A prospective multi-institutional study was carried out to evaluate automated percutaneous discectomy in the treatment of lumbar disc herniations. Of the 327 patients who prospectively met the study criteria and were followed for longer than 1 year, 75.2% were successfully treated. When patients (n = 168) who prospectively did not meet the study criteria were treated, the success rate was 49.4%. One case of discitis was reported; otherwise, no other serious complications were noted, and specifically no vascular or nerve damage was encountered. This study indicates that automated percutaneous discetomy can be used successfully to treat lumbar disc herniations with minimal morbidity and emphasizes the need for proper patient selection.

Early diagnosis of thoracic disc herniations has become more common with the advent of spinal magnetic resonance imaging (MRI). This early diagnosis combined with choosing the optimal surgical approach, to ensure adequate decompression without excessive cord and root manipulation, will achieve the optimum results. It is now clear that more lateral and anterior approaches to the thoracic spine are required to achieve this goal. We report our experience in the operative management of 21 patients with thoracic disc herniation using three different surgical approaches: transpedicular-transfacetal, posterolateral-extrapleural (costotransversectomy) and transthoracic-transpleural. The clinical and radiologic findings and results in all of our cases are reviewed as are the technique of and indication for each of the three surgical approaches.

INCE Mixter and Barr 21 first described herniated lumbar intervertebral disc-induced nerve root compression, numerous operative approaches have been used for treatment. Neural compromise caused by a herniated disc outside the confines of the spinal canal is more readily recognized by using computerized tomography and magnetic resonance imaging. Such herniations have been characterized as foraminal, 8 extraforaminal, 15 extreme-lateral, 1,23 far-lateral, 19 and extracanalicular 25 disc prolapse. We prefer the term "extraforaminal" because the boundaries of the neural foramen can be readily identified on computerized tomography and magnetic resonance images, and because extraforaminal lesions are distinct from intraspinal-foraminal, foraminal, and foraminal-extraforaminal lesions.The clinical and radiological characteristics of extraforaminal lesions have been reported. 1,8,10,14,23 Currently two surgical approaches commonly used for the treatment of this type of disc herniation are 1) a conventional approach via a midline laminotomy/fenestration, or one of its modifications, and 2) a paramedian approach. Removal of a truly extraforaminal herniated disc via the midline approach necessitates sacrificing a significant portion, if not all, of the facet joint. The paramedian approach, however, which is performed at the level of the facet joint, provides a more direct route to this lesion. Although several Materials and Methods Anatomical StudiesTwenty-four lumbar extraforaminal disc spaces were studied in three human cadavers. In one cadaver predissection, the arteries and Object. Familiarity with the microsurgical anatomy of the far-lateral compartment is essential for operating in patients with far-lateral discs. In this report the authors address the microsurgical anatomy studied in 24 extraforaminal lumbar disc spaces in three cadavers.Methods. Cadaveric dissections confirmed the authors' operative experience in which they found an arterial arcade to be associated with the nerve trunk. The main trunk of the lumbar artery was located lateral to the exiting nerve root in the region of intervertebral foramen. The trunk of the lumbar spinal nerve descending from the level above was 7 mm (Ϯ 3 mm [standard deviation]) lateral to the lumbar artery.Conclusions. Clarification of the microsurgical anatomy of the far-lateral compartment confirmed the authors' clinical impression that the optimum approach to far-lateral discs is via the inferomedial quadrant of the extraforaminal compartment. In this quadrant, exposure of the main nerve root can be facilitated by dividing the posterior primary ramus and a newly described arterial arcade that envelops the nerve trunk. Once this arcade is divided, the nerve can be retracted with relative ease and safety, and the disc can be removed more easily. KEY WORDS • spine • lumbar intervertebral disc • microsurgery • anatomical study • surgical approachS

We have developed a thoracoscopic first rib resection technique for treatment of thoracic outlet syndrome (TOS), employing new instruments designed for endoscopic surgery. A 49-year-old man with Paget-Schroetter syndrome was treated bilaterally, and a 25-year-old woman with neurologic symptoms was treated on the right side by thoracoscopic approach via three ports. Harmonic scalpel, endoscopic elevators, rongeurs, and an endoscopic drill were used. In two patients, approximately 80% of the first rib overlying the subclavian vessels and brachial plexus was successfully removed by this technique. We conclude that port-access first-rib resection is feasible and reproducible using the new instruments described.