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Study Design: Retrospective chart review., Objective: To determine the long-term efficacy of 2-stage total en bloc spondylectomy (TES)., Summary of Background Data: TES is a well-described technique to achieve tumor-free margins, but it is a highly destabilizing procedure that necessitates spinal reconstruction. A 2-stage anterior/posterior approach for tumor resection and instrumentation has been shown to be biomechanically superior to the single-stage approach in achieving rigid fixation, but few clinical studies with long-term outcomes exist., Methods: A retrospective review was performed on patients undergoing a 2-stage TES for a spinal tumor between 1999 and 2011. Results were compared with those from a literature review of case series, with a minimum of 2-year follow-up, reporting on a single-stage posterior-only approach for TES., Results: Seven patients were identified (average follow-up 52.7 mo). Tumor location ranged from T1 to L3 with the following pathologies: metastasis (n=3), hemangioma (n=1), leiomyosarcoma (n=1), giant cell tumor (n=1), and chordoma (n=1). There were no significant surgical complications. All 7 patients had intact spinal fixation. There were no failures of the orthogonal fixation (pedicle screws or anterior fixation). The average modified Rankin Scale scores improved from 2.7 preoperatively to 0.7 at last follow-up. None of the patients in our series suffered local disease recurrence at last follow-up or suffered neurological deterioration. These results were comparable with those noted in the literature review of posterior-only approach, where 12% of patients experienced instrument failure., Conclusions: TES is a highly destabilizing procedure requiring reconstruction resistant to large multiplanar translational and torsional loads. A 2-stage approach utilizing orthogonal vertebral body screws perpendicular to pedicle screws is a safe and effective surgical treatment strategy. Orthogonal spinal fixation may lower the incidence of instrumentation failure associated with complete spondylectomy and appears to be comparable with a single-stage procedure. However, larger prospective series are necessary to assess the efficacy of this approach versus traditional means.

Study Design: Retrospective case series., Objective: To identify the indications, techniques, and outcomes for instrumented fusion during thoracic discectomy., Summary of Background Data: Thoracic discectomy may require extensive bone removal to avoid spinal cord manipulation, but the indications and techniques for instrumented fusion during thoracic discectomy remain poorly delineated., Methods: The authors identified 220 consecutive patients who underwent thoracic discectomy between 1992 and 2012. Clinical and radiographic variables were compared between patients who underwent instrumented fusion and patients without instrumentation, and among surgical approaches utilized for discectomy., Results: Patient age for the entire cohort averaged 49±13.01 years, and mean clinical follow-up was 45 months (range, 1-218 mo). Patients underwent 226 thoracic discectomy procedures, including 48 thoracotomy, 136 thoracoscopy, and 42 posterolateral approaches. Seventy-eight patients required instrumented fusion and, compared with patients without instrumentation, were more likely to present with myelopathy (P<0.0001) and harbor giant (P=0.0012), calcified (P=0.019), or transdural (P=0.0004) herniated disks. Surgery with instrumentation resulted in greater blood loss (P<0.0001), longer hospital stay (P<0.0001), and a higher complication rate (22% vs. 9.9%), yet patients in both cohorts had similar rates of symptom resolution postoperatively. Of the patients who underwent thoracic discectomy without instrumentation, 3 (2.1%) developed delayed deformity or instability and required subsequent surgery for fixation and fusion at an average 6.3 months postoperatively (range, 4-8 mo). Patients who underwent instrumented fusion exhibited no nonunions or delayed deformity., Conclusions: Thoracic discectomy without fixation is a reasonable clinical option in carefully selected patients, but instrumented fusion is safe and effective in other patients. Indications for fixation and fusion are thus proposed.

We aimed to determine the clinical indications and surgical outcomes for thoracoscopic discectomy. Thoracic disc disease is a rare degenerative process. Thoracoscopic approaches serve to minimize tissue injury during the approach, but critics argue that this comes at the cost of surgical efficacy. Current reports in the literature are limited to small institutional patient series. We systematically identified all English language articles on thoracoscopic discectomy with at least two patients, published from 1994 to 2013 on MEDLINE, Science Direct, and Google Scholar. We analyzed 12 articles that met the inclusion criteria, five prospective and seven retrospective studies comprising 545 surgical patients. The overall complication rate was 24% (n=129), with reported complications ranging from intercostal neuralgia (6.1%), atelectasis (2.8%), and pleural effusion (2.6%), to more severe complications such as pneumonia (0.8%), pneumothorax (1.3%), and venous thrombosis (0.2%). The average reported postoperative follow-up was 20.5 months. Complete resolution of symptoms was reported in 79% of patients, improvement with residual symptoms in 10.2%, no change in 9.6%, and worsening in 1.2%. The minimally invasive endoscopic approaches to the thoracic spine among selected patients demonstrate excellent clinical efficacy and acceptable complication rates, comparable to the open approaches. Disc herniations confined to a single level, with small or no calcifications, are ideal for such an approach, whereas patients with calcified discs adherent to the dura would benefit from an open approach., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Object: Symptomatic herniated thoracic discs (HTDs) are rare, and patients infrequently require treatment of 2 or more disc levels. The authors assess the surgical management and outcomes of patients with multiple-level symptomatic HTDs., Methods: A retrospective review of a prospectively maintained database was performed of 220 consecutive patients treated surgically for symptomatic HTDs. Clinical and surgical results were compared between patients with single-level disease and patients with multiple-level disease and also among the different approaches used for surgical decompression., Results: Between 1992 and 2012, 56 patients (mean age 48 years; 26 male, 30 female) underwent 62 procedures for 130 HTDs. Forty-six patients (82%) had myelopathy, and 36 (64%) had thoracic radiculopathy; 24 patients had both conditions in varying degree. Symptom duration averaged 28 months. The surgical approach was dictated by disc size, consistency, and location. Twenty-three thoracotomy, 26 thoracoscopy, and 13 posterolateral procedures were performed. Five patients required a combination of approaches. Patients underwent 2-level (n = 44), 3-level (n = 7), 4-level (n = 4), or 5-level (n = 1) discectomies. Instrumented fusion was performed in 36 patients (64%). Thirteen patients harbored 19 additional discs, which were deemed asymptomatic/nonoperative. The mean hospital stay was 6.5 days. Complete disc resection was verified with postoperative imaging in every patient. The procedural complication rate was 23%, and the nature of complications differed based on approach. No patients had surgery-related spinal cord injury or new myelopathy. At a mean follow-up of 48 months, myelopathy and radiculopathy had resolved or improved at a rate of 85% and 92%, respectively. Using a general linear model, preoperative symptom duration (p = 0.037) and perioperative hospital length of stay (p = 0.004) emerged as negative predictors of myelopathy improvement. Most patients (96%) were satisfied with the surgical results. Compared with 164 patients who underwent single-level HTD decompression, patients requiring surgery for multiple-level HTDs were more often myelopathic (p = 0.012). Surgery for multiple-level HTDs was more likely to require a thoracotomy approach (p = 0.00055) and instrumented fusion (p < 0.0001) and resulted in greater blood loss (p = 0.0036) and higher complication rates (p = 0.0069). The rates of resolution for myelopathy (p = 0.24) and radiculopathy (p = 1.0), however, were similar between the 2 patient groups., Conclusions: The management of multiple-level symptomatic HTDs is complex, requiring individualized clinical decision making. The surgical approaches must be selected to minimize manipulation of the compressed thoracic spinal cord, and a patient may require a combination of approaches. Excellent surgical results can be achieved in this unique and challenging patient population.

Study Design: Retrospective review of a prospectively maintained surgical database., Objective: To report the indications, surgical procedures performed, and outcomes from the largest series of thoracoscopically treated herniated thoracic discs (HTDs). We also compared approach-related complications with an unmatched cohort undergoing thoracotomy for HTD., Summary of Background Data: Symptomatic HTDs are rare, and their surgical management is technically challenging., Methods: A prospectively maintained surgical database of all patients undergoing surgery for symptomatic HTDs by the senior author (blinded for review) was reviewed. As needed, the database was supplemented with hospital and clinic charts and telephone conversations with patients. A triportal method of thoracoscopic discectomy was performed in all cases., Results: Between 1994 and 2008, 121 patients underwent 125 thoracoscopic-assisted operations for 139 HTDs. Their mean age at surgery was 46.6 years. Indications for thoracoscopic resection currently include small symptomatic disc, anterior location, nonmorbidly obese patient, favorable chest anatomy, and T4-T11 location. Symptom duration averaged 32 months. Radiculopathy was the most common presentation, followed by myelopathy and pain (radiculopathic or back). The mean hospital stay was 4.8 days. Chest tubes remained in place for a mean of 3.2 days. At a mean follow-up of 2.4 years, myelopathy, radiculopathy, and back pain had resolved or improved at a rate of 91.1%, 97.6%, and 86.5%, respectively. Patients reported worsening in 0%, 1.2%, and 0% of cases, respectively. Most patients (97.4%) would be willing to undergo the operation again. The complication rate was acceptable. Patients undergoing thoracoscopic excision had less approach-related morbidity than an unmatched cohort undergoing excision using thoracotomy., Conclusion: Thoracoscopic-assisted microsurgical resection is a safe, effective, and minimally invasive method of treating symptomatic HTDs in appropriately selected patients. The symptoms of most patients improve or resolve with minimal morbidity.

Objective: To compare the biomechanics of costotransverse process screw fixation with those of pedicle screw fixation in a cadaveric model of the upper thoracic spine., Methods: Ten human thoracic spines were instrumented across the T3-T4 segment with costotransverse and pedicle screws. Nonconstraining pure moments (maximum, 6.0 Nm) were applied to induce flexion, extension, lateral bending, and axial rotation. The range of motion, lax zone, and stiff zone were determined in each specimen in the normal state, after 3-column destabilization, and after instrumentation. After flexibility testing was completed, axial screw pull-out strength was assessed., Results: In all directions of loading, both fixation techniques significantly decreased lax zone and range of motion at T3-T4 compared with the destabilized state (P < .001). During all loading modes except lateral bending, pedicle screw fixation allowed significantly less range of motion than costotransverse screw fixation. Pedicle screws provided 62% greater resistance to axial pull-out than costotransverse screws., Conclusion: The costotransverse screw technique seems to provide only moderately stiff fixation of the destabilized thoracic spine. Pedicle screw fixation seems to have more favorable biomechanical properties. These data suggest that the costotransverse process construct is better used as a salvage procedure rather than as a primary fixation strategy.

Background Context: Thoracic hyperextension fracture-dislocation is a rare pattern of traumatic spinal injury, typically associated with gross spinal instability and severe neurological deficit. These extremely unstable injuries require internal fixation despite their potentially benign clinical presentation., Purpose: We present a patient with a thoracic distraction injury who remained neurologically intact., Methods: The patient underwent thoracoscopic reduction and anterior fixation of the thoracic spine using a paired screw-rod construct., Results: Postoperatively, the patient remained neurologically intact and had no complications related to his thoracic fixation and fusion. Follow-up radiographs showed maintenance of thoracic alignment and bony fusion., Conclusions: The endoscopic approach to the anterior thoracic spine was an excellent treatment option for this thoracic distraction injury.

Background: This study compared porcine and human thoracic spine anatomies for a better understanding of how structures encountered during thoracoscopy differ between training with a porcine model and actual surgery in humans., Methods: Parameters were measured including vertebral body height, width, and depth; disc height; rib spacing; spinal canal depth and width; and pedicle height and width., Results: Although most porcine vertebral structures were smaller, porcine pedicle height was significantly greater than that of humans because the porcine pedicle houses a unique transverse foramen. The longus colli and psoas attach, respectively, to T5 and T13 in swine and to T3 and T12 in humans. In swine, the azygos vein generally was absent. The intercostal veins drained into the hemiazygos vein., Conclusions: Several thoracoscopically relevant anatomic differences between human and porcine spinal anatomies were identified. A thoracoscopic approach in a porcine model probably is best performed from the right side. The best general working area is between T6 and T10.

Objective and Importance: Traditionally, thoracic fractures that require anterior stabilization are treated through an open thoracotomy approach. Thoracoscopic instrumentation avoids many of the complications associated with an open thoracotomy but is technically challenging. We report the first cases of dual-rod internal fixation systems placed thoracoscopically for thoracic spinal trauma., Clinical Presentation: Two male patients sustained midthoracic spinal trauma falling from motorcycles in separate incidents. Both injuries led to unstable spinal columns, but the patients had no neurological deficits and had minimal spinal cord compression. One patient had a complex spiral fracture from T6 to T8; the other had T7 burst and T8 compression fractures. Based on the complex morphological features of the patients' fractures, anterior internal fixation was the treatment of choice for both. The two available options for an anterior stabilization were open thoracotomy and thoracoscopic instrumentation. Because extensive decompression was unnecessary, a thoracoscopic approach was used., Intervention: A dual-rod internal fixation system (Medtronic Sofamor Danek, Inc., Memphis, TN) was placed with two screws each in the T6 and T9 vertebral bodies of each patient. Thoracoscopy was used for direct visualization of the operative site with fluoroscopic guidance for screw placement. Surgery was completed without complications, and both patients did well afterward. Upright and supine x-rays demonstrated that the constructs were stable at 10 weeks and 6 months, respectively., Conclusion: Thoracoscopic instrumentation offers the advantages of a minimally invasive approach but is technically challenging. The characteristics of dual-rod fixation systems (small-profile components and step-wise insertion) provide the best biomechanical profile and facilitate thoracoscopic instrumentation.

Introduction: Microsurgical thoracoscopic approaches to the thoracic spine allow access to the spinal cord, spinal nerves, disc spaces, vertebral bodies, paravertebral soft tissues, and sympathetic chain with minimal invasiveness., Methods: Between January 1994 and January 2000, 241 thoracoscopic procedures were performed: 164 thoracic sympathectomies, 60 discectomies, 5 neurogenic tumor resections, 8 corpectomies and spinal reconstructions, 2 anterior releases, and 2 biopsies. Cases were reviewed to evaluate the efficacy, surgical results, and complications of the thoracoscopic procedures., Results: An adequate sympathectomy was achieved in all 164 sympathectomies. There was 100% relief of palmar and 95% relief of axillary hyperhidrosis. Reflex sympathetic dystrophy responded poorly to sympathectomy with recurrent pain. Thoracoscopic discectomy achieved complete decompression in 98% of patients. Gross total tumor resection was achieved in all five paraspinal neurogenic tumors. There was no operative mortality. Morbidity compared favorably with open surgical approaches to the thoracic spine., Conclusion: Thoracoscopic spinal surgery is an effective technique that provides full, direct access to the ventral thoracic spine. Its morbidity rate appears to be lower than that associated with open thoracotomy. It improves patient comfort and cosmetic results and shortens recovery. This technique has become the authors' surgical approach of choice for removing benign intrathoracic paraspinal neurogenic tumors and central herniated thoracic discs and for performing biopsies and thoracic sympathectomies. The senior author still prefers open surgical approaches for most thoracic corpectomies and spinal reconstruction procedures.

Object: In this review the authors address the surgical strategies required to resect residual herniated thoracic discs., Methods: Data obtained in 15 patients who had undergone prior thoracic discectomy and who harbored residual or incompletely excised symptomatic thoracic discs were reviewed retrospectively. The surgical procedures that had failed to excise the herniated discs completely included 11 posterolateral approaches, one thoracotomy, and three thoracoscopy-guided surgical procedures. Of the lesions that were incompletely resected or residual, there were 13 central calcified, two soft. 12 extradural, and three intradural discs. Indications for reoperation were often multiple in each patient and included misidentification of the level of disc disease at the initial operation (five cases), abandoning the procedure because of intraoperative spinal cord injury (three cases), inadequate visualization of the pathological entity (eight cases), migration of a soft disc fragment within the spinal canal (one case), and intradural disc extension (three cases). The symptoms at the time of reoperation included myelopathy in 13 patients and radicular pain in two patients. The mean interval before reoperation was 150 days (range 1 day-4 years). The reoperation procedures included one thoracotomy and 14 video-assisted thoracoscopic procedures performed ipsilateral (11 cases) or contralateral (four cases) to the site of the initial surgery. The herniated disc material was excised completely in all 15 cases without causing new neurological deficits. Reoperation complications included atelectasis in three patients, intercostal neuralgia in two, a loosened screw that required removal in one, residual intradural disc herniation that required a second reoperation in one patient, and a cerebrospinal fluid leak in one patient. Of the 13 patients who experienced myelopathy prior to operation, 10 recovered neurological function and three stabilized. All patients with radicular pain improved., Conclusions: Calcified, large, broad-based, centrally located, or transdural thoracic disc herniations can be difficult to resect. These lesions require a ventral operative approach to visualize the dura adequately for a safe and complete resection.

Object: The authors began using thoracoscopy to treat pathological conditions of the spine in 1992. In this study they delineate their clinical experience in which this procedure was used to resect herniated thoracic discs., Methods: Fifty-five patients underwent thoracoscopy for the resection of herniated thoracic discs. Thirty-six patients presented with myelopathies and 19 with incapacitating thoracic radicular pain. Forty-three patients underwent a single-level, 11 a two-level, and one a three-level discectomy. The mean operative time for thoracoscopic microdiscectomy was 3 hours and 25 minutes (range 80-542 minutes) and the mean blood loss was 327 ml (range 124-1500 ml). Compared with thoracotomy, which was performed in 18 patients, thoracoscopy was associated with a mean of 1 hour less operative time and less than one-half of the blood loss, duration of chest tube drainage, usage of pain medication, and length of hospitalization. Compared with costotransversectomy, which was performed in 15 patients, thoracoscopy permitted more complete resection of calcified and midline thoracic discs because it provided a direct view of the entire anterior surface of the dura. Thoracotomy was associated with a significantly greater incidence of prolonged, disabling intercostal neuralgia compared with the mild transient episodes of intercostal neuralgia associated with thoracoscopy (50% compared with 16%). Thoracotomy also was associated with a significantly higher incidence of postoperative atelectasis and pulmonary dysfunction than thoracoscopy (33% compared with 7%). Clinical and neurological outcomes were excellent (mean follow-up period 15 months). Among the 36 myelopathic patients, 22 completely recovered neurologically; five improved functionally but had some residual myelopathic symptoms; and nine stabilized. Among the 19 patients with isolated thoracic radiculopathies, 15 recovered completely and four improved moderately; no patient had worsened radicular pain., Conclusions: Thoracoscopic microdiscectomy is a reliable surgical technique that can be performed safely with excellent clinical and neurological results.

Microsurgical approaches for the treatment of pathology located in the ventral thoracic spine using video-assisted thoracic surgery (VATS) allow neurosurgeons to access the disc spaces, vertebral bodies, paravertebral soft tissues, spinal cord, spinal nerves, and sympathetic chain with minimally invasive surgery. This has been associated with substantial clinical benefits including reduced postoperative pain, lower complication rates and shorter recovery times when compared with standard thoracotomy techniques. This article describes the experience at our institution with VATS for discectomy (20 cases), corpectomy and spinal reconstruction (8 cases), thoracic sympathectomy (3 cases), and nerve sheath tumor removal (1 case). The technique can be mastered but requires surgeons to learn the new psychomotor skills needed to perform endoscopic spine surgery. The learning curve is steep. Special training in instructional seminars, surgical skill laboratories, and clinical preceptorships is needed before this surgical approach can be used clinically to treat spinal pathology. VATS has significant advantages compared to standard thoracotomy, including reduced incisional pain and avoidance of the postthoracotomy pain syndrome. If intercostal neuralgia develops postoperatively, it is milder and usually transient compared to the pain associated with standard thoracotomy. Better cosmetic outcomes, earlier mobilization, and faster recovery are added benefits. The surgical techniques are relatively new for neurosurgeons and require dedicated practice to master them. Once the surgical skills are perfected, VATS is feasible for spinal pathology and can be performed safely and effectively.

The authors report three patients (two males and one female) with herniated thoracic discs whose symptoms mimicked cardiac disease (severe intense stabbing pain beginning in the back and radiating to the lateral wall of the chest). They were evaluated for cardiac disease and angina, but the workup of the heart was negative. Magnetic resonance imaging and computed tomography myelography revealed the herniated thoracic discs. All patients underwent video-assisted endoscopic thoracic discectomy and recovered completely.

Thoracoscopic spinal surgery is technically feasible and can be performed safely with acceptable rates of morbidity and excellent clinical and neurologic results. Thoracoscopic techniques can be used for anterior decompression and internal fixation in cases in which pathologic processes lead to instability. This minimally incisional access technique can achieve the identical extent of spinal exposure, dissection, decompression, and reconstruction as those obtained with open techniques.

Study Design: Nondestructive flexibility testing was performed to quantify biomechanical parameters of human cadaveric thoracic spines before and after microdiscectomy., Objectives: To assess the biomechanical differences between the normal thoracic spine and the thoracic spine after microdiscectomy and to determine whether microdiscectomy results in spinal instability., Summary of Background Data: Previous studies have investigated thoracic disc properties and the biomechanical effects of thoracic ligament or bone trauma. No studies were found assessing the effects of thoracic discectomy., Methods: Eight motion segments (T4-T5 to T11-T12) from five human cadaveric thoracic spines were studied before and after microdiscectomy. Three-dimensional motion was recorded in response to nondestructive, nonconstraining pure moments. Parameters measured included the neutral zone, elastic zone, range of motion, rotational flexibility, and instantaneous axis of rotation., Results: The neutral zone, elastic zone, and range of motion increased a small but significant (average P = 0.02 for range-of-motion increase) amount in all directions after thoracic microdiscectomy (mean bilateral range of motion increase, 2.1 degrees; range, 0.5-4.2 degrees). Flexibility increased slightly during lateral bending and flexion. The instantaneous axis of rotation location usually did not change, but sometimes shifted slightly away from the discectomy site after microdiscectomy., Conclusions: Thoracic microdiscectomy had small effects on the immediate mechanics and kinematics of the thoracic spine and did not overtly destabilize the motion segments.

A video-assisted thoracoscopic microsurgical approach was developed in the laboratory and subsequently used clinically to resect abnormalities of the thoracic vertebrae, to decompress the thoracic spinal cord, and to reconstruct the thoracic vertebral bodies. This report describes the development of the clinical operative techniques for microsurgical thoracoscopic vertebrectomy, neural decompression, and spinal reconstruction. This minimally incisional approach was clinically used in 17 patients to treat vertebral osteomyelitis, tumors, and compression fractures. Microsurgical thoracoscopic techniques were performed using several narrow, flexible, working portals placed in small incisions in the intercostal spaces. Access to the thoracic spine was achieved through the pleural cavity after temporary deflation of one lung using a double-lumen endotracheal tube. The parietal pleura, segmental vessels, and rib heads were dissected off the surfaces of the involved vertebrae to expose the region of interest. Long narrow spine dissection tools were used to perform the spinal decommpression and reconstruction. This technique achieved the same amount of spinal dissection as that achieved with conventional open spinal procedures and used microsurgical visualization techniques. The small incisions with reduced soft tissue dissection may reduce postoperative pain, shorten the length of hospitalization, and have cosmetic and functional advantages. Thoracoscopic vertebrectomies and reconstruction of the spine were technically feasilble procedures that were performed with excellent clinical results. This minimally incisional technique provides a viable alternative to thoracotomy or to posterolateral approaches for thoracic vertebrectomy and vertebral body reconstruction.

A 30-year-old man presented with a subacute course of myelopathic signs and symptoms. Magnetic resonance imaging demonstrated an epidural mass lesion of the spinal canal at the cervicothoracic junction causing compression of the spinal cord. Laminectomy with resection of this lesion revealed a large varix with acute and chronic thrombus. Postoperatively, an improvement in neurological function occurred. Spinal epidural varicosities have been reported as an etiological factor in lumbar and sacral radiculopathies. This is the first reported case of spinal cord compression in association with spinal epidural varices. The diagnosis, pathophysiology, and management of this disorder are presented.