Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique
Summary
This protocol demonstrates the surgical technique for full endoscopic transforaminal resection of thoracic disc herniations.
Abstract
Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.
Introduction
Symptomatic thoracic disc herniations (TDHs) are a relatively rare (0.25%-0.75% of all symptomatic spinal disc herniations)1 spinal pathology wherein a portion of the nucleus pulposis herniates through the annulus fibrosis of the intervertebral disc, causing spinal cord or nerve root compression. TDHs are most commonly seen at the T7/8, T8/9 and T11/12 levels2. Patients with TDHs can present with back pain, thoracic radiculopathy and/or myelopathy2.
Surgery for patients with TDHs traditionally involves a relatively invasive approach, which is tailored according to the location of the disc herniation within the spinal canal. Posterolateral approaches (transpedicular, lateral extracavitary, costotransversectomy)3,4,5 are often preferred for paracentral disc herniations, while anterior approaches (transthoracic or retropleural)6,7 approaches may be required for central disc herniations. These surgical approaches typically require a relatively large amount of muscle dissection and bony removal in order to access the disc herniation. Complication rates associated with these traditional approaches vary (7.1%-24%)4,8,9 and can include neurological deterioration (2%-5%)10, durotomy/CSF leak, intercostal neuralgia, and pulmonary complications associated with anterior approaches.
Full endoscopic spine surgery is an ultra-minimally invasive technique for the treatment of spinal pathology that utilizes a small (<1 cm) incision and an endoscope to access the epidural space via the transforaminal or interlaminar route with a minimal amount of collateral tissue damage. Access via the transforaminal route requires only a small amount of the ventral, non-articulating portion of the superior articulating process to be removed. Outcomes of full endoscopic spine surgery for the treatment of lumbar disc herniations have been shown to be safe and effective11. When utilized in the context of TDHs, full endoscopic spine surgery allows access to the ventral epidural space of the thoracic spine without the need for extensive soft tissue dissection and bony removal seen with traditional approaches. A number of small literature series have documented the safety and efficacy of full endoscopic spine surgery for the resection of thoracic disc herniations, many of which show that the procedure can be performed on an outpatient basis12,13,14.
This study demonstrates the technique for full endoscopic thoracic discectomy and provides a review of the outcomes of this technique seen in the literature.
Protocol
Representative Results
Discussion
Thoracic disc herniations, though relatively rare, can be a source of uncontrolled pain and neurological deficits that substantially impact patients' quality of life2. Traditional surgical treatments of thoracic disc herniations are relatively invasive and associated with substantial postoperative morbidity4,8,9. Full endoscopic transforaminal thoracic discectomy provides an ultra-minimally invasive m…
Disclosures
The authors have nothing to disclose.
Acknowledgements
None.
Materials
| #10 blade scalpel | |||
| 3-0 Monocryl suture | Ethicon | Y427H | |
| 40 x 2 mm Guglielmi Detachable Coil | Boston Scientific/Target | M0013612040 | |
| C-arm/fluoroscope | GE Healthcare | ||
| Dermabond Topical Skin Adhesive | Ethicon | DNX6 | |
| Endoscope | Tessys, Joimax gmbh, Karlsruhe, Germany | ||
| Endoscopic Cannula | Tessys, Joimax gmbh, Karlsruhe, Germany | ||
| Endoscopic Drill/"Shrill" | Joimax gmbh, Karlsruhe, Germany | ||
| Endoscopic Irrigation Tubing | Joimax gmbh, Karlsruhe, Germany | ||
| Endoscopic Tower | Joimax gmbh, Karlsruhe, Germany | ||
| Guidewire/K-wire | Joimax gmbh, Karlsruhe, Germany | ||
| Jamshidi needle | Joimax gmbh, Karlsruhe, Germany | Biopsy needle | |
| Lead apron | |||
| Normal saline | |||
| Radiolucent operating table | Mizuho OSI Jackson Modular Surgical Table | ||
| Surgical drapes | Joimax gmbh, Karlsruhe, Germany | ||
| Surgical prep | |||
| Tessys Endo-Flexprobe | Joimax gmbh, Karlsruhe, Germany | TEFP32020 |
References
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