The transfacet pedicle-sparing approach for thoracic disc removal: cadaveric morphometric analysis and preliminary clinical experience

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✓ A number of operative techniques have been described for the treatment of herniated thoracic discs. The transfacet pedicle-sparing approach allows for complete disc removal with limited spinal column disruption and soft-tissue dissection. Fifteen cadaveric spinal columns were used for evaluation of exposure, development of thoracic microdiscectomy instrumentation, and establishment of morphometric measurements. This approach was used to remove eight thoracic discs in six patients. Levels of herniation ranged from T-7 through T-11. Preoperatively, all patients had moderate to severe axial pain, and three (50%) of the six had radicular pain. Myelopathy was present in four (67%) of the six patients. Through a 4-cm opening, the ipsilateral paraspinal muscles were reflected, and a partial facetectomy was performed. The disc was then removed using specially designed microscopic instrumentation. Postoperatively, the radiculopathy resolved in all patients. Axial pain and myelopathy were completely resolved or significantly improved in all patients.

The minimal amount of bone resection and muscle dissection involved in the operation allows for: 1) decreased operative time and blood loss; 2) diminished perioperative pain; 3) shorter hospitalization time and faster return to premorbid activity; 4) avoidance of closed chest tube drainage; and 5) preservation of the integrity of the facet—pedicle complex, with potential for improvement in outcome related to axial pain. This technique appears best suited for the removal of all centrolateral discs, although it has been used successfully for treating a disc occupying nearly the entire ventral canal. The initial experience suggests that this approach may be used to safely remove appropriately selected thoracic disc herniations with good results.

Article Information

Address reprint requests to: Charles B. Stillerman, M.D., Trinity Medical Center, 20 Burdick Expressway West, Suite 204, Minot, North Dakota 58701.

© AANS, except where prohibited by US copyright law.

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    Chart showing cadaveric morphometric measurements for thoracic discs. Each measurement was performed in 15 cadavers, using both sides of the same level for 30 measurements. Asterisk indicates a significant difference between a certain level compared to the initial level at T1–2 (p < 0.05) using Student's t-test. +/− represents standard deviation. Column A: The distance from the facet to disc remained constant over varying vertebral body levels except at T11–12 because of increased thickness of the facet joints at these levels. Column B: The vertical distance from the inferior articular process to the point on the facet directly over disc center increased with increasing levels. Column C: The width of the disc remained constant at all levels until T10–11.

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    Drawings showing the use of fluoroscopic guidance for localizing the incision. Left: The patient is placed prone on radiolucent chest rolls and secured with tape so that the table may be rolled away from the surgeon during the disc removal. Right: A small incision is centered over the appropriate disc space using fluoroscopy. Fluoroscopy is more desirable than plain films because it can be readily repeated to plan the skin incision, determine the portion of facet to be removed, and evaluate the extent of disc removal.

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    Diagrams showing steps in removal of disc using the transfacet pedicle-sparing approach. The scale bar represents 0.8 cm = 1 cm. Left: Before beginning the partial facetectomy, we reintroduce the fluoroscope for anteroposterior imaging, specifically to evaluate where the disc space is in relationship to the dorsally situated facet complex. This determines the boundaries of the partial facetectomy that is then performed. Center: After drilling of the facet, the dorsal portion of the neural foramen is entered. The foraminal soft tissue may be coagulated with bipolar cautery. The lateral margins of the annulus are identified. A large herniation can be identified along with the dura (situated medially), and the cephalad nerve root. Right: The lateral margin of the annulus is incised and the disc removal is performed using specially designed instrumentation. Diagram illustrates the postdiscectomy appearance.

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    Photograph of the Manny—Mark microdiscectomy instruments that were designed to facilitate disc removal without injuring the mesially situated spinal cord.

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    Case 3. Magnetic resonance (MR) images revealing a large extruded T10–11 disc in a patient presenting with pain and myelopathy. Left: Preoperative T1-weighted sagittal MR image demonstrating a large ventral lesion with dorsal displacement of the spinal cord. Center: A T1-weighted axial view. The ventral spinal canal is nearly entirely occupied with the disc. Arrows depict the extruded disc. Right: Postoperative gadolinium-enhanced MR image, axial view, obtained to assess the extent of disc removal. No intracanalicular disc material is present, and only normal postoperative changes are seen. The spinal cord has returned to its normal location and configuration.

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    Drawings depicting common approaches for discectomy. Left: Axial view demonstrating the trajectories used for the major thoracic discectomy procedures. Both the transfacet (TF) pedicle-sparing and transpedicular (TP) approaches use a posterolateral approach to thoracic discs. The transthoracic (TT) approach provides a more anterior orientation, whereas the lateral extracavitary (LEC) approach affords more direct access to the anterolateral thoracic spine. Center: Lateral view demonstrating the degree of bone removal for the TT and LEC approaches. In both approaches, a significant portion of vertebral body, pedicle, and facets are removed, generally requiring fusion. Right: Lateral view demonstrating degree of bone removal for the TF pedicle-sparing approach versus the TP approach. In addition to removal of the pedicle, the TP approach entails a more extensive facetectomy than does the TF approach.

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