Skip to main content

Advertisement

SpringerLink
Log in

Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients

  • Original Article
  • Published:
Neurosurgical Review Aims and scope Submit manuscript

Abstract

Thoracic disc herniations are associated with serious neurological consequences if not treated appropriately. Although a number of techniques have been described, there is no consensus about the best surgical approach. In this study, the authors report their experience in the operative management of patients with thoracic disc herniations using minimally invasive lateral transthoracic trans/retropleural approach. A series of 33 consecutive patients with thoracic disc herniations who underwent anterior spinal cord decompression followed by instrumented fusion through lateral approach is being reported. Demographic and radiographic data, perioperative complications, and clinical outcomes were reviewed. Forty disc levels in 33 patients (18F/15M; mean age, 52.9) were treated. Twenty-three patients presented with myelopathy (69 %), 31 had radiculopathy (94 %), and 31 had axial pain (94 %). Among patients with myelopathy, 14 (42.4 %) had bladder and/or bowel dysfunction. In the last eight cases (24 %), the approach was retropleural instead of transpleural. Patients were followed up for 18.2 months on average. The mean length of hospital stay was 5 days. None of the patients developed neurological deterioration postoperatively. Among 23 patients who had myelopathy signs, 21 (91 %) had improved postoperatively. The mean preoperative visual analog scale pain score, Oswestry Disability Index score, SF-36 PCS, and mental component summary scores were 7.5, 42.4, 29.6, and 37.5 which improved to 3.5, 33.2, 35.5, and 52.6, respectively. Perioperative complications occurred in six patients (18.1 %), all of which resolved uneventfully. Minimally invasive lateral transthoracic trans/retropleural approach is a safe and efficacious technique for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional approaches.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

  1. Arce CA, Dohrmann G (1985) Herniated thoracic disks. Neurol Clin 3:383–392

    CAS  PubMed  Google Scholar 

  2. Tokuhashi Y, Matsuzaki H, Uematsu Y, Oda H (2001) Symptoms of thoracolumbar junction disc herniation. Spine 26:512–518

    Article  Google Scholar 

  3. Vanichkachorn JS, Vaccaro AR (2000) Thoracic disk disease: diagnosis and treatment. J Am Acad Orthop Surg 8:159–169

    CAS  PubMed  Google Scholar 

  4. Abbott KH, Retter RH (1956) Protrusions of thoracic intervertebral disks. Neurology 6:1–10

    Article  CAS  PubMed  Google Scholar 

  5. Arseni C, Nash F (1960) Thoracic intervertebral disc protrusion. A clinical study. J Neurosurg 17:418–430

    Article  CAS  PubMed  Google Scholar 

  6. Bilsky MH (2000) Transpedicular approach for thoracic disc herniations. Neurosurg Focus 9(4):e3

    Article  CAS  PubMed  Google Scholar 

  7. Chi JH, Dhall SS, Kanter AS, Mummaneni PV (2008) The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment. Neurosurg Focus 25(2):E5

    Article  PubMed  Google Scholar 

  8. Dinh DH, Tompkins J, Clark SB (2001) Transcostovertebral approach for thoracic disc herniations. J Neurosurg 94(1 Suppl):38–44

    CAS  PubMed  Google Scholar 

  9. Hulme A (1960) The surgical approach to thoracic intervertebral disc protrusions. J Neurol Neurosurg Psychiatry 23:133–137

    Article  CAS  PubMed  Google Scholar 

  10. Khoo LT, Smith ZA, Asgarzadie F, Barlas Y, Armin SS, Tashjian V, Zarate B (2011) Minimally invasive extracavitary approach for thoracic discectomy and interbody fusion: 1-year clinical and radiographic outcomes in 13 patients compared with a cohort of traditional anterior transthoracic approaches. Clinical article. J Neurosurg Spine 14:250–260

    Article  PubMed  Google Scholar 

  11. Kim KD, Babbitz JD, Mimbs J (2000) Imaging-guided costotransversectomy for thoracic disc herniation. Neurosurg Focus 9(4):e7

    Article  CAS  PubMed  Google Scholar 

  12. Sheikh H, Samartzis D, Perez-Cruet MJ (2007) Techniques for the operative management of thoracic disc herniation: minimally invasive thoracic microdiscectomy. Orthop Clin North Am 38:351–361

    Article  PubMed  Google Scholar 

  13. Stillerman CB, Chen TC, Day JD, Couldwell WT, Weiss MH (1995) The transfacet pedicle-sparing approach for thoracic disc removal: cadaveric morphometric analysis and preliminary clinical experience. J Neurosurg 83:971–976

    Article  CAS  PubMed  Google Scholar 

  14. Bartels RH, Peul WC (2007) Mini-thoracotomy or thoracoscopic treatment for medially located thoracic herniated disc? Spine (Phila Pa 1976) 32:E581–E584

    Article  Google Scholar 

  15. Deviren V, Kuelling FA, Poulter G, Pekmezci M (2011) Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients. J Spinal Disord Tech 24:E40–E48

    Article  PubMed  Google Scholar 

  16. Russo A, Balamurali G, Nowicki R, Boszczyk BM (2012) Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations. Eur Spine J 21(Suppl 2):S212–S220

    Article  PubMed  Google Scholar 

  17. Smith WD, Dakwar E, Le TV, Christian G, Serrano S, Uribe JS (2010) Minimally invasive surgery for traumatic spinal pathologies: a mini-open, lateral approach in the thoracic and lumbar spine. Spine (Phila Pa 1976) 35:S338–S346

    Article  Google Scholar 

  18. Uribe JS, Dakwar E, Cardona RF, Vale FL (2010) Minimally invasive lateral retropleural thoracolumbar approach: cadaveric feasibility study and report of 4 clinical cases. Neurosurgery 68(1 Suppl Operative):32–39

    Google Scholar 

  19. Uribe JS, Smith WD, Pimenta L, Härtl R, Dakwar E, Modhia UM, Pollock GA, Nagineni V, Smith R, Christian G, Oliveira L, Marchi L, Deviren V (2012) Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine 16:264–279

    Article  PubMed  Google Scholar 

  20. Ayhan S, Nelson C, Gok B, Petteys RJ, Wolinsky JP, Witham TF, Bydon A, Gokaslan ZL, Sciubba DM (2010) Transthoracic surgical treatment for centrally located thoracic disc herniations presenting with myelopathy: a 5-year institutional experience. J Spinal Disord Tech 23:79–88

    Article  PubMed  Google Scholar 

  21. Bohlman HH, Zdeblick TA (1988) Anterior excision of herniated thoracic discs. J Bone Joint Surg Am 70:1038–1047

    CAS  PubMed  Google Scholar 

  22. De Giacomo T, Francioni F, Diso D, Tarantino R, Anile M, Venuta F, Coloni GF (2011) Anterior approach to the thoracic spine. Interact Cardiovasc Thorac Surg 12:692–695

    Article  PubMed  Google Scholar 

  23. Perot PL Jr, Munro DD (1969) Transthoracic removal of midlinethoracic disc protrusions causing spinal cord compression. J Neurosurg 31:452–458

    Article  PubMed  Google Scholar 

  24. Anand N, Regan JJ (2002) Video-assisted thoracoscopic surgery for thoracic disc disease: classification and outcome study of 100 consecutive cases with a 2-year minimum follow-up period. Spine (Phila Pa 1976) 27:871–879

    Article  Google Scholar 

  25. Burke TG, Caputy AJ (2000) Treatment of thoracic disc herniation: evolution toward the minimally invasive thoracoscopic technique. Neurosurg Focus 9(4):e9

    Article  CAS  PubMed  Google Scholar 

  26. Jho HD (1999) Endoscopic transpedicular thoracic discectomy. J Neurosurg 91(2 Suppl):151–156

    CAS  PubMed  Google Scholar 

  27. Johnson JP, Filler AG, Mc Bride DQ (2000) Endoscopic thoracic discectomy. Neurosurg Focus 9(4):e11

    CAS  PubMed  Google Scholar 

  28. Mack MJ, Regan JJ, McAfee PC, Picetti G, Ben-Yishay A, Acuff TE (1995) Video assisted thoracic surgery for the anterior approach to the thoracic spine. Ann Thorac Surg 59:1100–1106

    Article  CAS  PubMed  Google Scholar 

  29. McAfee PC, Regan JR, Fedder IL, Mack MJ, Geis WP (1995) Anterior thoracic corpectomy for spinal cord decompression performed endoscopically. Surg Laparosc Endosc 5:339–348

    Article  CAS  PubMed  Google Scholar 

  30. Oskouian RJ Jr, Johnson JP, Regan JJ (2002) Thoracoscopic microdiscectomy. Neurosurgery 50:103–109

    PubMed  Google Scholar 

  31. Perez-Cruet MJ, Kim BS, Sandhu F, Samartzis D, Fessler RG (2004) Thoracic microendoscopic discectomy. J Neurosurg Spine 1:58–63

    Article  PubMed  Google Scholar 

  32. Quint U, Bordon G, Preissl I, Sanner C, Rosenthal D (2012) Thoracoscopic treatment for single level symptomatic thoracic disc herniation: a prospective followed cohort study in a group of 167 consecutive cases. Eur Spine J 21(4):637–645

    Article  PubMed  Google Scholar 

  33. Ozgur BM, Aryan HE, Pimenta L, Taylor WR (2006) Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion. Spine J 6:435–443

    Article  PubMed  Google Scholar 

  34. Upadhyaya CD, Wu JC, Chin CT, Balamurali G, Mummaneni PV (2012) Avoidance of wrong-level thoracic spine surgery: intraoperative localization with preoperative percutaneous fiducial screw placement. J Neurosurg Spine 16(3):280–284

    Article  PubMed  Google Scholar 

  35. Fairbank JC, Couper J, Davies JB, O'Brien JP (1980) The Oswestry low back pain disability questionnaire. Physiotherapy 66:271–273

    CAS  PubMed  Google Scholar 

  36. Eleraky MA, Apostolides PJ, Dickman CA, Sonntag VK (1998) Herniated thoracic discs mimic cardiac disease: three case reports. Acta Neurochir (Wien) 140:643–646

    Article  CAS  Google Scholar 

  37. Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris HB (1997) Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints. Eur J Cardiothorac Surg 12:82–87

    Article  CAS  PubMed  Google Scholar 

  38. Huang TJ, Hsu RW, Sum CW, Liu HP (1999) Complications in thoracoscopic spinal surgery: a study of 90 consecutive patients. Surg Endosc 13:346–350

    Article  CAS  PubMed  Google Scholar 

  39. Payer M, Sottas C (2008) Mini-open anterior approach for corpectomy in the thoracolumbar spine. Surg Neurol 69:25–31

    Article  PubMed  Google Scholar 

  40. Roush TF, Crawford AH, Berlin RE, Wolf RK (2001) Tension pneumothorax as a complication of video-assisted thorascopic surgery for anterior correction of idiopathic scoliosis in an adolescent female. Spine 26:448–450

    Article  CAS  PubMed  Google Scholar 

  41. McCormick PC (1995) Retropleural approach to the thoracic and thoracolumbar spine. Neurosurgery 37:908–914

    Article  CAS  PubMed  Google Scholar 

  42. Karikari IO, Nimjee SM, Hardin CA, Hughes BD, Hodges TR, Mehta AI, Choi J, Brown CR, Isaacs RE (2011) Extreme lateral interbody fusion approach for isolated thoracic and thoracolumbar spine diseases: initial clinical experience and early outcomes. J Spinal Disord Tech 6:368–375

    Article  Google Scholar 

  43. Yanni DS, Connery C, Perin NI (2011) Video-assisted thoracoscopic surgery combined with a tubular retractor system for minimally invasive thoracic discectomy. Neurosurgery 1(Suppl):138–143

    Google Scholar 

  44. Blumenthal S, McAfee PC, Guyer RD, Hochschuler SH, Geisler FH, Holt RT, Garcia R Jr, Regan JJ, Ohnmeiss DD (2005) A prospective, randomized, multicenter Food and Drug Administration investigational device exemptions study of lumbar total disc replacement with the CHARITE artificial disc versus lumbar fusion: part I: evaluation of clinical outcomes. Spine (Phila Pa 1976) 30:1565–1575

    Article  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Mrs. Lori Justice for her secretarial assistance.

Conflict of interest

Dr. VD is a consultant for NuVasive, Inc. The other authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA

    Osman Arikan Nacar

  2. Department of Neurological Surgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey

    Mustafa Onur Ulu

  3. Division of Spine Surgery, Department of Orthopaedic Surgery, University of California San Francisco, 500 Parnassus Avenue, MBW 320, San Francisco, CA, 94143, USA

    Mustafa Onur Ulu, Murat Pekmezci & Vedat Deviren

Authors
  1. Osman Arikan Nacar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mustafa Onur Ulu
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Murat Pekmezci
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Vedat Deviren
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Mustafa Onur Ulu.

Additional information

Comments

Noel I. Perin, New York, USA

The authors reported on a series of 33 patients presenting with thoracic disc herniations who were candidates for anterior discectomy. They have discussed elegantly a novel minimally invasive tubular retractor-guided approach.

We have published our technique where we used two 1-cm ports for endoscopic exploration, to free any pleural adhesions and protect the lung and large vessels from injury during blind placement of the retractor. We also routinely took a segment of the rib to accommodate the tubular retractor and replaced it at the end of the procedure, plating it back, to avoid fractures of the ribs, which were much more painful. The authors also fused and plated all of their patients. We did not routinely fuse and almost never plated our patients, following a simple discectomy. The authors do not mention the use of the operating microscope during the discectomy which affords a distinct advantage when dissecting the dura from the disc. We commend the authors on their excellent results and low complication rates.

Florian Roser, Tübingen, Germany

Nacar and colleagues performed lateral transthoracic surgery for thoracic disc disease in 33 patients. They should be congratulated for the original concept and the minimally invasive approach reflected by the excellent results. Although the neurosurgeon can well adapt to new thoracic approaches, in cases like the presented, we like to approach interdisciplinarily, as the thoracic surgeon performs those approaches on a daily basis and not only 33 times over 5 years. This makes it even less “minimally invasive.” However, the XLIF for thoracic pathologies is the first step towards endoscopic or robotic procedures, like da Vinci-assisted surgeries, and publications like these might bring the audience towards these new frontiers.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Nacar, O.A., Ulu, M.O., Pekmezci, M. et al. Surgical treatment of thoracic disc disease via minimally invasive lateral transthoracic trans/retropleural approach: analysis of 33 patients. Neurosurg Rev 36, 455–465 (2013). https://doi.org/10.1007/s10143-013-0461-2

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10143-013-0461-2

Keywords

Search

Navigation