Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Summary

This protocol demonstrates the surgical technique for full endoscopic transforaminal resection of thoracic disc herniations.

Abstract

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.

Introduction

Symptomatic thoracic disc herniations (TDHs) are a relatively rare (0.25%-0.75% of all symptomatic spinal disc herniations)¹ spinal pathology wherein a portion of the nucleus pulposis herniates through the annulus fibrosis of the intervertebral disc, causing spinal cord or nerve root compression. TDHs are most commonly seen at the T7/8, T8/9 and T11/12 levels². Patients with TDHs can present with back pain, thoracic radiculopathy and/or myelopathy².

Surgery for patients with TDHs traditionally involves a relatively invasive approach, which is tailored according to the l....

Protocol

The protocol follows the human care guidelines of the Houston Methodist Hospital Institutional Review Board. A single patient was included in the study. Inclusion criteria: patient aged >18 years of age with a thoracic disc herniation causing symptoms of myelopathy and/or radiculopathy, a patient without medical comorbidities prohibiting 3-4 h of general anesthesia or prone positioning. Informed consent was obtained from the patient prior to participation in the study.

1. Preoperative planning

1. Obtain a preoperative MRI to evaluate the morphology of the disc herniation.
2. Obtain a preoperative CT scan....

Results

A 74-year-old male with a history of type-2 diabetes and hypertension presented with 3-4 months of mid-back pain and lower back pain along with progressive weakness in his proximal bilateral lower extremities. On physical exam, the patient was noted to have 4/5 strength in his bilateral psoas muscles, as well as 3+ patellar reflexes. MRI and CT imaging demonstrated a large, calcified T11/12 disc herniation with spinal cord compression and myelomalacia (Figure 2). Due to the patient's progres.......

Discussion

Thoracic disc herniations, though relatively rare, can be a source of uncontrolled pain and neurological deficits that substantially impact patients' quality of life². Traditional surgical treatments of thoracic disc herniations are relatively invasive and associated with substantial postoperative morbidity^4,8,9. Full endoscopic transforaminal thoracic discectomy provides an ultra-minimally invasive m.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
#10 blade scalpel
3-0 Monocryl suture	Ethicon	Y427H
40 x 2 mm Guglielmi Detachable Coil	Boston Scientific/Target	M0013612040
C-arm/fluoroscope	GE Healthcare
Dermabond Topical Skin Adhesive	Ethicon	DNX6
Endoscope	Tessys, Joimax gmbh, Karlsruhe, Germany
Endoscopic Cannula	Tessys, Joimax gmbh, Karlsruhe, Germany
Endoscopic Drill/"Shrill"	Joimax gmbh, Karlsruhe, Germany
Endoscopic Irrigation Tubing	Joimax gmbh, Karlsruhe, Germany
Endoscopic Tower	Joimax gmbh, Karlsruhe, Germany
Guidewire/K-wire	Joimax gmbh, Karlsruhe, Germany
Jamshidi needle	Joimax gmbh, Karlsruhe, Germany		Biopsy needle
Lead apron
Normal saline
Radiolucent operating table	Mizuho OSI Jackson Modular Surgical Table
Surgical drapes	Joimax gmbh, Karlsruhe, Germany
Surgical prep
Tessys Endo-Flexprobe	Joimax gmbh, Karlsruhe, Germany	TEFP32020