Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Symptomatic herniated thoracic discs remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less invasive approaches. Many of these techniques, such as thoracoscopy, have not been widely adopted due to technical difficulties. The current study was performed to examine the safety and early results of a minimally invasive lateral approach for symptomatic thoracic herniated intervertebral discs.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>Sixty patients from 5 institutions were treated using a mini-open lateral approach for 75 symptomatic thoracic herniated discs with or without calcification. The mean age was 57.9 years (range 23–80 years), and 53.3% of the patients were male. Treatment levels ranged from T4–5 to T11–12, with 1–3 levels being treated (mean 1.3 levels). The most common levels treated were T11–12 (14 cases [18.7%]), T7–8 (12 cases [16%]), and T8–9 (12 cases [16%]). Symptoms included myelopathy in 70% of cases, radiculopathy in 51.7%, axial back pain in 76.7%, and bladder and/or bowel dysfunction in 26.7%. Instrumentation included an interbody spacer in all but 6 cases (10%). Supplemental internal fixation included anterolateral plating in 33.3% of cases and pedicle screws in 10%; there was no supplemental internal fixation in 56.7% of cases. Follow-up ranged from 0.5 to 24 months (mean 11.0 months).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The median operating time, estimated blood loss, and length of stay were 182 minutes, 290 ml, and 5.0 days, respectively. Four major complications occurred (6.7%): pneumonia in 1 patient (1.7%); extrapleural free air in 1 patient (1.7%), treated with chest tube placement; new lower-extremity weakness in 1 patient (1.7%); and wound infection in posterior instrumentation in 1 patient (1.7%). Reoperations occurred in 3 cases (5%): one for posterior reexploration, one for infection in posterior instrumentation, and one for removal of symptomatic residual disc material. Back pain, measured using the visual analog scale, improved 60% from the preoperative score to the last follow-up, that is, from 7.8 to 3.1. Excellent or good overall outcomes were achieved in 80% of the patients, a fair or unchanged outcome resulted in 15%, and a poor outcome occurred in 5%. Moreover, myelopathy, radiculopathy, axial back pain, and bladder and/or bowel dysfunction improved in 83.3%, 87.0%, 91.1%, and 87.5% of cases, respectively.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The authors' early experience with a large multicenter series suggested that the minimally invasive lateral approach is a safe, reproducible, and efficacious procedure for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional surgical techniques and without the use of endoscopes. Symptom resolution was achieved at similar rates using this approach as compared with the most efficacious techniques in the literature, and with fewer complications in most circumstances.</jats:p></jats:sec>

Calcified giant thoracic disc herniations: considerations and treatment strategies

“…We accept that this small approach related complication rate may simply be due to the few number of patients in our study (rather than the use of a mini-open approach per se). However, it is worth noting that Uribe and colleagues [40] reviewed the literature on open (357 patients) versus minimally invasive approaches (466 patients) for thoracic disc herniations (not solely giant calcified) finding a complication rate of 36.7 % (0-182 %) and 28.4 % (0-92.3 %), respectively.…”

“…In his review of treatment of thoracic disc, Vaccarro recommended that 'the use intra-operative neurologic monitoring greatly reduces the risk of permanent neurologic injury and allows immediate intra-operative surgical correction if necessary' [43]. In their recent large series of 60 patients from 5 institutions, Uribe and colleagues [40] used intra-operative neuromonitoring for all patients. However, we accept that the use of intra-operative monitoring is an area of debate; there is limited literature to provide guidance and this issue remains a contentious topic even within our own unit.…”

Radiographic and clinical outcomes following combined lateral lumbar interbody fusion and posterior segmental stabilization in patients with adult degenerative scoliosis

“…There are an abundance of data in the literature on the ability of the LLIF surgery to significantly improve patient-reported outcome measures including visual analog score (VAS) for back and leg pain and the Oswestry Disability Index (ODI) for varying conditions. 10,18,21,29,[31][32][33]38,39,58 However, few single-center studies exist that evaluate the ability of the LLIF procedure in conjunction with PSIF to improve lumbar lordosis, correct coronal and sagittal plane deformity, and improve quality of life in patients with adult degenerative scoliosis.…”

“…It is now used to treat a multitude of conditions including degenerative disc disease, spondylolisthesis, foraminal stenosis, tumor, and trauma. 21,31,32,[37][38][39]58 Biomechanically, the interbody cage used in LLIF surgery applies an extension distraction moment to the anterior and middle columns of the lumbar spine and serves several purposes. First, it expands the interbody space, restoring lost disc space height and indirectly enlarging the neuroforamina, ultimately reducing nerve root compression.…”

Mini-Open Transthoracic Approach for Resection of a Calcified Herniated Thoracic Disc and Repair of the Dural Surface with Fibrin Glue: A Case Report

“…Perioperative complications using thoracoscopy have been reported. 18,[23][24][25] Repairing a dural tear is a complicated task to achieve endoscopically. 12,13,19 In our patient, the dura was stretched after a prolonged period of compression.…”