Percutaneous Endoscopic (Arthroscopic) Thoracic Discectomy

Table of Contents

Introduction
What is Percutaneous Thoracic Discectomy?
Who Should Consider this Procedure?
The Procedure
Postoperative Course
Advantages
Summary

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Introduction

Mid-back pain can be the price human beings pay for high-speed accidents and degenerative disk disease. It can be painful and disabling.

Side view of herniated thoracic disc.

Thoracic disk herniation occurs less frequent than lumbar and cervical disk herniations. Often thoracic disk conditions fail to respond to conservative treatment and the patient lives with pain. In many cases, simple treatments such as heat, physiotherapy, rest, exercise, and pain medication bring relief. But other sufferers are not so fortunate. If one or more of their vertebral disks rupture and press on the nerve roots, the pain radiating along the chest and spine can be incapacitating and severe. For many, the only treatment is surgical removal of part of the herniated disk; which, until now, has required a major traumatic operation. Traditional thoracic discectomy requires general anesthesia, the dissection of muscle and removal of bone, and bone fusion. Thoracic disks are difficult to approach surgically because of the ribs, the narrow spinal canal, and the critical position of the spinal cord. This traumatic approach often requires going through the chest, resection of ribs and part of the vertebral body, collapsing of the lung, often requiring bone fusion and metal plate screws. This constitutes risk of spinal cord injury or other traumatic complications. A long post surgical recuperation and hospitalization are also needed for this traumatic surgery.

Top view of herniated thoracic disc.

Now there is a new and much less traumatic procedure, for some disk patients, known as percutaneous arthroscopic thoracic discectomy with laser thermodiskoplasty, an outpatient procedure.

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What is Percutaneous Thoracic Endoscopic Discectomy with Laser Thermodiskoplasty?

Percutaneous Thoracic Endoscopic Discectomy with Laser Thermodiskoplasty is a new minimally invasive spine surgery procedure to remove and shrink (by laser) a herniated disk in the mid-back. By using local anesthesia and the help of x-rays and arthroscopy (endoscopy) for guidance, the specially designed micro-spinal instruments, a discectome probe and a laser probe are inserted into the herniated disk space. A portion of the offending disk is removed with cutting, laser vaporization, and suction, besides laser shrinkage of the bulging disk, instead of the open traumatic surgery.

Percutaneous arthroscopic thoracic discectomy is different from the standard traumatic thoracic disk surgery because there is no muscle dissection, bone removal, bone fusion, or a long incision, except for a puncture wound to accommodate the needle, micro-instruments, and the laser probe that are inserted into the herniated disk. Therefore, complications that occur with conventional surgery are eliminated with this less traumatic procedure.

 

A suction probe removes the disc material (discectomy).

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Who Should Consider This Procedure?

Percutaneous thoracic discectomy is specifically designed for patients with uncomplicated, herniated discs accompanied by the following:

1. Intractable pain radiating along the spine and chest wall.
2. Symptoms often include sensory loss, tingling, muscle spasms, and numbness.
3. A positive CT or MRI scan for disc herniation
4. No improvement of symptoms after eight weeks of conservative therapy
5. Positive myelogram is helpful

The procedure is not designed for patients with:

1. Evidence of acute or progressive degenerative spinal cord diseases
2. Evidence of neurologic or vascular pathologies mimicking a herniated disk
3. Evidence of advanced spondylosis (significant bony spurs) with disk space narrowing, diffuse annular bulging and other spine irregularities
4. Evidence of significant bony spurs blocking entry to disk space
5. Evidence of severe spinal canal or lateral recess narrowing
6. Evidence of a large extruded disk or a free fragment of disk material
7. Existence of other pathologies or conditions such as fractures, tumors, or active infections

Only patients with clinical abnormalities confirmed by physical examination, x-rays and scans are considered for the new procedure. Tests are done prior to the procedure.

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The Procedure

The procedure is performed under local anesthesia with the patient awake and in a prone or lateral position. A small needle is inserted into the disk for discography, and is followed by insertion of a slightly larger metal tube or sleeve.

Through the sleeve, a small incision is made in the disk itself. Using x-ray control, the micro-instruments (forceps, curettes, cutters), the Discectome (which is a hollow probe with a cutting knife inside) and the laser probe are inserted into the disk space through the sleeve. The disk material is removed or vaporized, and the disk bulge is shrunken further by laser. The procedure takes about 30 minutes, on average. X-ray exposure is minimal.

The supporting structure of the disk is not affected. Upon completion, the needle is removed and a small band-aid is applied over the tiny incision.

 

A band-aid covering the wound after surgery.

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Postoperative Course

The patient may feel relief from pain immediately following the procedure. This is an outpatient procedure. Walking and mild exercise are usually encouraged on the same day. Some patients experience mild muscle spasms that can generally be relieved with mild analgesics. Pain in the area of the operation is usually minimal. From the day of discharge, a daily exercise program is recommended. There is a re-evaluation examination several days later. Little, if any, postoperative medication is required for most patients. Normal activities can usually be resumed at the doctorÕs discretion within a few days to two weeks.

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Advantages

The primary advantage of this procedure is that there is no interference with the muscles, bones, joints or manipulation of the nerves in the mid-back area. Since insertion of the micro-instruments through the skin and muscle is the only wound, there is no scarring in or around the nerves postoperatively. Additionally, it is an outpatient procedure. Unfortunately, patients who have large free fragments of disk in the spinal canal, as determined by the x-rays and scans, usually cannot benefit from this procedure. However, the laser can shrink the disk bulge further.

It is essential to understand that a small percentage of patients are not relieved of their pain with this procedure. There appears to be much less risk and complication from performing percutaneous thoracic discectomy than the conventional traumatic thoracic discectomy surgery.

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Summary

Percutaneous arthroscopic thoracic discectomy with laser thermodiskoplasty requires no hospitalization, and provides earlier return to work and to previous daily activities. Pain is minimal. Rare patient complications include mild muscle spasms and transient pain. It is, after all, a minimally invasive spine surgery!

If you have any questions concerning this procedure, please feel free to discuss the percutaneous thoracic endoscopic discectomy procedure with us further.

Contents courtesy California Center for Minimally Invasive Spine Surgery
Used by permission