Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience

Clinical article

Juan S. UribeDepartment of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida;

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William D. SmithDepartment of Neurosurgery, University Medical Center, Las Vegas, Nevada;

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Luiz PimentaMinimally Invasive and Reconstructive Spine Surgery, Instituto de Patologia da Coluna, São Paulo, Brazil;

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Roger HärtlDepartment of Neurosurgery, Weill Cornell Medical College, New York; and

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Elias DakwarDepartment of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida;

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Urvij M. ModhiaDepartment of Orthopaedic Surgery, University of California, San Francisco, California

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Glen A. PollockDepartment of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida;

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Vamsi NagineniDepartment of Neurosurgery, Weill Cornell Medical College, New York; and

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Ryan SmithDepartment of Neurosurgery, University Medical Center, Las Vegas, Nevada;

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Ginger ChristianDepartment of Neurosurgery, University Medical Center, Las Vegas, Nevada;

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Leonardo OliveiraMinimally Invasive and Reconstructive Spine Surgery, Instituto de Patologia da Coluna, São Paulo, Brazil;

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Luis MarchiMinimally Invasive and Reconstructive Spine Surgery, Instituto de Patologia da Coluna, São Paulo, Brazil;

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Vedat DevirenDepartment of Orthopaedic Surgery, University of California, San Francisco, California

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Object

Symptomatic herniated thoracic discs remain a surgical challenge and historically have been associated with significant complications. While neurological outcomes have improved with the abandonment of decompressive laminectomy, the attempt to minimize surgical complications and associated morbidities continues through less invasive approaches. Many of these techniques, such as thoracoscopy, have not been widely adopted due to technical difficulties. The current study was performed to examine the safety and early results of a minimally invasive lateral approach for symptomatic thoracic herniated intervertebral discs.

Methods

Sixty patients from 5 institutions were treated using a mini-open lateral approach for 75 symptomatic thoracic herniated discs with or without calcification. The mean age was 57.9 years (range 23–80 years), and 53.3% of the patients were male. Treatment levels ranged from T4–5 to T11–12, with 1–3 levels being treated (mean 1.3 levels). The most common levels treated were T11–12 (14 cases [18.7%]), T7–8 (12 cases [16%]), and T8–9 (12 cases [16%]). Symptoms included myelopathy in 70% of cases, radiculopathy in 51.7%, axial back pain in 76.7%, and bladder and/or bowel dysfunction in 26.7%. Instrumentation included an interbody spacer in all but 6 cases (10%). Supplemental internal fixation included anterolateral plating in 33.3% of cases and pedicle screws in 10%; there was no supplemental internal fixation in 56.7% of cases. Follow-up ranged from 0.5 to 24 months (mean 11.0 months).

Results

The median operating time, estimated blood loss, and length of stay were 182 minutes, 290 ml, and 5.0 days, respectively. Four major complications occurred (6.7%): pneumonia in 1 patient (1.7%); extrapleural free air in 1 patient (1.7%), treated with chest tube placement; new lower-extremity weakness in 1 patient (1.7%); and wound infection in posterior instrumentation in 1 patient (1.7%). Reoperations occurred in 3 cases (5%): one for posterior reexploration, one for infection in posterior instrumentation, and one for removal of symptomatic residual disc material. Back pain, measured using the visual analog scale, improved 60% from the preoperative score to the last follow-up, that is, from 7.8 to 3.1. Excellent or good overall outcomes were achieved in 80% of the patients, a fair or unchanged outcome resulted in 15%, and a poor outcome occurred in 5%. Moreover, myelopathy, radiculopathy, axial back pain, and bladder and/or bowel dysfunction improved in 83.3%, 87.0%, 91.1%, and 87.5% of cases, respectively.

Conclusions

The authors' early experience with a large multicenter series suggested that the minimally invasive lateral approach is a safe, reproducible, and efficacious procedure for achieving adequate decompression in thoracic disc herniations in a less invasive manner than conventional surgical techniques and without the use of endoscopes. Symptom resolution was achieved at similar rates using this approach as compared with the most efficacious techniques in the literature, and with fewer complications in most circumstances.

Abbreviations used in this paper:

EBL = estimated blood loss; LOS = length of stay; ORT = operating room time; TDH = thoracic disc herniation; VAS = visual analog scale; XLIF = extreme lateral interbody fusion.
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