Thoracic spine approaches [Neurosurgery Wiki]

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====== Thoracic spine approaches ======

Since the end of the nineteenth century, the wide dissemination of [[Pott's disease]] has ignited debates about which should be the ideal [[route]] to perform ventrolateral [[decompression]] of the dorsal rachis in case of [[paraplegia]] due to [[spinal cord compression]] in tuberculosis [[spondylitis]]. It was immediately clear that the optimal approach should be the one minimizing the surgical manipulation on both neural and extra-neural structures, while optimizing the exposure and surgical maneuverability on the target area. The first attempt was reported by Victor Auguste Menard in [[1894]], who described, for the first time, a completely different route from traditional [[laminectomy]], called [[costotransversectomy]]. The technique was conceived to drain tubercular paravertebral abscesses causing paraplegia without manipulating the [[spinal cord]]
((Ménard V. Causes de la paraplégie dans le mal de
Pott. Son traitement chirurgical par l’ouverture
directe du foyer tuberculeux des vertebres. Rev
Orthop 1894; 5: 47-64.)).

The procedure defined by Capener in [[1954]] 
((CAPENER N. The evolution of lateral rhachotomy. J Bone Joint Surg Br. 1954 May;36-B(2):173-9. doi: 10.1302/0301-620X.36B2.173. PMID: 13163099.))
resulted in better results for the treatment of [[spinal tuberculosis]], due to the effect of [[antibiotic]]s
((Benzel EC. Spine Surgery: Techniques,
Complication Avoidance, and Management, 3th
Ed. Saunders, Philadelphia 2012.))

Over the following decades many other routes have been described all over the world, thus demonstrating the wide interest on the topic. Surgical development has been marked by the new technical achievements and by instrumental/technological advancements, until the advent of portal surgery and endoscopy-assisted techniques. Gagliardi et al. retraced the milestones of this [[history]] up to 2022, through a [[systematic review]] on the topic
((Gagliardi F, Pompeo E, De Domenico P, Snider S, Roncelli F, Acerno S, Mortini P. HISTORY OF EVOLUTION OF POSTERO-LATERAL APPROACHES TO THE THORACIC SPINE: FROM CURE OF POTT'S DISEASE TO EPIDURAL TUMOR RESECTION. J Neurol Surg A Cent Eur Neurosurg. 2022 Jan 10. doi: 10.1055/a-1734-2085. Epub ahead of print. PMID: 35008121.)).
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[[Thoracic disc herniation surgery]] is challenging because of: the difficulty of anterior approaches, the
proportionately tighter space between [[cord]] and canal compared to the [[cervical]] and [[lumbar]] regions,
and the watershed blood supply which creates a significant risk of [[spinal cord injury]] with attempts to
manipulate the cord when trying to work anteriorly to it from a posterior approach. Thoracic disc herniations are calcified in 65% of patients considered for surgery
((Stillerman CB, Chen TC, Couldwell WT, et al.
Experience in the surgical management of 82
symptomatic herniated thoracic discs and review
of the literature. J Neurosurg. 1998; 88:623–633))
(more difficult to remove from a posterior or lateral approach than non-calcified discs).

For centrally located anterior access: a transthoracic or lateral approach gives the best acess. Some prefer a left-sided approach to avoid the vena cava, others prefer a right-sided approach because the heart does not impede access.




----
Various different approaches have been tried for the surgical removal of TDH, but most of them are cumbersome surgeries such as thoracotomy or thoracoscopic or anterior approaches with or without instrumentation. The requirement for a simplified, familiar, and less morbid surgery has motivated some new approaches. A [[pedicle sparing transfacet approach]] (PSTA) was first described in 1995, but to date no sufficient clinical series has been presented in the literature to report on its feasibility and applicability along with complication and morbidity rates. 

Surgery for [[thoracic disc herniation]] is comparatively rare and often demanding. The goal is to achieve sufficient [[decompression]] without manipulating the [[spinal cord]]. Individual planning and various surgical techniques and approaches are required. 



Surgical treatment can be divided into anterior, lateral and posterior approaches and is an area of contention in the literature. Available evidence consists mostly of single-arm, single-institutional studies with limited sample sizes.

Anterior approaches had longer LOS and higher, although not statistically significant, complication rates. No difference was found with regard to discharge disposition. In light of these findings, surgeons should weigh the risks and benefits of each surgical technique during tailoring of decision making
((Kerezoudis P, Rajjoub KR, Goncalves S, Alvi MA, Elminawy M, Alamoudi A, Nassr 
A, Habermann EB, Bydon M. Anterior versus posterior approaches for thoracic disc 
herniation: Association with postoperative complications. Clin Neurol Neurosurg. 
2018 Apr;167:17-23. doi: 10.1016/j.clineuro.2018.02.009. Epub 2018 Feb 6. PubMed 
PMID: 29428625.
)).

The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc. 

Medially located large calcified discs should be operated through an anterolateral [[transthoracic approach]], whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers
((Arts MP, Bartels RH. Anterior or posterior approach of thoracic disc
herniation? A comparative cohort of mini-transthoracic versus transpedicular
discectomies. Spine J. 2013 Oct 24. pii: S1529-9430(13)01595-7. doi:
10.1016/j.spinee.2013.09.053. [Epub ahead of print] PubMed PMID: 24374099.)).

Anterolateral retroperitoneal, anterior transthoracic, posterolateral, and lateral approaches are performed in [[discectomy]] with or without fusion and internal fixation. However, patients who have undergone any operation at these levels are predisposed to postoperative recurrence, neurological aggravation, and adjacent segment degeneration, and the outcomes are inferior than those in lower lumbar spine
((Sanderson SP, Houten J, Errico T, et al. The unique characteristics of “upper” lumbar disc herniations. Neurosurgery 2004;55:385–9.))
((Ido K, Shimizu K, Tada H, et al. Considerations for surgical treatment of patients with upper lumbar disc herniations. J Spinal Disord 1998;11:75–9.)).
----




===== Posterior =====

posterior (midline laminectomy): primary indication is for decompression of posteriorly situated
intracanalicular pathology (e.g. metastatic tumor) especially over multiple levels. There is a high
failure and complication rate when used for single-level anterior pathology (e.g. midline disc
herniation)

=====  Posterolateral =====


a) lateral gutter: laminectomy plus removal of pedicle

b) [[transpedicular approach]]
((Le Roux PD, Haglund MM, Harris AB. Thoracic Disc
Disease: Experience with the Transpedicular Approach in Twenty Consecutive Patients.
Neurosurgery. 1993; 33:58–66))

c) [[costotransversectomy]]

d) [[Pedicle sparing transfacet approach]]

===== Anterolateral =====

[[Anterolateral transthoracic endoscopic approach]]
 ([[transthoracic approach]]): usually through the pleural space

===== Lateral extracavitary =====
 (retrocoelomic)
((Uribe JS, Smith WD, Pimenta L, et al. Minimally
invasive lateral approach for symptomatic thoracic
disc herniation: initial multicenter clinical experience.
J Neurosurg Spine. 2012; 16:264–27))
: an approach posterior (external) to the pleural space

===== Thoracoscopic surgery =====


[[Video-assisted thoracoscopic surgery]] is an alternative to open surgical approaches
((Stillerman CB, Chen TC, Couldwell WT, et al.
Experience in the surgical management of 82
symptomatic herniated thoracic discs and review
of the literature. J Neurosurg. 1998; 88:623–633))
((Dohn DF. Thoracic Spinal Cord Decompression:
Alternative Surgical Approaches and Basis of
Choice. Clin Neurosurg. 1980; 27:611–623)).