Abordaje lateral retropleural mínimamente invasivo para hernia de disco torácica gigante calcificada: reporte de caso / Minimally Invasive Lateral Retropleural Approach for Calcified Giant Thoracic Disc Herniation: Case Report

Introducción: Las hernias de disco torácicas (HDT) representan solo el 0.15-1.8% de las hernias de disco tratadas quirúrgicamente. Se han descrito distintos tipos de abordajes que reportan diferentes índices de éxito y complicaciones. El objetivo es presentar el caso quirúrgico de una HDT resuelta por un abordaje lateral retropleural mínimamente invasivo y exponer las ventajas del mismo. Descripción: Se presenta el caso de una paciente de 29 años, que consultó por dorsalgia y paresia crural izquierda 4/5. La TC y RM mostraron una HDT gigante calcificada T8-9. Bajo monitoreo neurofisiológico y visión microscópica, se realizó un abordaje lateral retropleural izquierdo mínimamente invasivo, con resección parcial de la costilla para luego utilizar un sistema de dilatadores y retractores tubulares. Se confirmó el nivel bajo radioscopía, y se completó con el drilado de la cabeza costal para exponer el espacio y la HDT calcificada de manera precoz. Se realizó la discectomía del fragmento herniado, incluyendo drilado intracanal de la porción calcificada y se completó la descompresión incluyendo la porción posterior de los platillos vertebrales y el pedículo inferior. Parte del fragmento herniado se encontraba íntimamente adherido al saco dural, por lo que creímos conveniente dejar este remanente para evitar complicaciones. La paciente evolucionó favorablemente, recuperando de manera completa el déficit motor y el dolor que motivaron la consulta. Consideramos que no fue necesario realizar ningún tipo de fusión intersomática. Discusión: Los distintos abordajes propuestos tienen sus ventajas y desventajas. El desarrollo de las técnicas mínimamente invasivas sumado a la posibilidad de exponer precozmente la lesión resultan ventajas importantes en estos casos. La necesidad de fusión es un tema controversial, donde la mayoría de los trabajos sugieren que no es mandatoria. Conclusión: el abordaje lateral retropleural mínimamente invasivo es una técnica segura, que permitió una visualización precoz de la HDT sin desplazar el estuche dural y logrando una adecuada descompresión. Además, evita la morbilidad que podría representar la toracotomía transtorácica y la necesidad de fusión

Introduction: Thoracics disc herniations (TDH) represent just 0.15-1.8% of all surgically treated herniated discs. Many approaches had been described with different amount of success and complications. The objective is to present a TDH surgical case using a minimally invasive lateral retropleural approach and describe the advantages of this approach. Case description: we present a 29 years old female who presented with dorsal pain and right leg weakness 4/5. CT and MRi showed a calcified giant TDH T8-9. The surgery was performed under neurophysiological monitoring and using a surgical microscope. A minimally invasive left lateral retropleural approach was performed, with partial resection of a rib. Finally, we used dilators and tubular retractors. After radioscopic confirmation of T8-9, we completed the approach by drilling rib ́s head in order to early expose the spinal canal with the TDH. We resected the herniated fragment of the TDH, drilled the calcified intraspinal canal portion and completed the decompression including the posterior portion of the endplates and the inferior pedicle. The most anterior portion of the TDH was intimately attached to the dural sac, so we decided to leave this remanent in order to avoid complications. The patient had a good postoperative recovery, the leg weakness and pain improved significantly. From our perspective, we consider that no intersomatic fusion was necessary. Discusion: each approach has it advantages and disadvantages. The evolution of minimally invasive techniques together with the early visualization of TDH became important advantages in these cases. The need of fusion remains controversial, and most of the literature suggest that is not mandatory. Conclusión: the minimally invasive lateral retropleural approach is a safe technique that offers an early visualization of the TDH without manipulation of the dural sac and allows an adequate decompression. Furthermore, this approach avoids the morbidity of a transthoracic approach and the requirement of fusion.

Anatomic measurement and clinical significance of the middle and lower thoracic segments in normal adults / Medición anatómica e importancia clínica de los segmentos torácico medio e inferior en adultos normales

Thoracic disc herniation (TDH) has high technical difficulty and serious complications, and the clinical anatomy of thoracic intervertebral foramen is less. Collecting 10 adult male cadavers, measuring the longitudinal diameter of the dorsal root ganglion (D1), the transverse diameter of the dorsal root ganglion (D2), horizontal sagittal diameter of the upper edge of the intervertebral disc (S1), the high of intervertebral foramen (H1), the height of articulationes costovertebrales (H2), the height of intervertebral disk (H3), the angel of the dorsal root ganglion (a). The aim of this study is to explore the safe area of middle and lower thoracic section and provide anatomical basis for the selection of operative cannula. Mastering the certain rules of the anatomical structure of the middle and lower thoracic segments, and referring to the above parameters in clinical, is conducive to the selection of the working casing during surgery.

La hernia de disco torácico (TDH) tiene una alta dificultad técnica y complicaciones graves, y la anatomía clínica del agujero intervertebral torácico es menor. Recolectando 10 cadáveres machos adultos, midiendo el diámetro longitudinal del ganglio de la raíz dorsal (D1), el diámetro transversal del ganglio de la raíz dorsal (D2), el diámetro sagital horizontal del borde superior del disco intervertebral (S1), el colmo del intervertebral agujero (H1), la altura de las articulaciones costovertebrales (H2), la altura del disco intervertebral (H3), el ángel del ganglio de la raíz dorsal (α). El objetivo de este estudio es explorar el área segura de la sección torácica media y baja y proporcionar una base anatómica para la selección de la cánula operatoria. Dominar ciertas reglas de la estructura anatómica de los segmentos torácicos medio e inferior, y referirse a los parámetros anteriores en clínica, es propicio para la selección de la carcasa de trabajo durante la cirugía.

Abordaje transtorácico mínimamente invasivo para la hernia de disco dorsal. Técnica quirúrgica y resultados a corto y mediano plazo / Minimally invasive transthoracic approach for dorsal disc herniation. Surgical technique and results in the short and medium term

Introducción: Existen múltiples técnicas para la descompresión medular en la columna torácica, cada una con sus ventajas y desventajas y con distintos requerimientos de destre-zas quirúrgicas. Se han desarrollado técnicas mínimamente invasiva que disminuyen las tasas de morbilidad, con buenos resultados funcionales. Objetivo: El objetivo del trabajo es describir la técnica quirúrgica y presentar los resulta-dos iniciales en 2 años consecutivos de trabajo. Materiales y métodos: Se evaluaron los pacientes operados en 2017 y 2018 con hernia de disco dorsal tratadas con técnica de abordaje transtorácico mínimamente invasivo. Descri-biendo detalladamente la técnica quirúrgica, la evolución y las complicaciones a corto y mediano plazo. Resultado: Se evaluaron 8 pacientes. El seguimiento promedio fue de 9 meses (3 ­ 26 meses) con una edad promedio de 54 años (28 ­ 66 años). Los motivos de consulta fue-ron en su mayoría dolor dorsal y diferentes grados de compromiso medular (mo-tor/sensitivo). Los niveles fueron distales a T6 y proximales a T12. Todos los pacientes mantuvieron o mejoraron su función neurológica. No se presentaron complicaciones ma-yores. Conclusiones: Si bien se trata de una serie pequeña de casos, son más que suficientes para demostrar que se puede llevar a cabo una técnica novedosa, mínimamente invasiva, utili-zando el separador con visión tubular y el microscopio que aporta luz y magnificación, permitiendo trabajar a cuatro manos cara a cara entre dos cirujanos. Presentando bajas tasas de morbimortalidad y una rápida recuperación.

Introduction: There are multiple techniques for spinal decompression in the thoracic spine, each with its advantages and disadvantages and with different requirements for sur-gical skills. Minimally invasive techniques have been developed that decrease morbidity rates, with good functional results. Objective: The objective of the study is to describe the surgical technique and present initial results in 2 consecutive years of work. Materials and methods: Patients operated in 2017 and 2018 with dorsal disc hernia treat-ed with a minimally invasive transthoracic approach technique were evaluated. Describing in detail the surgical technique and the evolution and complications in the short and medi-um term. Conclusions: Although it is a small series of cases, they are more than enough to demon-strate that a novel, minimally invasive technique can be carried out, using the tubular vi-sion separator and the microscope that provides light and magnification, allowing to work with four hands, face to face between two surgeons. Presenting low rates of morbidity and mortality and rapid recovery.

Abordaje alternativo torácico. Tratamiento quirúrgico de la hernia discal torácica. Caso clínico / Alternative thoracic approach. Surgical treatment of the thoracic disc hernia. Clinical case

Introducción El objetivo de este trabajo es describir una modificación en la técnica de la vía de abordaje posterior como alternativa viable en el tratamiento quirúrgico de la discopatía torácica. Materiales y métodos Paciente femenina de 29 años con diagnóstico de hernia discal torácica central (T11) sintomática. Se realizó tratamiento quirúrgico mediante discectomía por abordaje posterior modificado. Resultados Evolución favorable con reversión total de los síntomas y signos presentados, sin complicaciones perioperatorias, y seguimiento a los 3 y 6 meses con controles clínicos, radiográficos y tomográficos aceptables. Discusión Se describieron para el tratamiento de la discopatía torácica sintomática numerosos abordajes anteriores, posteriores y toracoscópicos. No hay precedente publicado en la bibliografía sobre por vía posterior modificada utilizada como alternativa de tratamiento de esta patología. En la actualidad, todas las técnicas descritas son opción válida para el tratamiento de las discopatías torácicas sintomáticas. A pesar de ser un solo caso tratado con el tipo de abordaje empleado, la intención es convertirlo en una alternativa válida para los cirujanos espinales no familiarizados con la vía anterior. Aún faltan estudios prospectivos, de mayor seguimiento y con mayor número de pacientes para validar la técnica quirúrgica empleada. Nivel de evidencia clínica Nivel IV.

Background The aim of this paper is to describe a modification in the posterior approach technique as a viable alternative in the surgical treatment of thoracic disc disease. Materials and methods A 29-year-old female patient with a diagnosis of a symptomatic central (T11) thoracic disc herniation. Surgical treatment was performed by discectomy by modified posterior approach. Results The outcome was favourable with total reversion of the signs and symptoms presented. There were no perioperative complications, and follow-up at 3 and 6 months was acceptable with clinical, radiographic and tomographic controls. Discussion Numerous anterior, posterior and thoracoscopic approaches have described for the treatment of symptomatic thoracic disc disease. There is no precedent published in the literature on the modified posterior route used as an alternative treatment of this pathology. At present, all the techniques described are a valid option for the treatment of symptomatic thoracic disc diseases. Despite being a single case treated with the type of approach employed, the intention is making it a valid alternative for spinal surgeons unfamiliar with the anterior route. There is a lack of prospective studies, with longer follow-up and a larger number of patients in order to validate the surgical technique used. Evidence level IV.

Ultrasound-Guided Posterolateral Approach for Midline Calcified Thoracic Disc Herniation

OBJECTIVE: Symptomatic thoracic disc herniation often requires prompt surgical treatment to prevent neurological deterioration and permanent deficits. Anterior approaches offer direct visualization and access to the herniated disc and anterior dura but require access surgeons and are often associated with considerable postoperative pain and pulmonary complications. A disadvantage with using posterior approaches in the setting of central calcified thoracic disc herniation however, has been the limited visualization of anterior dura and difficulty to accurately assess the extent of decompression. METHODS: We report our experience with intraoperative ultrasound (US) guidance during a modified posterior transpedicular approach for removal of a central calcified thoracic disc herniation with a review of pertinent literature. RESULTS: The herniated thoracic disc was successfully removed with posterior approach with the aid of intraoperative US. The patient had significant neurological improvement at three months follow-up. CONCLUSION: Intraoperative ultrasound is a simple yet valuable tool for real-time imaging during transpedicular thoracic discectomy. Visualization provided by intraoperative US increases the safety profile of posterior approaches and may make thoracotomy unnecessary in a selected group of patients, especially when a patient has existing pulmonary disease or is otherwise not medically fit for the transthoracic approach.

Acute Paraplegia Secondary to Thoracic Disc Herniation of the Adjacent Segment Following Thoracolumbar Fusion and Instrumentation

Proximal junctional disease is a well-recognized postoperative phenomenon in adults who are undergoing long thoracolumbar fusion and instrumentation, and is attributed to increased a junctional stress concentration. In general, the onset of symptoms in these patients is insidious and the disease progresses slowly. We report on a contrary case of rapidly progressing paraplegia secondary to acute disc herniation at the proximal adjacent segment after long posterior thoracolumbar fusion with cement augmentation at the upper instrumented vertebra and the supra-adjacent vertebra. The patient was treated with a discectomy through the costo-transverse approach combined with extension of the posterior instrumentation. The patient's neurological status improved markedly. Stress concentration at the proximal junction disc space may have caused accelerated disc degeneration which in turn lead to this complication.

Posterior Epidural Migration of Thoracic Disc Fragment

Migration of a disc fragment to the posterior epidural space is rare, especially in the thoracic spine. Only four such cases of posterior epidural migration of thoracic disc fragments have been reported. The authors report a case of 66-year-old man who presented with back pain and right leg weakness due to posterior epidural migration of thoracic disc fragment. The patient was successfully treated by laminectomy and partial facetectomy with disc removal.

Percutaneous Endoscopic Thoracic Discectomy: Posterolateral Transforaminal Approach

OBJECTIVE: Development of diagnostic tools has resulted in early detection of thoracic disc herniations(TDH) even when the herniated disc is soft in consistency. In some of the cases, it is considered better not to opt for surgical treatment due to the unduly high morbidity and potential complications associated with conventional approaches. The authors have applied percutaneous endoscopic thoracic discectomy(PETD) technique to soft TDHs in order to avoid the morbidity associated with conventional approaches. METHODS: Eight consecutive patients (range, 31 to 75 years) with soft lateral or central TDH (from T2-3 to T11-12) underwent PETD between May 2001 and June 2004. The patient was positioned in a prone position with intravenous sedation and local anesthetic infiltration. The authors introduced a cannula into the thoracic intervertebral foramen using endoscopic foraminoplasty technique. Discectomy was performed with mechanical tools and a laser under continuous endoscopic visualization and fluoroscopic guidance. Functional status was assessed preoperatively and postoperatively using the Oswestry Disability Index(ODI). RESULTS: The mean ODI scores improved from 52.8 before the surgery to 25.8 at the final follow-up. In cases of myelopathy, long tract signs showed improvement. The mean operative time was 55 minutes, and no patient required conversion to open surgery. CONCLUSION: The technique allows a smaller incision and less morbidity. Soft TDH is amenable to this minimally invasive approach in selected patients with myeloradiculopathy.

Treatment of Upper Thoracic Disc Herniation Using Transthoracic Approach without Division of Latissimus Dorsi: Technical Note / 대한척추외과학회지

Thoracic disc herniation is a rare condition in which a posterior approach, extrapleural approach, posterolateral approach, or transthoracic approach is currently used. The posterior approach is not recommended in thoracic disc herniation surgery because of the risk of spinal cord injury. The transthoracic approach makes it possible to remove the intervertebral disc and is considered a standard method. However, due to an extensive transverse skin incision, division of the latissimus dorsi muscles, and rib resection, the conventional open approaches involve a risk of complications, such as infection and post-thoracotomy pain syndrome; and a long period of rehabilitation and recovery is required. Excision of the intervertebral disc under thoracoscopic guidance can reduce the damage to the skin and muscles, but the equipment and surgical materials are expensive and a long learning curve is required. Therefore, we report a case and a new muscle splitting transthoracic approach that can be performed by incising 10 cm of skin longitudinally and preserving the serratus anterior and latissimus dorsi muscles.

Surgical Result of Interbody Fusion in Thoracic Disc Herniation: Anterior Transthoracic Approach and Posterior Approach Performed by using Cage

OBJECTIVE: Thoracic disc herniation is an uncommon cause of thoracic cord compression. Experience with decompressive laminectomy for thoracic disc herniation proved disappointing and stimulated the development of anterior transpleural approach that does not require retraction of the spinal cord. This study is performed to evaluate the effectiveness of interbody fusion using cage in thoracic disc herniation by retrospectively analyzing data on operations performed at our institution. METHODS: There were eight patients who had undergone operation for single thoracic disc herniation between January 1997 and May 2001. There were five men and three women. All patients presented with pain and/or neurological deficits. Affeted levels were as follows, four patients at T11-T12, two patients at T10-T11, T9-T10 and T12-L1 respectively one case. An anterior transthoracic approach were performed in seven patients. Posterior approch was performed one patient. In all cases, carbon cage instrumentation was used. The mean follow up period was 32.6month(25-57 months). Cases were reviewed to evaluate the efficacy, surgical results, and complication of the operation. RESULTS: An adequate disectomy was achieved in all eight cases. Symptomatic improvement was shown in eight patients. There was no operative mortality. Postoperative follow up imaging studies, especially plain radiography demonstrated no instrumentation failure. CONCLUSION: Interbody fusion by using carbon cage is considered useful for thoracic disc herniation without significiant injury in thoracic structure and improvement of symptoms.

Lateral Extracavitary Approach to Thoracic Cord Tumor and Disc Herniation

We treated 9 patients of ventrally or ventrolaterally located thoracic lesions with lateral extracavitary approach, six cases of ventrally located thoracic cord tumor, and three cases of central disc herniation. After operation, the patients' neurological symptoms were effectively improved and there were no signigicant postoperative c omplications. Compared to transthoracic approach, this approach is less invasive and enable simultaneous vertebral reconstruction and posterior spinal fixation. Although relatatively small in number experienced, lateral extracavitry approach is considered to be a alternative method to transthoracic approach for the treatment of ventrally and ventrolaterally located thoracic lesion.

An Operative Case of Soft Disc Protrusion in Upper Thoracic Level: A Case Report

A case of T3-4 disc herniation is reported as follows. A 23 year-old patient was presented with paraparesis and anterior chest pain. With the anterolateral approach(transthoracic transpleural approach), decompression and removal of a disc fragment was refered; which resulted is an almost complete recovery of the patient. MRI of the thoracic spine suggested a soft disc herniation. In addition, literatures were reviewed in conjunction with this case report.

Transthoracic Interbody Fusion with Carbon Cage for Thoracic Disc Herniation Which was Downward Migrated

The authors report a case of thoracic disc herniation at T11/12 level which was downward migrated, presenting with signs of progressive spinal cord compression. The lesion was diagnosed by MRI. The operation was done by transthoracic transpleural approach using surgical microscope and the rib was not resected due to floating ribs of T11, 12. A Carbon cage with cancellous bones were used for the graft at the partial corpectomy site. The result of operation was good.

Thoracic Disc Herniations

Thoracic disc herniation is so uncommon that only four cases have been literally reported to Korean Neurosurgical Journal Since 1972. Authors report here another 7 cases of thoracic disc herniation and analyse clinical findings and surgical outcome of 11 cases including 4 cases previously reported from other hospitals. Results are as follows: 1) Male dominancy in incidence was quite evident(10 : 1), and most patients were middle aged(30-50). 2) About a half of the patients had sudden onset of spinal cord compression symptoms, and the remaining half had insidious onset. 3) In 7 of 11 patients, diagnosis could be done by myelography alone, but in 4 of 11 cases, myelographic findings were equivocal and contrast CT scan were required for confirmation. 4) Thoracic disc herniations were more frequent in mid-thoracic discs(T5-T8 disc). 5) Considering the direction and location of disc herniations, 7 cases were paramedian, 2 cases central and 1 case was posterolateral. 6) Transthoracic transpleural approach were adequate for central or paramedian disc herniations, and posterolateral or transpedicular approach for lateral herniations.

Thoracic Disc Herniation: 1 Case Report / 대한정형외과학회잡지

Thoracic disc herniation is an uncommon cause of thoracic cord compression. Herniation in this region is of particular importance because of the serious disorders of nervous function which result from anterior compresstion of the spinal cord. Early diagnosis and prompt surgical treatment are imperative because of the progressive and serious neurological deficit which results from delay. Numerous problems remain as to the safest surgical approach to the prolapsed thoracic intervertebral disc. We treated a case of herniated intervertebral disc occuring at Tll–T12 using the anterior approach. The result was favourable.

A Case of Thoracic Disc Herniation Treated by Transthoracic Transpleural Approach

Thoracic disc herniation is uncommon and only represents 0.25% to 0.75% of all symptomatic disc lesions. The difficulty in diagnosis has been the one of the major problems in the treatment of thoracic disc herniation. But at now, the use of computed tomography with or without water soluble contrast media makes the diagnosis more acurate. Recently, we diagnosed a case of T4, T5 disc herniation by computed tomography with iopamidol. Operation by transthoracic, transpleural approach was done with microsurgical technique, and the result was good. The case is reviewed and other surgical techniques on the literature is discussed.

A Case of Thoracic Disc Herniation Theated by Transpedicle Approach

A case of T8-9 disc herniation presenting with signs of spinal cord compression is reported. The patient was subjectd to a transpedicle approach through a midline incision and was cured completely. The other surgical techniques and the diagnostic value of the spine CT are also discussed.