Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance

Abstract

OBJECTIVE Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs. METHODS A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores. RESULTS A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade. CONCLUSIONS The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon’s arsenal for the confident tackling of all TDHs.

Perspective: Transthoracic, posterolateral, or transpedicular approaches to thoracic disks, not laminectomy

“…Lam Risks Neuro Deficits Arts [2] Spine 1]. [2,3,6,[8][9][10][11][12][13][14] Interestingly, the overall percentages of good/excellent outcomes for TDH are lower than for lumbar disk herniation (LDH) due to the frequently encountered delays in diagnosis, prolonged cord microtrauma, and decreased blood supply to critical areas of the thoracic cord.…”

“…(2021) series, 86% had myelopathy (i.e., including 72% with weakness), while 66% showed sensory deficits. [ 11 ]…”

“…Three studies effectively utilized transpedicular (TP), minimally invasive TP (MI TP), and partial TP (PTP) approaches to TDH [ Table 1 ]. [ 9 - 11 ] One year after Le Roux et al . (1993) utilized TP surgery to address 6 central, and 14 lateral TDH, all 20 patients demonstrated significant improvement with 8 patients showing no residual deficits.…”

“…[ 11 ] Their average operative time was 197.2 minutes, average estimated blood loss (EBL) was 238.8 cc, the average length of stay was 44 days, and the reoperation rate was 14% (6 reoperations). [ 11 ]…”

Commentary: Minimally Invasive Retropleural Thoracic Diskectomy: Step-by-Step Operative Planning, Execution, and Results

“…Various posterolateral approaches have gained significant popularity and represent an optimal surgical strategy for a significant number of patients with TDH, especially with paracentral locations regardless of the calcification and soft central disk herniations because of the familiarity with posterior approaches and favorable complication profile. 1,4 An instrumented fusion is often necessary for most posterolateral approaches for TDH. Although there are data supporting the safety and efficacy of posterolateral approaches even in patients with central calcified disk herniation, truly central TDH especially if calcified can be challenging to access using a posterolateral approach regardless of the lateral trajectory (transfacet, transpedicular, lateral extracavitary approaches, and costotransversectomy) and maybe better treated using an anterior/ anterolateral approach.…”