May 1994 - Volume 19 - Issue 9 - Contributor Index : Spine
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`May 1994 - Volume 19 - Issue 9 - Contributor Index
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`Author Name
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`Article
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`Ragland, David R. PhD,
`MPH
`
`Occupational Disability Due to Low Back Pain: A New Interdisciplinary Classification Based on a
`Phase Model of Disability
`Krause, Niklas; Ragland, David R.
`Spine. 19(9):1011-1020, May 1994.
`
`Abstract
`
`PDF (981 KB)
`
`+ Favorites
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`Ronchetti, Peter J. BS
`
`Changes in Shape of the Adolescent Idiopathic Scoliosis Curve After Surgical Correction
`Stokes, Ian A. F.; Ronchetti, Peter J.; Aronsson, David D.
`Spine. 19(9):1032-1036, May 1994.
`
`Abstract
`
`PDF (533 KB)
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`+ Favorites
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`Rosenthal, Daniel MD
`
`Removal of a Protruded Thoracic Disc Using Microsurgical Endoscopy: A New Technique
`Rosenthal, Daniel; Rosenthal, Raul; de Simone, Anna
`Spine. 19(9):1087-1091, May 1994.
`
`Abstract
`
`PDF (448 KB)
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`+ Favorites
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`Rosenthal, Raul MD
`
`Removal of a Protruded Thoracic Disc Using Microsurgical Endoscopy: A New Technique
`Rosenthal, Daniel; Rosenthal, Raul; de Simone, Anna
`Spine. 19(9):1087-1091, May 1994.
`
`Abstract
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`PDF (448 KB)
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`http://journals.lww.com/spinejournal/pages/contributorindex.aspx?filter=R&year=1994&issue=05000[6/20/2013 8:08:20 PM]
`
`WARSAW2019
`NuVasive, Inc. v. Warsaw Orthopedic, Inc.
`Case IPR2013-00208
`
`Page 1
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`

`

`SPlNE Volume 19, Number 9, pp 1087—1091
`@1994, J. B. Lippincott Company
`
`l Removal of a Protruded Thoracic Disc
`Using Microsurgical Endoscopy
`A New Technique
`
`Daniel Flosenthal, MD,* Haul Rosenthal, MD,t and Anna de Simone, MD-t
`
`Studv Design. The first clinical Implementation of a
`microsurgical endoscopic technique for removal of tho-
`racic disc herniation is described.
`
`Dbiective. To decompress the Sptl'lal cord with a
`ventral approach. combining microsurgical and endo-
`scopic techniques, while reducing the “approach-relat-
`ed trauma.“
`Methods. A detailed description of the preoperative
`preparation as well as the surgical technique is given.
`Advantages and dies dventag as of the microsurgical
`endoscopic technin us are discussed and compared
`with outer surgical procedures described in the litera-
`ture.
`Results. A herniated disc at TIE-"IT:r was removed
`
`and the spinal cord was decompressscl. The patient
`recovered complevel»...I and was dlSChflrgecl at the EW-
`enth postoperative dav. He returned to work 4 weeks
`later.
`
`Conclusions. The microsurgical endoscopic tech-
`nique allows spinal cord decompression wilh a sub-
`stantial reduction in surgical trauma. It mav shorten
`bed confinement and allow aarlv return to active life.
`Application of this technique in other areas is being
`studied. [Key words: disc herniation. dorsal spine. en-
`doscopic sorgerv, spinal cord compressionr ventral ap-
`proach to the spine] Spine 1sea:1e:1na1—tns1
`
`Thoracic disc herniation is a rare cause of spinal cord
`compression that presents a variety of nonspecific
`symptoms leading to a wrong or delayed diagno-
`sis.1°’13‘16’18'23’25’29 Until the early 19605, numerous
`reports indicated that thoracic disc herniation had a
`subtle onset, required a complex therapy, and had a
`poor prognosis.3’“’18 Arseni and Nash3 noted that the
`condition of about 50% of their patients deteriorated or
`remained unchanged after surgical decompression via a
`dorsal approach (laminectomy). In the following years,
`a variety of techniques, such as the costotransversecto-
`my6’13’21 (and its modification,12 the arthropediculec-
`tomy5’23) and the transthoracic8’22’24’25 approaches,
`were reported to be suitable for removing thoracic disc
`herniation without manipulating the spinal cord. How-
`ever, these techniques entail the use of thoracotomy or
`
`From the *Department of Neurosurgery, University Hospital, Frank-
`furt am Main/Germany, tDepartment of Surgery, Nordwest Hospital,
`Frankfurt am Main/Germany, and tDepartment of Neuroradiology,
`University Hospital, Frankfurt am Main, Germany.
`Accepted for publication October 27, 1993.
`
`wide bony resection of vertebral structures to reach the
`ventral part of the spine. Better imaging techniques
`(computed tomography and magnetic resonance imag-.
`ing) and the development of new surgical procedures
`have substantially improved the prognosis of thoracic
`disc protrusion.2
`We report on a new microsurgical endoscopic tech-
`nique (MET) that permits disc removal while substan-
`tially reducing the “approach-related” trauma.
`
`l Surgical Technique and Postmortem Studies
`
`Fresh, unautopsied cadavers were used for the study. After the
`body was placed in a left lateral decubitus position (Figure 1),
`the intervertebral space to be operated upon was located under
`endoscopic and fluoroscopic control. We prefer a dextrolateral
`approach because the aorta and the heart are displaced to the
`left paravertebral area, improving spinal visualization and re-
`ducing the risk of complications. Four trocars (Ethicon, Ham-
`burg, Germany) then are inserted in a triangular fashion along
`the middle axillary line, converging to the disc space (Figure
`1). A rigid endoscope with a 30° angle optic (Karl Storz,
`Tfittlingen, Germany) with a single chip camera attached to it
`(Karl Storz, Tiittlingen, Germany) were introduced through
`one of the trocars, leaving the other three as working channels
`(Figure 1).
`Surgery began by splitting the parietal pleura, starting at
`the medial part of the intervertebral space and extending up to
`the costovertebral process. The segmental arteries and the
`sympathetic nerve was mobilized out of the operation field and
`preserved. Part of the posterior aspect of the vertebral body
`and the proximal portion of the costovertebral process were
`drilled off, improving visualization of the spinal canal. Bone
`and disc removal were restricted to the posterior third of the
`intervertebral space and the costovertebral area so stability
`was not compromised. Removal of the disc and the posterior
`longitudinal ligament, using special forceps and rongeurs, then
`were performed. The instruments must be about 33 cm long to
`reach the spine comfortably. If fusion is required, bone can be
`harvested from the ribs, iliac crest, or fibula; the positioning of
`the patient makes this possible. When surgery was finished,
`chest tubes were placed and set under water-sealed suction.
`Between July and November 1992 and with the help of the
`Pathology Department of the University Hospital, Frankfurt
`am Main, we were able to standardize the approach. Twenty-
`eight thoracic discs were removed in six cadavers under con-
`ditions similar to those per training in the operating theater.
`The mean operative time for disc removal and inspection of
`
`Page 2
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`Page 2
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`

`

`1088 Spine ' Volume 19 ' Number 9 ' 1994
`
`
`
`Figure 1. Position on the operating table and distribution in the
`operating theater. The surgeons (S) and nurse with the instru-
`ments (I) are standing in front of the patient. The monitor (M) is
`placed at the back. The "working channels" (1, 2, 3) converge
`toward the spine. The channel forthe optical system (4) is situated
`ventrally.
`
`the spinal canal was 2.17 hours. The last six discs and poste-
`rior ligaments were removed in a mean time of 1.38 hours.
`Clinical work was started after the technique was standard-
`ized, skills were developed, and the approach was performed
`safely.
`
`extradural mass between T6—T7 (Figure 2, left). The preop-
`erative diagnosis was thoracic disc herniation. Somatosensory-
`and motor-evoked potentials showed a slight increase in la-
`tencies on both sides.
`J
`After analyzing the clinical and radiologic findings, we
`decided to remove this lesion using MET. Consent to use the
`new approach was obtained from the patient before surgery
`and after detailed information was provided.
`Using MET, a herniated, sequestrated thoracic disc was
`removed. The postoperative course was uneventful. The pa-
`tient was able to walk 24 hours after surgery, without body
`jacket. The chest drainages were removed on the second post-
`operative day (after 200 cc of serum was drained). The post-
`operative control MRI showed that the spinal canal was com-
`pletely decompressed and free of disc material (Figure 2,
`right).
`’
`.
`Upon discharge, he was still complaining about numbness
`in the genital region, although it had improved compared to
`the preoperative status). No other deficits were observed. The
`wounds were closed and the sutures were removed on the sixth
`day. Somatosensory- and motor-evoked potentials still
`showed a slight increase in latency. He was discharged on the
`7th postoperative day.
`The first follow up examination took place 6 weeks after
`the patient’s discharge. Clinical symptoms and somatosen-
`sory-evoked potentials had normalized. The patient had been
`working for 2 weeks without problems.
`
`I Discussion
`
`Case Report. Upon admission to the hospital, a 30-year-old
`man was complaining of bilateral pain at the T7 level, gait
`disturbances, and numbness in the genital region that had
`begun 4 weeks earlier.
`Cerebrospinal fluid examination showed no abnormality.
`Plain x-rays of the dorsal region were normal. The MRI ex-
`amination revealed a clear, ventrally located intraspinal and
`
`Pathophysialagic Considerations
`The first surgical treatment of thoracic disc herniation
`was reported by Adson18 in 1922, who performed a
`laminectomy and disc removal. The results obtained in
`subsequent years were disappointing and helped to doc-
`ument that the dorsal approach has an unpredictable
`
`
`
`Figure 2. (A) Preoperative MRI
`shows the herniated disc be-
`tween T6~T7 and spinal cord
`compression (arrow). (B) Postop-
`erative MRI: The spinal cord is.
`decompressed. The gap between
`T6—T7 (arrow) shows where the
`intervertebral space was en-
`tered. The spinal cord is decom-
`pressed.
`
`Page 3
`
`

`

`
`
`Removal of a Protruded Thoracic Disc - Rosenthal et a1 1089
`
`outcome and is exceedingly risky, probably because spi-
`nal cord retraction is required to reach the disc, which is
`situated anterior to the spinal cord.27
`Experimental and clinical reports demonstrated that
`compressive lesions situated ventrally in the thoracic
`spine frequently were followed by poor results when
`surgical treatment was attempted using the dorsal ap-
`proach.“’9 A logical explanation for this is that the spi-
`nal canal is narrower at the thoracic level and manipu-
`lation leads to microcontusions that worsen the already
`compressed and ischemic, probably causing secondary
`damage. Deficits in blood supply through the segmental
`arteries also were discussed. Doppman and Girton10
`found neurologic deterioration in all patients in whom
`ligature or thrombosis of a segmental artery occurred.
`On the other hand, Currier9 described abundant collat-
`eral circulation around the neural foramina, routinely
`ligating the segmental vessels unilaterally, without ad-
`verse effects. A combination of microcontusions and
`alterations in microcirculation probably is the more ap-
`propriate explanation for this phenomenon.
`
`Indications for MET
`Laminectomy has been practically abandoned and re-
`placed by ventral, ventrolateral, or dorsolateral ap-
`proaches, which have improved results because of the
`reduction in spinal cord manipulation.5’8’12’17’18’22’23'25
`Early surgical decompression is accepted as the treat-
`ment of choice,2’9 and a wide variety of techniques has
`been described for this purpose.5’6’8’12’21’23"25 All re-
`quire either bony removal of vertebral structures (caus-
`ing or worsening instability) or a thoracotomy to gain
`access to the ventral spinal canal and minimize cord
`manipulation.
`The posterolateral, lateral, and transpedicular tech-
`niques have been criticized because of postoperative
`instability in some cases,”"19 insufficient visibility over
`the midline,19’7‘7 and sectioning of muscle or ribs to
`improve visibility.19
`During the last 10 years, 16 patients with thoracic
`disc protrusions have been successfully treated at our
`department using the transthoracic approach. Although
`Arce and Dohrmann2 reported that the best results are
`obtained with this technique, it has become unpopular
`for discectomy and is reserved only for special indica-
`tions, such as vertebral body resection and fusion.” The
`need for a second surgical team (thoracic surgeon),12
`insufficient exposure of the thoracic spine,19’28 and re-
`spiratory complications derived from thoracotomy20 are
`considered to be its main disadvantages by most au-
`thors.19’2°’27’28
`Microsurgical endoscopy permits the same approach
`as the transthoracic route, except for thoracotomy.
`With appropriate instruments, any lesion situated ven-
`trally and compressing the cord probably can be re-
`moved with this technique.
`
`
`
`Figure 3. Horizontal view at the T6 level. The patient is in the left
`lateral decubitus. 1, right lung (collapsed); 2, heart and pericar-
`dium; 3, esophagus; 4, aorta; 5, forceps and endoscope; 6, left
`lung; 7, surgeon.
`
`Preoperative Considerations
`Patients who will undergo surgery using MET need to
`have their pulmonary function optimized. For patients
`with asthma or emphysema, pulmonary functional sta-
`tus should be improved before surgery is considered.
`Marked respiratory deficit can be a contraindication for
`MET because unilateral ventilation may worsen hypox-
`emia.
`
`Advantages and Difficulties
`One problem to consider is that microsurgical endos-
`copy does not differ much from the hazards neurosur-
`geons are familiar with during microsurgical operations.
`Some abilities, however, need to be acquired. The sur-
`geon needs to look at the monitor in front of him or her
`with his or her head tilted up in a 90° angle while
`coordinating hand movements. Placing the surgeon and
`his or her assistant ventrally facilitates orientation and
`coordination. Nevertheless, we believe a period of prac-
`tice and adaptation is mandatory.
`The advantage of the left lateral decubitus position is
`that the spine can be reached while avoiding direct
`contact with the aorta, esophagus, and the pericardium,
`because these structures are displaced to the left para-
`vertebral area (Figure 3). Because of the intubation
`associated with using a Robertshaw—type tube (Mallinc—
`krodt Laboratories, Athlone, Ireland) and intraopera-
`tive unilateral ventilation, the lung on the surgical side is
`
`Page 4
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`Page 4
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`

`

`- 1090 Spine ° Volume 19 0 Number 9 ° 1994
`
`without further lung retraction. Reducing trauma to the
`thoracic wall and to the lung parenchyma may prevent
`a variety of complications.7’2° This was confirmed in
`our patient by an insignificant intraoperative blood loss
`(100 ml), reduced consumption of analgesics in the post-
`operative period, and a considerable reduction in the
`amount of bed confinement after surgery.
`The lack of instruments suitable for MET may com-
`plicate surgery..We have used a variety of instruments
`that were designed for abdominal laparoscopic surgery.
`Some prototypes and further applications for MET are
`now being developed at our department.
`MET ensures disc removal. It permits a wide expo-
`sure of the thoracic spine by changing only the insertion
`site of the trocars. A review of the literaturel’2 showed
`that out of 258 patients, only 12 (4.6%) had a disc
`protrusion above T4, and 24 (9.3%) below T12, mak-
`ing MET suitable for over 80% of patients. Under ex-
`perimental conditions, we were able to reach the spine
`successfully from T4 to T11. Clinical experience will
`undoubtedly show us the real potential of this method.
`Herniated soft disc (medial or lateral) or calcified pro-
`trusions can be removed without compromising the spi-
`nal cord.
`
`In case fusion is needed, bone grafts can be brought
`into the thoracic cavity by dilating the holes made by the
`trocars. As a result of early mobilization, the incidence
`of thrombosis decreases as well. This is significant, es-
`pecially in elderly and high risk patients.
`Finally, by getting the same benefits as with other
`surgical procedures—early release and return to work
`(reducing hospitalization time up to 50%)—this tech-
`nique helps decrease therapy costs.
`
`I Conclusions
`
`MET is a modification of the thoracic approach that
`allows complete disc removal with a substantial reduc-
`tion in surgical trauma (fewer wound and pulmonary
`complications). It shortens confinement to bed (reducing
`the risk of thrombosis) and reduces the postoperative
`period (early discharge). A training period is obligatory,
`although it should be learned easily by those familiar
`with microsurgical techniques.
`
`Acknowledgments
`
`We are grateful to Prof. K. Hiibner, Head and Chairman
`of the Department of Pathology from the University
`Hospital, Frankfurt am Main, and his coworkers for
`enabling us to perform postmortem studies. We also
`thank to Mrs. W Dutiné for her help in preparing this
`article.
`
`References
`
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`thoracic disc herniation. Neurosurgery 1986;19:449—51.
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`Removal of a Protruded Thoracic Disc 0 Rosenthal et al 1091
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`pedicle to protruded thoracic discs. J Neurosurg 1978;48:
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`
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`'
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`
`Address reprint requests to:
`
`Germany
`
`Daniel Rosenthal, MD
`Klinik for Neurochirurgie
`Klinileum der Johann Wolfgang Goethe Universitat
`Schleusenweg 2-16
`60528 Frankfurt am Main
`
`Page 6
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`Page 6
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`