Introduction: Thoracic disc herniation with clinically significant canal stenosis can be treated surgically with discectomy. There are multiple approaches to the thoracic disc space. In cases of paracentral and central disc herniation with extensive calcification, a retrodiaphragmatic approach can be used. Intraoperative risks of this approach include correct level identification, spinal cord injury during discectomy, increased operative time using fluoroscopy, and inadequate discectomy. We report our experience using intraoperative computerized tomography (iCT) with stereotactic navigation with automatic registration. This case involves a patient with a right, calcified, paracentral disc herniation at T11-12.
Methods: The patient was placed in the left lateral decubitus position onto a Trumpfe operative table attached to the Brainlab Airo iCT scanner. Any metallic attachments to the table were kept out of the scan area. Fluoroscopy was used to localize levels and check spine alignment. Lateral exposure to the spine was obtained; a midline incision at T10 placed to attach the navigation reference array. Intraoperative scan was then obtained and automatic registration was done by the system. Registration accuracy was confirmed with visualization of the spine compared to the reference array as well as left-right orientation and prior fluoroscopic checks.
Results: The intraoperative imaging and automatic registration for navigation eliminated fluoroscopy intraoperatively. Our ability to accurately account for the medial extent of our instruments decreased the risk of spinal cord injury. Post-operative outcome was improved when a second intraoperative scan showed inadequate decompression and better decompression was achieved.
Conclusions: ICT and navigation with Brainlab has not been done for a lateral approach. Our experience showed that while there was increased preoperative preparation for the procedure, there was improved overall safety and efficacy of the procedure with this method. Further study should be done to analyze cost-effectiveness as well as patient outcome compared to traditional methods
Patient Care: Use of intraoperative accurate navigation in technically challenging procedures can improve safety and efficacy of surgical interventions.
Learning Objectives: 1. Discuss the technical aspects for using the intraoperative imaging with automatic registration for navigation of lateral approach spinal surgery 2. Compare intraoperative navigation with use of fluoroscopy 3.Learn ways to improve the safety and efficacy of spinal surgery with poor visualization