Posteriorlateral Endoscopic Thoracic Microdecompressive
Discectomy
John C. Chiu M.D., D.Sc., FRCS
California Spine Institute
Thousand Oaks, California, USA
Nosrat Javidan M.D.
Clinical Assistant Professor - Orthopedic Surgery
Harbor - UCLA Medical Center
Los Angeles, California, USA
James Thacker M.D.
Pain Medicine
California Spine Institute
Thousand Oaks, California, USA
Citation:
John C. Chiu, Nosrat Javidan & James Thacker: Posteriorlateral Endoscopic Thoracic
Microdecompressive Discectomy: The Internet Journal of Minimally Invasive Spinal
Technology. 2008; Volume 2, Number 3.
Posterolateral endoscopic thoracic microdecompression discectomy (PETD) through an
endoscope is an alternative procedure for treating symptomatic herniated thoracic discs,
to achieve less tissue trauma than is caused by current conventional thoracic disc
surgery and thoracoscopic procedures. The purpose of this article is to demonstrate the
surgical indications, instrumentation, anesthesia, surgical technique, safety and efficacy
of this less traumatic outpatient endoscopic procedure, potential complications and their
avoidance. In addition, lower energy non-ablative laser is applied for shrinkage and
tightening of the disc (laser thermodiskoplasty). This endoscopic minimally invasive
spinal surgery (MISS) has numerous advantages, but requires thorough knowledge of
the PETD procedure, the surgical anatomy, specific surgical training and hands-on
experience in a laboratory and working closely with an experienced endoscopic surgeon
through its steep surgical learning curve. The rationale and technique of this minimally
invasive percutaneous endoscopic operation to relieve symptoms of protruded thoracic
discs are presented.
Neurosurgeons, Orthopedic Surgeons and Spinal surgeons have long sought to find a
procedure of choice by which to treat thoracic disc herniations. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 ,
10 , 11 , 12 The threat of spinal cord, neural, vascular, and pulmonary injury has
stimulated many attempted approaches including posterior laminectomy (seldom
performed as it is too likely to result in neurologic injury), costo-transversectomy, trans
thoracic, trans pleural, posterolateral, trans-facet pedicle-sparing, trans-pedicular and,
more recently, transthoracic endoscopic and posterolateral endoscopic procedures. 1 , 2
, 3 , 4 , 5 , 6 , 10 , 11 , 12 , 13
1
Many clever minimally invasive surgical endoscopic thoracic procedures have been
developed including video-assisted thoracic surgery (VATS), 1 , 10 , 11 , 12 , 13 , 14 , 15 , 16 ,
17 , 18 , 19 , 22 thoracic sympathectomy and others attempting to reduce operative trauma
23 , 24 , 25 , 26 , 27 .
In the past, surgery was not contemplated unless considerable cord compression and/or
neurological deficit were present. 5 , 6 , 10 , 11 , 12 , 13 A significant number of patients
complain of thoracic spinal and paraspinal pain, intercostal or chest wall pain, upper
abdominal pain, and occasionally low back pain due to thoracic disc protrusions without
severe neurologic deficit or dramatic radiological abnormalities. With improved
diagnostic methods such as MRI scans 8 , 10 (the method of choice), CT myelograms,
and CT scans the diagnosis of these thoracic disc protrusions is now far more common.
Usually, such patients receive some period of physical therapy, injection therapy and
analgesics, and, if not cured, are expected to live with their discomfort because potential
severe postoperative complications are feared if usual surgical treatment is attempted.
With laser thermodiskoplasty PETD 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22
evolved from minimally invasive techniques used in the lumbar and cervical areas, 10 , 11
, 12 , 13 , 14 , 15 , 16 and from the basic approach for performing thoracic discography. 9 ,
10 We also have utilized pre- or intra-operative discograms and pain provocation tests
on almost all cases to confirm the diagnosis and the appropriate levels to treat. This
chapter describes the surgical technique, safety and efficacy of a method for treating
thoracic disc protrusions by outpatient PETD.
Surgical Indications
The PETD approach is indicated 10 , 11 , 12 in the following clinical situations:
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Pain in the thoracic spine, often radiating to the chest wall, with possible
numbness and parasthesia in an intercostal distribution due to thoracic
disc herniation
No improvement of symptoms after a minimum of 12 weeks of conservative
management
MRI or CT scan positive for disc herniation, consistent with the level of
clinical symptoms
Confirmatory pre- or intra- operative discogram and pain provocation test
Multiple thoracic discs may be treated at one sitting 10 , 11 , 12 , 13 , 14 , 15 , 16 ,
17 , 18 , 19
Contraindications
The PETD approach is contraindicated in the following clinical situations:
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Severe cord compression or total block on radiographic studies
Advanced spondylosis with severe disc space narrowing or osteophytes
blocking entry into the disc space.
Instruments And Preparation
This surgical equipment and these instruments
PETD
10
, 11 , 12 , 13 are necessary to perform
2
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Digital fluoroscopy equipment (C-arm) and monitor
Full radiolucent C-arm/fluoroscopic carbon-fiber surgical table
Endoscopic tower equipped with digital video monitor, DVT/VHS recorder,
light source, photo printer, with tri chip digital camera system (Figure 1)
Thoracic endoscopic discectomy set (Karl Storz, Tuttlingen, Germany),
including 4-mm 0-degree endoscope (Figure 1)
Thoracic operating endoscope, 3.5 mm 6-degree, and diagnostic
endoscopes, 2.5 mm 0-degree and 30-degree (Figure 1)
Thoracic discectomy sets (2.5 and 3.5 mm) (Blackstone Medical, Inc.,
Springfield, MA, USA) with short and long discectomes. (Figure 1)
Endoscopic grasping and cutting forceps and scissors (Figure 1)
Endoscopic probe, knife, rasp, and burr (Figure 1)
More aggressively toothed trephines used for spurs and spondylitic ridges
at the anterior and posterior disc space (Figure 1)
Holmium: YAG laser generator (Trimedyne, Irvine, CA, USA) with and
550µm holmium bare fiber with flat tip right angle (side-firing) probe (Figure
2)
Figure 1: Video digital endoscopic tower and PETD instrument.
Figure 1a: Video digital endoscopic tower
3
Figure 1b: Thoracic endoscopes 0°, 6°, 30° and tri-chip digital camera
4
Figure 1c: Endoscopic working cannula systems, trephines, rasp, and burs
Figure 1d: Long and short discectomes, various type of forceps and ronguers
Figure 2: Holmium YAG laser equipment for laser thermodiskoplasty
Figure 2a: 85 Watt double pulse Holmium: YAG laser generator (Trimedyne-Omnipulse)
5
Figure 2b: 550µm holmium bare fiber with flat tip, and right angle (side-firing) probe.
Figure 2c: Single use side firing probes.
6
Figure 2d: Reusable short side firing probes.
Anesthesia 10 , 11 , 12
Selected patients are treated in an operating room under local anesthesia and
monitored conscious sedation. The anesthesiologist maintains mild sedation, but the
patient is able to respond. Two grams Ancef and 8.0 mg of dexamethasone are given
intravenously at the start of anesthesia. A BIS surface electroencephalogram (EEG)
(Aspect Medical System, Inc. Newton, MA, USA) provides added precision of
anesthesia.
Patient Positioning 10 , 11 , 12 , 13
Patients are prone on the table with a radiolucent 20-degree angled sponge under the
symptomatic side of the chest angling it into an obliquely up position (Figure 3). The
arms are supported on arm boards over the head. Since only local anesthesia and mild
sedation are used, the extremities, buttocks and shoulders are restrained from sudden
motion with adhesive tape.
Figure 3: Patient Positioning and localization
Figure 3: Patient positioning
7
Figure 3b: Localization and placement of needle (portal)
8
Figure 4: Surgical approach for posteriorlateral endoscopic thoracic discectomy
for needle and stylette placement into the disc
Figure 4a: Axial view illustration for needle placement
Figure 4b: Cross section cadaveric cryomicrotome: posteriorlateral surgical approach
9
Localization 10 , 11 , 12
Levels are identified by counting under C arm fluoroscopy from the twelfth rib up, and
from C7 of the cervical spine down for upper level thoracic discectomies. Radio-opaque
markers are placed on the skin at appropriate sites. 13 The midline, the levels, and point
of entry (operating portal) for surgery are marked on the skin with a marking pen (Figure
3). Using sterile technique, the level of the disc can be accurately identified by inserting
a 18-gauge needle into a disc under fluoroscopic guidance (Figures 4, 5). The portal of
entry is to be marked at 4-5 cm away from the midline at the mid-thoracic area (T5-T8
inclusive) at the respective thoracic disc level, 6-7 cm from the midline at the lower
thoracic area (T9-T12 inclusive), and at the upper thoracic area (T1-T4 inclusive).
Positioning of the instruments is checked throughout the procedure by C-arm
fluoroscopy in two planes as needed. After the involved levels are identified, sterile
needle electrodes are placed in the intercostal muscles innervated from those levels for
continuous neurophysiological EMG monitoring, 10 , 11 , 12 , 13 , 28 a ground electrode
having been previously placed.
Surgical Technique 10 , 11 , 12 , 13
Under local anesthesia a beveled 20gauge, 3.5-inch spinal needle is inserted into the
portal of entry, as described under localization and fluoroscopic guidance (Figure 5).
The needle is incrementally advanced under C arm fluoroscopic guidance at a 35- to
45-degree angle from the sagittal plane, targeting toward the center of the disc, into the
“safety zone,” between the interpedicular line medially, and the rib head at the costovertebral articulation, laterally 10 , 11 , 12 and medial to costo-transverse junction (Figure
5). During the needle insertion, one must keep the needle tip immediately along the
medial aspect of the rib head to avoid entering the spinal canal medially, and medial to
the costo-vertebral junction to avoid pleural puncture. After the annulus is punctured,
the needlepoint is incrementally advanced to the center of the disc. The stylette of the
spinal needle is removed. Isovue® contrast (Bracco Diagnostics, Inc., Princeton, NJ,
USA) is injected, observing the ease and volume of injection, the fluoroscopic
appearance in AP and lateral projections, and the patient's description of the location,
concordance and intensity of any pain produced. If the discogram and pain provocation
tests are confirmatory, surgery is performed.
10
Figure 5: Fluoroscopic views for placement of needle/stylette
Figure 5ab: Needle placement into "safety zone" at the neuro foramen between
interpedicular line and the rib head.
Figure 5cd: Increment advance of stylette placement into center of the disc
11
Through the spinal needle placed for the discogram, a narrow 12-inch plain wire guide
is passed into the center of the disc. The needle is then removed. A 3-4 mm skin
incision is made at the site. The discectomy cannula containing its dilator is passed over
the guide wire, and is advanced to the annulus. A trephine replaces the dilator and
incises the annulus. The cannula then advances a short distance into the disc space.
The disc is decompressed using curettes, trephine, micro-forceps, discectome and the
laser (Figures 6 to 9). Disc removal is aided by a rocking excursion of the cannula in a
25-degree arc, a “fan sweep” motion from side to side, that creates an oval cone
shaped area of removed disc totaling up to 50 degrees (Figure 7).
12
During the procedure the endoscope is utilized for visualization, and under
magnification additional disc material and osteophytes are removed with micro-curettes,
rasps, forceps and discectome (Figures 8, 9). Large spurs or a rib head obstructing
entry to the disc space can be removed or can be perforated by a set of more
aggressive-toothed trephines (Figure 6). A Holmium: YAG laser (Figure 2) is used to
ablate additional disc (500 joules at 10 watts, 10 Hz, five seconds on and five seconds
off) and then, at a lower power setting (300 joules at 5 watts), (Table 1) to shrink and
contract the disc further reducing the profile of the protrusion and hardening the disc
tissue, laser thermodiskoplasty 10 , 11 , 12 , 13 (Figure 7). This may also cause Sinovertebral neurolysis or denervation. The discectome is again used briefly to remove
charred debris from use of the laser. The disc space can be directly visualized by
endoscopy for confirmation of disc decompression (Figure 9). The probe and cannula
are removed. Marcaine (0.25%) is infiltrated subcutaneously about the wound. A bandaid is applied over the tiny wound.
Figure 6: Fluoroscopic view of PETD with micro forceps, trephine, laser probe,
and rasp
Figure 6a: Micro grasper forceps
Figure 6b: Side fire laser probe
13
Figure 6c: Trephine
Figure 6d: Endoscopic rasp
14
Figure 7: Surgical technique of thoracic discectomy with "fan sweep" maneuver
and endoscopic view of laser application
Figure 7a: Discectomy with micro forcep
Figure 7b: "Fan sweep" maneuver
15
Figure 7c: Holmium bare laser flat tip fiber in action
Figure 8: Endoscopic view of thoracic discectomy
Figure 8a: Intradiscal endoscopic view
16
Figure 8b: Endoscopic disc removal with cutter forceps
Figure 8c: Disc fragments removed
Figure 8d: Laser application for disc decompression
17
Table 1: Laser setting for thoracic laser thermodiskoplasty.
Post Operative Care 10 , 11 , 12 , 13
The patient is checked neurologically prior to leaving the operating room. An upright
portable chest x-ray done in the Recovery Room rules out a pneumothorax. Ambulation
begins immediately after recovery, and the patient is usually discharged one hour after
surgery. They may shower the following day. Ice pack is helpful. Mild analgesics and
muscle relaxant are required at times. A progressive exercise program begins the
second post-operative day. Usually patients are allowed to return to work in one to two
weeks, provided heavy labor and prolonged sitting are not involved. Most patients found
this procedure extremely gratifying.
Outcome
Among 360 consecutive surgical patients, average age 44.9 (16-72), with a total of 448
herniated thoracic discs demonstrated good to excellent results in 91% of patients, fair
results in 5%, and poor in 4% (Table 2). Response to treatment was evaluated by using
modified MacNab criteria, Oswestry disability score/index (ODI), visual analogue pain
scale (VAS), patient satisfaction scoring, pain diagram and/or patient target
achievement score (PTA). Average satisfaction score was 93.9%. Eighteen patients
(5%) had persistent thoracic pain, although overall their pain lessened. Postoperatively
on average the patients resumed usual activity in a few days and in 3 , 4 , 5 , 6 , 7 weeks
resumed full active lives. 10 , 11 , 12 , 13
18
Table 2: Post Endoscopic Thoracic Discectomy – (360 cases) Symptomatic
Improvements
Case Illustration
A 71-year old senior engineer had complained of ten months history of progressive
increasing, intractable mid back pain and muscle spasm. Past history was noncontributory. Neurologic examination showed parathoracic muscle spasm was palpable
adjacent to the painful T8-T9 level, hypalgesia in T8 dermatome. MRI demonstrated a
large protruded thoracic disc at T8-9 level (Figure 10). Physical therapy, analgesics, and
epidural steroid injections did not alleviate his discomfort. He was treated by PETD at
T8-9. Postoperatively, he had complete relief of his symptoms.
Discussion
Percutaneous endoscopic thoracic microdiscectomy is a minimally invasive surgical
procedure for treating symptomatic herniated thoracic discs through an operating
endoscope with much less tissue trauma and zero mortality. It has numerous
advantages, but requires thorough knowledge of the surgical anatomy, the PETD
procedure, specific surgical training and hands-on experience in a laboratory and
working closely with an experienced endoscopic surgeon through its steep surgical
learning curve, in order for a MISS surgeon to become competent and avoid possible
complications.
Advantages
The advantages 7 , 10 , 11 , 12 , 13 , 14 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 29 , 30 of PETD are
numerous; in addition to those of MISS, advantages include:
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No general anesthesia required.
Commonly done under local anesthesia.
Small incision and less scarring without multiple or large incision
Minimal blood loss
Zero mortality
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No need of lung collapse or opening of the pleural cavity.
No post-operative pleural effusion, intercostal neuralgia and
pneumothorax.
No significant infection
Avoiding injury to blood vessels.
No resection of rib.
No spinal fusion or fixation needed.
No dissection of muscle, bone, ligaments, or manipulation of the dural sac,
spinal cord or nerve roots
Little or no epidural bleeding.
Minimal use of analgesics post-operatively.
Same-day outpatient procedure.
Less traumatic, physically and psychologically.
Does not promote further instability of spinal segments.
Early return to usual activities including work.
Costs less than conventional discectomy.
Multiple level discectomy feasible and well tolerated 10 , 11 , 12 , 13 , 14 , 29 , 30 .
Least challenging to medically high risk patients such as those with cardiopulmonary problems, the aged and the morbidly obese.
Exercise programs can begin same day as surgery.
Direct endoscopic visualization and confirmation of the efficacy of surgery
contribute to a safe and effective outcome.
Disadvantages
This technique is useful in select patients and is not appropriate to patients with severe
thoracic disc extrusions causing cord compression with severe neurologic deficit
(parparesis) and in patients with severe congenital or acquired stenosis of the spinal
canal. In patients with severe spondylosis and foraminal stenosis, this technique may
not be suitable as insertion of the endoscope may not be feasible.
Potential Complications And Their Avoidance
A thorough knowledge of the procedure and surgical anatomy of the thorax and thoracic
spine, careful selection of patients and pre-operative surgical planning with appropriate
diagnostic evaluations facilitate the PETD and prevent potential complications. 2 , 3 , 10 ,
11 , 12 , 13 , 29 , 30 All potential complications of open approaches for thoracic disc surgery
are possible but rare or much less frequent 3 , 7 , 10 , 11 , 12 , 13 , 14 , 21 , 22 , 23 , 24 , 25 , 26 ,
27 , 29 , 30 in PETD, with no rib resection or deliberate collapse of the lung required.
Pneumothorax, pulmonary injury and post operative atelectasis: Pneumothorax is
a potential complication in all approaches to thoracic discs, including PETD. Introducing
the spinal needle into the “safety zone” of the disc, with the interpedicular line medially
and rib head laterally at the neuroforamen, to protect it from penetrating the pleura.
Direct endoscopic visualization helps to avoid pulmonary injury. Atelectasis is not a
problem. Chest x-ray is obtained immediately after completing the operation to rule out
pneumothorax, and to initiate treatment if present.
Infection: Avoided by careful sterile technique, using prophylactic antibiotics I-V
intraoperatively and the much smaller incisional area compared to open posterolateral
and transthoracic approaches, as well as the multi-port thoracoscopic approaches.
20
Aseptic discitis: May be prevented by aiming the laser beam in a “bowtie” fashion to
avoid damaging the endplates (at 6 and 12 o'clock).
Hematoma (subcutaneous and deep): May occur with PETD but is minimized by careful
technique, the small incision (3 mm), not prescribing aspirin or NSAID's within a week
prior to surgery, and by application of digital pressure or an I-V bag over the operative
site for the first 5 minutes after surgery, and application of ice bag thereafter.
Vascular injuries: The thoracic aorta and its segmental branches, the intercostal artery
and vein, the azygos, hemiazygos and accessory hemiazygous veins are at risk in open
procedures, lateral, anterior and postero-lateral approaches to thoracic discs. Strict
adherence to the technique and knowledge of the applicable surgical anatomy should
avoid such injuries. No vascular injury has been reported with PETD.
Neural injury: Extremely rare with PETD; no spinal cord injuries have been reported.
Nerve root injury (intercostal nerve) causing intercostal neuralgia, or chest pain, though
possible, can be avoided with intraoperative neurophysiologic monitoring (EMG/NCV) 22
of intercostal muscles at and immediately below the operated levels. By using direct
endoscopic visualization (Figure 9) intercostal injury related to open chest surgery and
thorascopic surgery can be avoided. No nerve injuries were noted in 300-plus cases at
our center. The initial spinal needle placement can be onto the posterior, superior
surface of the rib into the “safety zone” at neuroforamen avoiding the intercostal nerve
lying in the inferior surface of the rib, in the costal groove. This maneuver and observing
the strict boundaries of the interpedicular lines protects the spinal cord.
Figure 9: Endoscopic view after PETD
Figure 9a: After PETD, hollow disc defect and end plates
Figure 9b: Grasper forcep for disc removal below the intercostal nerve
21
Figure 9c:
Figure 10: Large herniated T-10 and T-12 discs, pre and post operative MRI scans
Figure 10a: Preoperative MRI
Figure 10b: Post operative MRI
22
Sympathetic chain and rami communicantes: Prone position for surgery avoids
pressure on the brachial plexus which can cause compression plexopathy.
Complications are only a remote possibility; observing the surgical anatomy of the
parathoracic area and keeping needle placement within the “safety zone” should
sufficiently guard against this.
Excessive sedation: Avoided by surface EEG monitoring providing more precise
estimation of the depth of sedation and reduces amount of anesthetics and prevents
excessive or insufficient sedation. Patients are able to respond throughout the
procedure and this provides a further means of evaluating their level.
Improper localization: A major complication of all disc surgeries is operating at the
wrong level. Proper utilization of C-arm fluoroscopy for proper anatomical localization
avoids complications caused by poor placement of instruments or operating at the
wrong disc level. Routine pain provocation test and discogram gives additional
verification of the proper level.
Dural tears: These are common in all other approaches to the thoracic disc, but have
not been reported in PETD.
Soft tissue injuries due to prolonged forceful retraction, as occurs in many disc
operations, are not at issue with PETD.
Inadequate decompression of disc material: Minimized by using multiple modalities
and instruments such as forceps, trephines, discectome, burr and rasp and application
of laser to both vaporize tissue and to perform thermodiskoplasty.
Conclusions
Posterior endoscopic thoracic discectomy performed for symptomatic herniated thoracic
disc with added laser “tightening” of the disc (thermodiskoplasty) is an easier, safe and
efficacious procedure. This minimally invasive less traumatic outpatient procedure
results in less morbidity, more rapid recovery and significant economic savings. In a
multi center study 10 , 11 , 29 , 30 of percutaneous endoscopic spinal discectomy (32,420
cases), mortality rate was zero and morbidity rate was less than 1% with patient
satisfaction of over 90% for thoracic discs. There are no reported spinal cord injuries,
23
intercostal neuralgia, dural tears, and no significant infection, vascular injury, or
pulmonary complications.
PETD requires a knowledgeable and competent surgeon with a thorough appreciation
of the surgical anatomy of the thorax and thoracic spine intercostal nerves and vessels,
the relationship of the rib heads, pedicles, disc spaces, and spinal cord. To perform the
procedure, spine surgeon must have specific surgical training with hands-on experience
in the laboratory and most importantly, must spend time working through the steep
surgical learning curve with an endoscopic spinal surgeon expert at this procedure.
Address for Correspondence
John C. Chiu, M.D., D.Sc., F.R.C.S
Department of Neurospine Surgery
California Center for Minimally Invasive Spine Surgery
California Spine Institute Medical Center
1001 Newbury Road
Thousand Oaks, CA 91320 USA
Telephone: (805) 375-7900
Fax: (805) 375-7906
Email: chiu@spinecenter.com
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