10 Applied Anatomy and Percutaneous Approaches to the Thoracic Spine

Jacobaeus, a professor of internal medicine in Stockholm, Sweden, is credited with performing the first thoracoscopic procedure in 1910. This groundbreaking procedure was a technique for lysis of tuberculous pleural adhesions.1 In 1990, the modern era of thoracoscopy began with the introduction of video imaging to standard endoscopy. Mack and colleagues in 1993 and Rosenthal and colleagues in 1994 first reported the technique of video-assisted thoracoscopic surgery (VATS).^2,3 Thoracic disk herniations were treated first by thoracoscopic spine procedures.

In a further attempt to reduce tissue trauma and enhance postoperative outcome, percutaneous endoscopic thoracic diskectomy (PETD) has been developed to treat thoracic disk herniations from a direct posterior or posterolateral approach. Jho described the technique of endoscopic transpedicular thoracic diskectomy with 0- and 70-degree 4-mm endoscopes, requiring relatively small 1.5- to 2-cm incisions and minimal tissue dissection. This avoided the need for separate skin incisions in the chest wall for postoperative chest drainage as were used in thoracoscopic approaches.⁴ Also, Chiu et al demonstrated the safety and efficacy of posterolateral endoscopic thoracic diskectomy followed by application of a low-energy nonablative laser for disk thermodiskoplasty using a 4-mm 0-degree endoscope.⁵ Currently, PETD has been described as a safe procedure with outcomes similar to or better than those seen with classic procedures for the treatment of thoracic disk herniations.

Introduction

Thoracic disk herniations present a unique challenge for the spine surgeon in terms of patient selection, surgical technique, and potential complications. Symptomatic thoracic disk herniations are a relatively rare condition, representing less than 1% of all disk herniations.^6,7 The increased rigidity of the thoracic cage, which causes the thoracic spine to have decreased flexion, extension, and rotation compared with the cervical and lumbar spine is likely the main cause of the low incidence of symptomatic thoracic disk herniations.^8–10

Thoracic disk herniations are frequently an acute event and manifest clinically with acute paraparesis or even paraplegia. A review of the literature suggests that patient presentation may be extremely variable. Thoracic disk herniations have mimicked systemic, cardiac, renal, and orthopedic diseases.^11,12 Neurogenic claudication is most commonly attributable to lumbar stenosis, although others have reported this as a presentation of lower thoracic disk herniations.^13,14

A few patients with thoracic disk herniations may require surgical intervention, and they present with a wide variety of symptoms. In contrast, a large variety of surgical approaches have been developed to treat thoracic disk herniations. These include posterior, posterolateral, and lateral approaches; transthoracic approaches; and thoracoscopic approaches.^15–17 The difficulty the spine surgeon encounters when treating these patients is shown clearly with the discrepancy between the small percentage of patients seen with this disease and the large number of surgical techniques developed. Disk herniations in the thoracic region represent a challenging pathology because the thoracic spinal canal is the narrowest among all spinal regions, the blood supply to the thoracic cord is precarious, and the approach to the thoracic region is more difficult.^18,19 Approaches to thoracic disk herniations all have advantages and disadvantages.

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