Article Figures & Data
Figures
- Figure 1
Fluoroscopic views of the transforaminal approach of patient 1. (A) Insertion of the needle at T10-T11 level at anteroposterior (AP) view until needle tip reaches the midpedicular line. (B) After reaching the disc at the AP view, the C-arm is turned to lateral position, the needle tip is observed a few millimeters behind the posterior intervertebral disc line due to the disc protrusion. (C) The needle is now observed inside the disc space, and intraoperative discography is performed by injecting a mixture of radiopaque dye and methylene blue. (D) A guide wire is inserted through the needle and the dilator followed over the guide wire, note the tip of the dilator at the same point where the needle tip had touched the disc extrusion. (E) The guide wire is removed and the operating sheath is inserted over the dilator. (F) Through the endoscope, a dissector touches the disc herniation. (G and H) Progressive reamers are inserted inside the disc to assure nucleotomy.
- Figure 2
(A and B) After insertion of the transforaminal endoscope, it is possible to identify the superior articular process (SAP) and the disc herniation (*). The radiofrequency probe is used to palpate and clean the SAP. (C) A trephine is used to open de annulus. (D and E) Further disc material is resected using the Lowe punch. (F) A burr is used to complete discectomy. (G and H) At the end of the surgery, it is possible to notice the widened foramen (green area).
- Figure 3
Endoscopic view of the interlaminar approach. (A) After preparing the operating field it is possible to identify the inferior articular process (IAP), the superior articular process (SAP), and the interlaminar window with the flavum ligament (*). (B) After drilling the IAP and enlarging the interlaminar window, the SAP is ready to be drilled. (C) It is possible to see the burr drilling the inferior laminae and the SAP, lateral to the flavum ligament (*) it is possible to identify the opening of the spinal canal. (D) Above the pedicle (P), it is possible to identify the extruded disc herniation (arrow) and the partially compressed dural sac (circle). (E) Lowe punch resecting the disc herniation. (F) Dural sac free at the end of the surgery.
- Figure 4
(A) Sagittal T2-weighted magnetic resonance imaging (MRI) showing the extruded disc herniation with caudal migration (arrow). (B and C) Axial T2-weighted MRI showing the paramedian disc herniation with migration medial to pedicle. (E and F) Postoperative images showing good resection of the disc herniation. It is possible to see the partial facetectomy (arrow head), with complete preservation of the spinal muscles. (G) Computed tomographic image showing partial facetectomy. (D and H) Intraoperative images showing access to the intervertebral disc and manipulation of the instrument medial to the pedicle.
- Figure 5
(A and B) Sagittal and axial T2-weighted magnetic resonance images of patient 1 showing a T10-T11 foraminal disc herniation.
- Figure 6
(A) Patient 1 axial magnetic resonance image (MRI) showing a T10-T11 foramina disc herniation; the green arrow shows the selected transforaminal approach, which is a straight forward direction to the disease, avoiding bone resection. (B and C) Patient 2 axial MRI showing a T7-T8 paramedian disc herniation; the green arrow shows the selected interlaminar approach, the need of medial facetectomy is more adequate than a lateral facetectomy that would be needed in a transforaminal approach (red arrow), because it allows navigation inside the spinal canal to access the migrated material, sparing the pedicle.
Tables
- Table 1
Published patients series of interlaminar full endoscopic spine surgery for thoracic disc herniations.
Patient Series Pathology N (M:F) Age, y (range) Operative Time, min Length of Stay, d Follow-Up, mo Postoperative Course Complications Ruetten, 20187 T1-T2 (6), T4-T5 (1), T7-T8 (2), T9-T10 (4), T10-T11 (5), T11-T12 (2) 20 (8:12) 53 (23–71) 95 (35–135) 3 (2–5) 18 All patients with radiculopathy showed symptom regression. Preoperative thoracic spine pain was reduced, but not significantly. Epidural hematoma ×1 (revision), transient intercostal neuralgia, deterioration of myelopathy Hur, 201915 T10-T11 1 (1:0) 65 95 Not reported 1.5 Paresthesia immediately subsided, motor grade improved from G2-G3 to G3-G4 None Liu L, 202016 T10-T11 and ossification of ligamentum flavum 1 (0:1) 58 110 3 6 Motor grade improved from G4 to G4+ bilaterally. The VAS score improved from 8 to 5. None All patients received general anesthesia.
F, female; M, male; VAS, visual analog score.
Patient Level Approach Anesthesia Total Time, min Irrigation Time, min Hospital Stay, h Complications Patient 1: female, 38 y T10–T11 Transforaminal Local and sedation 50 32 6 None Patient 2: male, 39 y T7–T8 Interlaminar General 80 70 3 None
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