A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations

Abstract

Thoracic disc herniation (TDH) is a rare, but technically challenging, disorder. Apart from their unfamiliarity with this condition, surgeons are often posed with challenges regarding the diverse methods available to address TDH, the neurological disturbances accompanying the disorder, the prospect of iatrogenic cord damage during surgical procedures, and the complications associated with various surgical approaches. In today's era, when minimally invasive surgery has been incorporated into almost every aspect of managing spine disorders, it is necessary for surgeons to be aware of the various minimally invasive techniques available for the management of these rare and difficult conditions. In this review article, we provide a synopsis of the epidemiology, clinical features, and technical aspects of TDH, starting from level identification to intraoperative neuromonitoring and including important steps and guidance for all the minimally invasive approaches to TDH. We conclude the review by providing insights into the clinical decision-making process and outline the specific aspects of "giant" thoracic discs and indications for fusion in certain conditions. Outcomes of minimally invasive surgery for these conditions are generally favorable. The location of herniation is an important factor for surgical planning.

Keywords: Discectomy; Giant thoracic herniations; Minimally invasive spine surgery; Spinal endoscopy; Thoracic disc herniations; Thoracic myelopathy.

Fig. 1.

An axial cut through the T8–9 level showing the directions of various approaches.

Fig. 2.

Thoracoscopic approach for a central disc herniation. (A, B) Preoperative magnetic resonance imaging (MRI) showing central disc herniation. (C, D) Postoperative MRI showing adequate decompression of the cord. (E, F) Intraoperative picture of thoracoscopy ports and skin incision. The circles in panels A and B indicate the location of the central disc herniation.

Fig. 3.

Three-dimensional computed tomography scan of the thorax showing the rib head overlying the disc space. It is necessary to remove the rib head during transthoracic procedures in order to access the disc space. The red circle indicates the amount of rib head to be removed to access the disc space.

Fig. 4.

(A, B) Needle placement through the foramen. (C, D) Obturator placement over a guide wire. (E) Placement of the working cannula. (F) Endoscopic forceps for removal of herniated fragments.

Fig. 5.

A flow chart to guide the selection of the appropriate surgical approach. TDH, thoracic disc herniation; TMED, tubular microendoscopic discectomy.