A minimally invasive tubular retractor-assisted retropleural approach for thoracic disc herniations - case series and technical note

Abstract

Purpose: Thoracic disc herniations are uncommon and carry a high risk for neurological deterioration. Traditional surgical approaches include thoracotomy, costotransversectomy or posterior approaches with considerable morbidity. In this technical note with case series, we describe a minimally invasive tubular retractor-assisted retropleural approach for simple and less invasive microsurgical exploration of thoracic disc herniations from a lateral angle.

Methods: Surgical technique consisted of partial rib resection and retropleural dissection followed by the placement of a tubular retractor (METRx Tubes, Medtronic) for an anterior-lateral exposure of the disc and neuroforamen. Epidemiological, clinical and surgical patient data were acquired.

Results: Between 2017 and 2020, six patients were surgically treated using the minimally invasive tubular retractor-assisted retropleural approach. Microsurgical exposure of the disc and neural structures was achieved from a lateral direction without requiring thoracotomy or lung deflation. Control imaging confirmed resection in all cases without relevant residuum. As postoperative complications, one dural injury and one postoperative pneumothorax occured. No neurologic deterioration or recurrence occurred during a median follow-up of 3 months.

Conclusion: The described tubular retractor-assisted retropleural exposure serves as a feasible minimally invasive microsurgical approach to the anterior-lateral thoracic spine.

Keywords: Minimally invasive spine surgery; Retropleural dissection; Thoracic disc herniation; Thoracic spine surgery; Tubular retractor–assisted surgical approach.

Fig. 1

Schematic illustration of partial resection of the lower rib (a) and positioning of the tubular retractor (b) for the retropleural, retractor-assisted approach to thoracic disc herniations

Fig. 2

Insertion of the tubular retractor (a) with the aid of intraoperative fluoroscopy at the level Th 10/11 (b) and drilling of the head of the rib and posterior lateral part of the disc (c) allows removal of the disc herniation with optimal anterior/lateral exposure of the disc space (d,§) and dura (d,*). (e) illustrates the wound after closure

Fig. 3

Preoperative (a–d) and postoperative (e–f) MRI of patient No. 5 with a mediolateral left-sided, partially calcified disc herniation at level Th 7/8 causing relevant spinal cord compression, with spinal cord and radicular compression completely removed in (e) and (f)