Thoracic spine approaches

Thoracic spine approaches

Since the end of the nineteenth century, the wide dissemination of Pott’s disease has ignited debates about which should be the ideal route to perform ventrolateral decompression of the dorsal rachis in case of paraplegia due to spinal cord compression in tuberculosis spondylitis. It was immediately clear that the optimal approach should be the one minimizing the surgical manipulation on both neural and extra-neural structures, while optimizing the exposure and surgical maneuverability on the target area. The first attempt was reported by Victor Auguste Menard in 1894, who described, for the first time, a completely different route from traditional laminectomy, called costotransversectomy. The technique was conceived to drain tubercular paravertebral abscesses causing paraplegia without manipulating the spinal cord 1).

The procedure defined by Capener in 1954 2) resulted in better results for the treatment of spinal tuberculosis, due to the effect of antibiotic3)

Over the following decades many other routes have been described all over the world, thus demonstrating the wide interest on the topic. Surgical development has been marked by the new technical achievements and by instrumental/technological advancements, until the advent of portal surgery and endoscopy-assisted techniques. Gagliardi et al. retraced the milestones of this history up to 2022, through a systematic review on the topic 4).


Thoracic disc herniation surgery is challenging because of: the difficulty of anterior approaches, the proportionately tighter space between cord and canal compared to the cervical and lumbar regions, and the watershed blood supply which creates a significant risk of spinal cord injury with attempts to manipulate the cord when trying to work anteriorly to it from a posterior approach. Thoracic disc herniations are calcified in 65% of patients considered for surgery 5) (more difficult to remove from a posterior or lateral approach than non-calcified discs).

For centrally located anterior access: a transthoracic or lateral approach gives the best acess. Some prefer a left-sided approach to avoid the vena cava, others prefer a right-sided approach because the heart does not impede access.


Various different approaches have been tried for the surgical removal of TDH, but most of them are cumbersome surgeries such as thoracotomy or thoracoscopic or anterior approaches with or without instrumentation. The requirement for a simplified, familiar, and less morbid surgery has motivated some new approaches. A pedicle sparing transfacet approach (PSTA) was first described in 1995, but to date no sufficient clinical series has been presented in the literature to report on its feasibility and applicability along with complication and morbidity rates.

Surgery for thoracic disc herniation is comparatively rare and often demanding. The goal is to achieve sufficient decompression without manipulating the spinal cord. Individual planning and various surgical techniques and approaches are required.

Surgical treatment can be divided into anterior, lateral and posterior approaches and is an area of contention in the literature. Available evidence consists mostly of single-arm, single-institutional studies with limited sample sizes.

Anterior approaches had longer LOS and higher, although not statistically significant, complication rates. No difference was found with regard to discharge disposition. In light of these findings, surgeons should weigh the risks and benefits of each surgical technique during tailoring of decision making 6).

The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc.

Medially located large calcified discs should be operated through an anterolateral transthoracic approach, whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers 7).

Anterolateral retroperitoneal, anterior transthoracic, posterolateral, and lateral approaches are performed in discectomy with or without fusion and internal fixation. However, patients who have undergone any operation at these levels are predisposed to postoperative recurrence, neurological aggravation, and adjacent segment degeneration, and the outcomes are inferior than those in lower lumbar spine 8) 9).


posterior (midline laminectomy): primary indication is for decompression of posteriorly situated intracanalicular pathology (e.g. metastatic tumor) especially over multiple levels. There is a high failure and complication rate when used for single-level anterior pathology (e.g. midline disc herniation)

a) lateral gutter: laminectomy plus removal of pedicle

b) transpedicular approach 10)

c) costotransversectomy

d) Pedicle sparing transfacet approach

(transthoracic approach): usually through the pleural space

(retrocoelomic) 11) : an approach posterior (external) to the pleural space

Video-assisted thoracoscopic surgery is an alternative to open surgical approaches 12) 13).


1)

Ménard V. Causes de la paraplégie dans le mal de Pott. Son traitement chirurgical par l’ouverture directe du foyer tuberculeux des vertebres. Rev Orthop 1894; 5: 47-64.
2)

CAPENER N. The evolution of lateral rhachotomy. J Bone Joint Surg Br. 1954 May;36-B(2):173-9. doi: 10.1302/0301-620X.36B2.173. PMID: 13163099.
3)

Benzel EC. Spine Surgery: Techniques, Complication Avoidance, and Management, 3th Ed. Saunders, Philadelphia 2012.
4)

Gagliardi F, Pompeo E, De Domenico P, Snider S, Roncelli F, Acerno S, Mortini P. HISTORY OF EVOLUTION OF POSTERO-LATERAL APPROACHES TO THE THORACIC SPINE: FROM CURE OF POTT’S DISEASE TO EPIDURAL TUMOR RESECTION. J Neurol Surg A Cent Eur Neurosurg. 2022 Jan 10. doi: 10.1055/a-1734-2085. Epub ahead of print. PMID: 35008121.
5) , 12)

Stillerman CB, Chen TC, Couldwell WT, et al. Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg. 1998; 88:623–633
6)

Kerezoudis P, Rajjoub KR, Goncalves S, Alvi MA, Elminawy M, Alamoudi A, Nassr A, Habermann EB, Bydon M. Anterior versus posterior approaches for thoracic disc herniation: Association with postoperative complications. Clin Neurol Neurosurg. 2018 Apr;167:17-23. doi: 10.1016/j.clineuro.2018.02.009. Epub 2018 Feb 6. PubMed PMID: 29428625.
7)

Arts MP, Bartels RH. Anterior or posterior approach of thoracic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies. Spine J. 2013 Oct 24. pii: S1529-9430(13)01595-7. doi: 10.1016/j.spinee.2013.09.053. [Epub ahead of print] PubMed PMID: 24374099.
8)

Sanderson SP, Houten J, Errico T, et al. The unique characteristics of “upper” lumbar disc herniations. Neurosurgery 2004;55:385–9.
9)

Ido K, Shimizu K, Tada H, et al. Considerations for surgical treatment of patients with upper lumbar disc herniations. J Spinal Disord 1998;11:75–9.
10)

Le Roux PD, Haglund MM, Harris AB. Thoracic Disc Disease: Experience with the Transpedicular Approach in Twenty Consecutive Patients. Neurosurgery. 1993; 33:58–66
11)

Uribe JS, Smith WD, Pimenta L, et al. Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine. 2012; 16:264–27
13)

Dohn DF. Thoracic Spinal Cord Decompression: Alternative Surgical Approaches and Basis of Choice. Clin Neurosurg. 1980; 27:611–623

Thoracic radiculopathy

Thoracic radiculopathy is the pain and resulting symptoms associated with compression on the nerve or nerve roots of the thoracic spine. When the symptoms radiate or refer distally from the spine into the back and outward along the ribs to the anterior chest wall it is considered radiculopathy.

Epidemiology

Thoracic radiculopathy represents an uncommon spinal disorder that is frequently overlooked in the evaluation of spinal pain syndromes 1).

Etiology

Anything that encroaches on, or presses on a nerve, and disrupts its function at the nerve root can be considered a cause of nerve root entrapment.

Degenerative disc disease that results in wear on the intervertebral disc, and a reduction in disc height may result in loss of space at the intervertebral foramen. Herniated discs can place pressure on the nerve in addition to inflammation that irritates the nerve. Degenerative joint disease that results in the formation of bony spurs on the facet joints can narrow the intervertebral space placing pressure on the exiting nerve. Trauma or muscle spasm can put pressure on the peripheral nerve, producing symptoms along that nerve’s distribution path.


The symptoms of thoracic radiculopathy, regardless of the cause, are often not recognized, as there is typically no associated motor deficit. When the etiology is disc herniation or trauma, motor deficit or myelopathy may be observed in the advanced stages.

Furthermore, the typical presentation of band-like thoracic or abdominal pain can mimic a myriad of conditions 2).

With many differential diagnoses to consider, it is not surprising that thoracic radiculopathy is often not discovered for months, or years, after symptoms arise 3).

Rarer causes of thoracic radiculopathy described in the literature include post-thoracotomy, paravertebral mesothelial cyst, and myodil cyst 4).


Thoracic radiculopathy has been reported as a complication of spinal cord stimulation (SCS) paddle lead implantation by several authors and commonly presents as abdominal pain.

Lee et al., from the Houston Methodist Hospital performed a search of all patients who underwent either placement of a new epidural paddle lead electrode or revision of an epidural paddle lead electrode for SCS in the thoracic region from January 2017 to January 2018. They then investigated all cases of immediate postoperative abdominal pain.

They identified 7 patients who had immediate postoperative abdominal pain among 86 cases of epidural SCS procedures. Most patients were discharged on postoperative days 1-3. No patients required revisions or removals of their SCS for any reason.

They conclude that the etiology of immediate postoperative abdominal pain after thoracic paddle lead implantation for SCS is most likely thoracic radiculopathy. They hypothesized that small, transient epidural hematomas could be the cause of this thoracic radiculopathy. They argue that all patients with immediate postoperative abdominal pain and no other neurologic deficits after thoracic paddle lead implantation for SCS should first be treated conservatively with observation and pain management 5).

References

1) , 3)

O’Connor RC, Andary MT, Russo RB, DeLano M. Thoracic radiculopathy. Phys Med Rehabil Clin N Am. 2002 Aug;13(3):623-44, viii. Review. PubMed PMID: 12380552.
2) , 4)

Mammis A, Bonsignore C, Mogilner AY. Thoracic radiculopathy following spinal cord stimulator placement: case series. Neuromodulation. 2013 Sep-Oct;16(5):443-7; discussion 447-8. doi: 10.1111/ner.12076. Epub 2013 May 17. PubMed PMID: 23682904.
5)

Lee JJ, Sadrameli SS, Desai VR, Austerman RJ, Leonard DM, Dalm BD. Immediate Abdominal Pain after Placement of Thoracic Paddle Leads for Spinal Cord Stimulation: A Case Series. Stereotact Funct Neurosurg. 2019 Jan 3:1-6. doi: 10.1159/000495415. [Epub ahead of print] PubMed PMID: 30605913.

Update: Idiopathic thoracic intravertebral spinal cord herniation

Idiopathic spinal cord herniation (ISCH) is an uncommon cause of thoracic myelopathy in which the spinal cord herniates or prolapses through an anterior or lateral defect in the dura mater.
Idiopathic herniation, which results from a dural defect of unknown origin, is distinguished from herniation with a documented traumatic cause or with postoperative origin. Since the first report of idiopathic spinal cord herniation was published by Wortzman et al in 1974 1).
92 cases have been reported in the literature till 2006 2).
It is a frequently misdiagnosed condition. It preferentially affects women and causes progressive thoracic myelopathy that presents as a Brown Séquard syndrome or as spastic paraparesis. Although its etiology and pathogenesis are controversial, ISCH is characterized by the presence of an anterior dural defect that allows the incarceration of a segment of the cord. Typically, a C-shaped ventral displacement and kinking of the cord are visible on sagittal MRI. Surgery aimed at stopping or reversing myelopathic symptoms is usually recommended for symptomatic patients. Surgical options include reduction of the hernia and direct suturing, or enlargement of the dural defect, with or without patching. Suturing under the cord in a very tight space can be troublesome and may lead to neurological deterioration. The authors present the case of a symptomatic ISCH in which nonpenetrating titanium microstaples were used to close the dural defect after cord reduction. The patient experienced a good outcome, and the follow-up MRI study showed adequate cord repositioning and stability of the suture. The use of microstaples, which allows for an easier and faster dural closure than conventional suturing, is a novel technical adjunct that has not been previously reported for this condition. In addition, microstaples produce minimal metallic artifact that does not hinder the quality of follow-up MR images 3).
see Sadek AR, Nader-Sepahi A. Idiopathic thoracic intravertebral spinal cord herniation. Br J Neurosurg. 2016 Dec 14:1-2. [Epub ahead of print] PubMed PMID: 27967246 from the Department of Neurosurgery, Wessex Neurological Centre , University Hospital Southampton , Southampton , UK.

1) Wortzman G, Tasker RR, Rewcastle NB, Richardson JC, Pearson FG. Spontaneous incarcerated herniation of the spinal cord into a vertebral body: a unique cause of paraplegia. Case report. J Neurosurg. 1974 Nov;41(5):631-5. PubMed PMID: 4424434.
2) Barrenechea IJ, Lesser JB, Gidekel AL, Turjanski L, Perin NI. Diagnosis and treatment of spinal cord herniation: a combined experience. J Neurosurg Spine. 2006 Oct;5(4):294-302. PubMed PMID: 17048765.
3) Delgado-López PD, Gil-Polo C, Martín-Velasco V, Martín-Alonso J, Galacho-Harriero AM, Araus-Galdós E. Spinal cord herniation repair with microstaples: case report. J Neurosurg Spine. 2016 Nov 4:1-4. [Epub ahead of print] PubMed PMID: 27813449.
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