Thoracic Herniated Nucleus Pulposus

Abstract

Minimally invasive spine surgery in the treatment of thoracic disc disease has benefited from an explosion in technology over the past decade. However, to be valuable, the minimally invasive surgical approach in the treatment of thoracic disc disease must achieve the goal of equal outcomes when compared to open surgical procedures while at the same time preserve the safety of the procedure and minimize complications. The symptomatic herniated thoracic disc is a relatively rare clinical entity that presents a significant challenge to the spine surgeon. Clinical presentation is highly variable and can present insidiously or acutely as myelopathy and/or pain. The variability of symptoms and their similarities to more common non-spinal pathologies often leads to delayed diagnosis. Indications to remove thoracic herniated discs include myelopathy or severe radiculopathy refractory to conservative management. Removal of the thoracic herniated disc is complicated by the following: a narrow thoracic spinal canal, sensitivity of the spinal cord to minimal retraction, the rib cage, and the proximity of the lungs, heart, great vessels, and diaphragm. The earliest attempts to surgically treat herniated thoracic discs were by laminectomy, resulting in significant morbidity and mortality. The dismal results drove surgeons to develop and refine a variety of techniques and approaches falling into three main categories of posterolateral (including transpedicular and transfacet), lateral (extracavitary and costotransversectomy), and transthoracic approaches. Over the last few decades, minimally invasive surgical techniques have been applied to the thoracic spine to decrease approach-related morbidity of open thoracic discectomy. This chapter will discuss the minimally invasive posterolateral, lateral, and transthoracic approaches and compare them to their open counterparts in terms of indications, outcomes, and complications. The multitude of approaches available to today’s spine surgeon allows the surgeon to tailor each surgery to the individual patient’s anatomy and pathology, disc location, medical comorbidities, and the surgeon’s comfort level and familiarity with the various techniques. Because of the technically demanding nature of these procedures and the dire consequences of spinal cord injury from working in the thoracic spine, surgeons interested in adopting these techniques must have experience with open and minimally invasive techniques and also a practice that offers continued experience in treating this disease.