Endoscopic transforaminal thoracic foraminotomy and discectomy for the treatment of thoracic disc herniation

Abstract

Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6-41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery.

Figure 1

The target disc was identified under fluoroscopic guidance (a), and the entry point between the rib head and the facet was marked on the skin (b).

Figure 2

Discography was performed to confirm the target disc and to help identify the location of the herniation; the needle was parallel to the upper endplate of the lower vertebral body.

Figure 3

A sequential dilator was then inserted over the wire towards the posterolateral margin of the facet (a). A working cannula was guided to the extraforaminal region over the dilator (b).

Figure 4

An Ellman radiofrequency probe (a) and a shaver (b) were used to expose the foraminal structure.

Figure 5

The herniated disc material was removed using a grasper (a), radiofrequency (b), and the Holmium-YAG laser (c).

Figure 6

Preoperative MRI images of a T8-9 disc herniation compressing the spinal cord, which caused the patient to have mid back pain radiating to the shoulder blade ((a) and (b)). Postoperative MRI images showing removal of the extruded disc material ((c) and (d)).