Introduction: The appropriate approach for surgical removal of thoracic disc herniations is controversial. The posterior approach has led to high rates of neurological deterioration due to spinal cord manipulation. The open and thoracoscopically assisted anterior approach entails a larger magnitude of surgery if open and is technically demanding if approached thoracoscopically. Approaching the thoracic disc posteriorly following unilateral facetectomy and pediculectomy was first described in 1995 but has failed to gain popularity due to unpredictable outcomes and complications.
The purpose of this study is to present a new technique for posterior thoracic discectomy following a hemilaminectomy, unilateral facetectomy and hemipediculectomy. This approach is facilitated by using a high speed dorsally shielded curved drill-like device. The device is entered ventral to the dural sac, thus allowing removal of calcified and soft disc fragments without vigorous manual maneuvers and spinal cord manipulation.
Methods: The side of maximal disc protrusion is approached through a hemilaminectomy, unilateral facetectomy and hemipediculectomy. The superior half of the pedicle is removed and the disc is transforaminally exposed. The disc excision is facilitated using the described device.
Six patients, presenting neurological deterioration and pyramidal signs, underwent posterior thoracic discectomy applying this approach. The treated levels were D3-4 (1), D5-6 (1), D11-12 (3) and D12-L1 (1).
Results: All procedures were uneventful. The curved configuration of the device allowed access to the disc space without rib head removal and extending the approach laterally. Remaining transforaminal. hemipediculectomy allowed better visualization and working space. Continuous irrigation of the device head precluded thermal damage to the tissues. Pedicle fixation and fusion concluded all procedures. No dural tears were observed and none of the patients deteriorated neurologically.
Conclusions: We believe that this approach allows for a smaller, shorter and neurologically safer procedure for thoracic disc herniation removal.
Patient Care: The suggested approach for thoracic disc herniation removal allows for a neurologically safer procedure, with a shorter duration and smaller strain for the patient. Our experience shows that this technique can significantly improve the clinical outcome, as supported by this series.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Identify the problematic nature of existing approaches to thoracic TLIF. 2) Describe the characteristics if the suggested approach. 3) Consider possible improvements for this approach