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.
posterior muscle dissection. As a result, patient stays are brief with the majority of patients being discharge the following morning.
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.
1 Anand N, Regan JJ: Video-assisted thoracoscopic surgery for thoracic disc disease: Classification and outcome study of 100 consecutive cases with a 2-year minimum follow-up period. Spine 2002;27:871-879.
2 Arlet V: Anterior thoracoscopic spine release in deformity surgery: A meta-analysis and review. Eur Spine J 2000;9(suppl 1):S17-S23.
3 Awwad EE, Martin DS, et al: Asymptomatic versus symptomatic herniated thoracic disc: Their frequency and characteristics as detected by computed tomography after myelography. Neurosurgery 1991;28:180-186.
4 Birch BD, Desai RD, et al: Surgical approaches to the thoracolumbar spine. Neurosurg Clin N Am 1997;8:471-485.
5 Burgos J, Rapariz JM, et al: Anterior endoscopic approach to the thoracolumbar spine. Spine 1998;23:2427-2431.
6 Cunningham BW, Kotani Y, et al: Video-assisted thoracoscopic surgery versus open thoracotomy for anterior thoracic spinal fusion. A comparative radiographic, biomechanical, and histologic analysis in a sheep model. Spine 1998;23:1333-1340.
7 Dickman CA, Mican CA: Multilevel anterior thoracic discectomies and anterior interbody fusion using a microsurgical thoracoscopic approach. J Neurosurg 1996;84:104-109.
8 Dickman CA, Rosenthal D, et al: Thoracic vertebrectomy and reconstruction using a microsurgical thoracoscopic approach. Neurosurgery 1996;38:279-293.
9 Dickman CA, Rosenthal D, et al: Reoperation for herniated thoracic discs. J Neurosurg 1999;91(suppl 2):157-162.
10 Faciszewski T, Winter RB, et al: The surgical and medical perioperative complications of anterior spinal fusion surgery in the thoracic and lumbar spine in adults. Spine 1995;20:1592-1599.
11 Ferson PF, Landreneau RJ, Dowling RD, Hazelrigg SR, Ritter P, Nunchuck S, Perrino MK, Bowers CM, Mack MJ, Magee MJ: Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease. J Thorac Cardiovasc Surg 1993;106:194-199.
Fessler RG, Sturgill M: Review: Complications of surgery for thoracic disc disease. Surg Neurol 1998;49:609-618.
Hazelrigg SR, Landreneau RJ, Boley TM, Priesmeyer M, Schmaltz RA, Nawarawong W, Johnson JA, Walls JT, Curtis JJ: The effect of muscle-sparing versus standard posterolateral tho-racotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394-401.
Horowirz BH, Moossy JJ, et al: Thoracic discectomy using video assisted thoracoscopy. Spine 1994;19:1082-1086.
Huang TJ, Hsu RW, et al: Video-assisted thoracoscopic treatment of spinal lesions in the thoracolumbar junction. Surg Endosc 1997;11:1189-1193.
Huang TJ, Hsu RW, et al: Complications in thoracoscopic spinal surgery: A study of 90 consecutive patients. Surg Endosc 1999;13:346-350.
Huntington CF, Murrell WD, et al: Comparison of thoracoscopic and open thoracic discectomy in a live ovine model for anterior spinal fusion. Spine 1998;23:1699-1702.
Karahalios DG, Apostolides PJ, et al: Thoracoscopic spinal surgery. Treatment of thoracic instability. Neurosurg Clin N Am 1997;8:555-573.
Kuklo TR, Lenke LG: Thoracoscopic spine surgery: Current indications and techniques. Orthop Nurs 2000;19/6:15-22.
Landreneau RJ, Hazelrigg SR, Mack MJ, Dowling RD, Burke D, Gavlick J, Perrino MK, Ritter PS, Bowers CM, DeFino J: Postoperative pain-related morbidity: Video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285-1289.
Larson SJ, Holst RA, Hemmy DC, Sances A: Lateral extracavitary approach to traumatic lesions of the thoracic and lumbar spine. J Neurosurg 1976;45:628-637.
McAfee PC, Regan JR, et al: The incidence of complication in endoscopic anterior thoracolumbar spinal reconstructive surgery. Spine 1995;20:1624-1632.
Newton PO, Shea KG, et al: Defining the pediatric spinal thoracoscopy learning curve: Sixty-five consecutive cases. Spine 2000;25:1028-1035.
Newton PO, Wenger DR, et al: Anterior release and fusion in pediatric spinal deformity. A comparison of early outcome and cost of thoracoscopic and open thoracotomy approaches. Spine 1997;22:1398-1406.
Niemeyer T, Freeman BJ, et al: Anterior thoracoscopic surgery followed by posterior instrumentation and fusion in spinal deformity. Eur Spine J 2000;9:499-504.
Nymberg SM, Crawford AH: Video-assisted thoracoscopic releases of scoliotic anterior spines. AORN J 1996;63:561-562, 565-569, 571-575; quiz 576, pass.
Oskouian RJ Jr, Johnson JP, et al: Thoracoscopic microdiscectomy. Neurosurgery 2002;50/1: 103-109.
Otani K, Yoshida M, et al: Thoracic disc herniation. Surgical treatment in 23 patients. Spine 1988;13:1262-1267.
Peker S, Akkurt C, et al: Multiple thoracic disc herniations. Acta Neurochir (Wien) 1990; 107/3-4:167-170.
Perez-Cruet MJ, Fessler RG, Noel PI: Review: Complications of minimally invasive spinal surgery. Neurosurgery 2002;51(suppl 2):26-36.
Perez-Cruet MJ, Foley KT, Isaacs RE, Rice-Wyllie L, Wellington R, Smith MM, Fessler RG: Microendoscopic lumbar discectomy: Technical note. Neurosurgery 2002;51(suppl 2):129-136. Perez-Cruet MJ, Smith MM, Foley KT: Microendoscopic lumbar discectomy; in Perez-Cruet MJ, Fessler RG (eds): Outpatient Spinal Surgery. St Louis, Quality Medical Publishing, 2002, pp 171-183.
Perot PL, Munro DD: Transthoracic removal of midline thoracic disc protrusions causing spinal cord compression. J Neurosurg 1969;31:458.
Ransohoff J, Spencer F, et al: Transthoracic removal of thoracic discs: Case reports and technical notes. J Neurosurg 1969;31:459-461.
Regan JJ: Percutaneous endoscopic thoracic discectomy. Neurosurg Clin N Am 1996;7/1:87-98. Regan JJ, Guyer RD: Endoscopic techniques in spinal surgery. Clin Orthop 1997;335:122-139. Rosenthal D, Dickman CA: Thoracoscopic microsurgical excision of herniated thoracic discs. J Neurosurg 1998;89/2:224-235.
38 Rosenthal D, Rosenthal R, et al: Removal of a protruded thoracic disc using microsurgical endoscopy. A new technique. Spine 1994;19:1087-1091.
39 Roush TF, Crawford AH, et al: Tension pneumothorax as a complication of video-assisted thoras-copic surgery for anterior correction of idiopathic scoliosis in an adolescent female. Spine 2001;26:448-450.
40 Stillerman CB, Chen TC, et al: Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 1998;88:623-633.
41 Stillerman CB, Chen TC, et al: The transfacet pedicle-sparing approach for thoracic disc removal: Cadaveric morphometric analysis and preliminary clinical experience. J Neurosurg 1995;83: 971-976.
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]
Haid RW Jr, Subach BR, Rodts GE Jr (eds): Advances in Spinal Stabilization. Prog Neurol Surg. Basel, Karger, 2003, vol 16, pp 277-289
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