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Shinobu Takahashi, Shigehiro MoriKawa, Yasuo Saruhashi, Yoshitaka MatsUsue, and Mamoru Kawakami

percutaneously with navigated fenestration. 3 , 9 We discuss the percutaneous fenestration of a midthoracic, intramedullary, neurenteric cyst in an 8-year-old boy performed with combined thoracoscopy and intraoperative magnetic resonance image guidance. Fenestration was successful via an anterior, transthoracic, transvertebral approach, and the cyst showed marked and lasting shrinkage. The innovative method we describe is minimally invasive and should be considered as an alternative to more invasive conventional surgery, especially in children with cystic lesions of the spine

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Daniel Rosenthal and Curtis A. Dickman

T horacoscopy is an anterior transthoracic endoscopic approach to the thoracic cavity and mediastinum. In cardiothoracic and spine surgery, this technique has become a well-established, valuable surgical approach because it is associated with less morbidity and more rapid recoveries than thoracotomy. 1, 8, 9, 14, 15, 17, 20, 23–25, 33, 34, 39 We began using thoracoscopy to treat pathological conditions of the thoracic spine in 1992. This report delineates our clinical experience using thoracoscopy to resect herniated thoracic discs in 55 patients

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Peter Kan and Meic H. Schmidt

TE : Application of thoracoscopy for diseases of the spine . Ann Thorac Surg 56 : 736 – 738 , 1993 28 McAfee PC , Regan JR , Fedder IL , Mack MJ , Geis WP : Anterior thoracic corpectomy for spinal cord decompression performed endoscopically . Surg Laparosc Endosc 5 : 339 – 348 , 1995 29 Oskouian RJ , Johnson JP : Endoscopic thoracic microdiscectomy . J Neurosurg Spine 3 : 459 – 464 , 2005 30 Oskouian RJ Jr , Johnson JP , Regan JJ : Thoracoscopic microdiscectomy . Neurosurgery 50 : 103 – 109 , 2002 31 Overby

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Curtis A. Dickman and Ronald I. Apfelbaum

T he use of thoracoscopy has rapidly increased during the past decade and has been used to treat a wide array of pathological processes involving the thorax and mediastinum. 1, 15, 17 Thoracoscopy has also been applied successfully to a variety of spinal operations: sympathectomies, thoracic discectomies, corpectomies, spinal reconstructions and internal fixations, anterior releases to correct spinal deformities, decompressions of the spinal cord and nerve roots, stabilization of the thoracic spine, and to obtain biopsies of vertebral lesions. 3–6, 10, 11, 18

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Mark E. Oppenlander, Justin C. Clark, James Kalyvas, and Curtis A. Dickman

or lateral HTDs. 4 , 8 , 15 Anterolateral approaches, consisting of thoracotomy or thoracoscopy, best address large, midline, calcified disc herniations. 10 , 16 , 28 , 34 , 35 , 39 , 45 We report our experience on the management of patients with multiple-level symptomatic HTDs, treated via thoracotomy, thoracoscopy, and/or posterolateral approaches. Patient characteristics, surgical variables, and outcomes are compared among the different approaches and also to those of an unmatched cohort of patients undergoing single-level HTD decompression. In this manner

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Jonathan S. Hott, Iman Feiz-Erfan, Kathy Kenny, and Curtis A. Dickman

two patients (25%) with giant HTDs who underwent thoracoscopy. Neurological function recovered to baseline in one patient. In the other, in whom preoperative status was Frankel Grade D, improved function (Frankel Grade C) persisted at the last follow-up examination. In general, open thoracotomy allowed better control of the solid mass lesion, avoiding leverage and allowing multiple points of dissection to separate the HTD from the spinal cord. At last follow-up examination, symptoms had resolved completely in one patient who presented only with radicular pain

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Kaushik Das and Martin Rothberg

Recent technical advances have revolutionized the fields of surgical endoscopy, laparoscopy, thoracoscopy, and microsurgical spinal endoscopy. The authors discuss the rich history and recent evolution of these techniques.

Thoracoscopy had been widely used for the treatment of pleural conditions associated with tuberculosis. It was largely abandoned in the 1950s when effective antituberculosis medications were introduced. In the 1980s the development of video-assisted endoscopic procedures in the fields of general surgery, orthopedics, and otolaryngology provided new impetus to revive thoracoscopy. As a result of these advances thoracoscopy replaced open thoracotomy in many cardiothoracic procedures.

These improvements led to the application of these techniques to treat disorders of the spine. By the mid-1990s microsurgical endoscopy was being used effectively to treat thoracic disc disease, perform anterior surgical release procedures for scoliosis, resect tumors, and even to conduct complex spinal fusions and reconstructions. As technology continues to improve, there is no doubt that thoracoscopic surgery will find a permanent place in the armamentarium of techniques used to treat pathological entities of the spine.

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Curtis A. Dickman, Daniel Rosenthal, and John J. Regan

evaluated by the authors and by independent radiologists. Results The surgical procedures first performed to treat thoracic disc herniations included 11 transpedicular or costotransversectomy approaches, one thoracotomy, and three thoracoscopy-guided surgical approaches. In all 15 cases, the initial excision was unsuccessful. The locations of the disc herniations are provided in Table 1 . TABLE 1 Location of thoracic disc herniations in 15 patients in whom initial surgery failed Disc Level No. of Patients T5–6 1 T6

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Daniel Rosenthal and Curtis A. Dickman

Object

The authors began using thoracoscopy to treat pathological conditions of the spine in 1992. In this study they delineate their clinical experience in which this procedure was used to resect herniated thoracic discs.

Methods

Fifty-five patients underwent thoracoscopy for the resection of herniated thoracic discs. Thirty-six patients presented with myelopathies and 19 with incapacitating thoracic radicular pain. Forty-three patients underwent a single-level, 11 a two-level, and one a three-level discectomy. The mean operative time for thoracoscopic microdiscectomy was 3 hours and 25 minutes (range 80-542 minutes) and the mean blood loss was 327 ml (range 124-1500 ml). Compared with thoracotomy, which was performed in 18 patients, thoracoscopy was associated with a mean of 1 hour less operative time and less than one-half of the blood loss, duration of chest tube drainage, usage of pain medication, and length of hospitalization. Compared with costotransversectomy, which was performed in 15 patients, thoracoscopy permitted more complete resection of calcified and midline thoracic discs because it provided a direct view of the entire anterior surface of the dura. Thoracotomy was associated with a significantly greater incidence of prolonged, disabling intercostal neuralgia compared with the mild transient episodes of intercostal neuralgia associated with thoracoscopy (50% compared with 16%). Thoracotomy also was associated with a significantly higher incidence of postoperative atelectasis and pulmonary dysfunction than thoracoscopy (33% compared with 7%). Clinical and neurological outcomes were excellent (mean follow-up period 15 months). Among the 36 myelopathic patients, 22 completely recovered neurologically; five improved functionally but had some residual myelopathic symptoms; and nine stabilized. Among the 19 patients with isolated thoracic radiculopathies, 15 recovered completely; four improved moderately; and none had worsened radicular pain.

Conclusions

Thoracoscopic microdiscectomy is a reliable surgical technique that can be performed safely with excellent clinical and neurological results.

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Patrick P. Han and Curtis A. Dickman

Five patients who harbored large intrathoracic paraspinal neurogenic tumors were treated using thoracoscopic techniques to achieve gross-total tumor resection. All tumors were entirely intrathoracic except one that had an intraspinal extension, and all tumors were treated entirely thoracoscopically except for this one. Gross-total resection was achieved in all cases. The mean clinical follow-up period was 6.8 months. Postoperatively, one patient developed Horner's syndrome. The only other complication was transient intercostal neuralgia (two patients), which has resolved in both patient. No evidence of disease was demonstrated clinically or on follow-up imaging in any patient. Thoracoscopy is an excellent modality with which to treat these tumors, in part because it is associated with significantly less morbidity than open thoracotomy and costotransversectomy procedures. Endoscopic transthoracic approaches reduce the approach-related soft-tissue morbidity by preserving the normal tissues of the chest wall, avoiding rib retraction and muscle transection, reducing postoperative pain, and facilitating recovery. This technique has become the senior author's (C.A.D.'s) surgical approach of choice for the removal of intrathoracic benign paraspinal neurogenic tumors. It has also become the preferred method by which to perform thoracic sympathectomy and remove central, herniated thoracic discs.