal of the herniated thoracic disc. Since the majority of the functioning disc is left in place, no iatrogenic instability is created from extensive disc removal that would require bone fusion. Although the series presented is small, the technique is promising as a new minimally invasive approach to thoracic spine pathology that can lead to reduced operative times, less blood loss, and quicker patient recoveries.


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Mick J. Perez-Cruet, MD, MS

Institute for Spine Care, Department of Neurosurgery Chicago Institute of Neurosurgery and Neuroresearch, Rush-Presbyterian-St. Luke's Medical Center, 1725 West Harrison Street Suite 970, Chicago, IL 60612 (USA)

Tel. +1 708 250 3194, Fax +1 312 942 2176, E-Mail [email protected]

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