Chapter 25 Posterolateral Endoscopic Thoracic Discectomy

Sang-Ho Lee, MD, PhD, Ho-Yeong Kang, MD, Ho-Yeon Lee, MD, PhD

Posterolateral endoscopic thoracic discectomy (PLETD) has been developed from percutaneous endoscopic lumbar discectomy “>[1–9]. However, this procedure is technically demanding because the thoracic discs are difficult to approach surgically, even for the experienced surgeon [8–13].

There are two kinds of percutaneous posterolateral endoscopic thoracic discectomy. The first is C-arm–guided percutaneous endoscopic thoracic discectomy (PETD) using a rigid working channel scope [8]. The working channel allows passage of a side-firing holmium:yttrium-aluminum-garnet (Ho:YAG) laser and microforceps. The excellent visualization via the endoscope permits the surgeon to selectively remove a portion of the herniated disc. After the anular anchorage is loosened by the side-firing laser, the herniated fragment can be easily removed by the microforceps. The second is real-time computed tomography (CT)–guided percutaneous endoscopic thoracic anuloplasty (PETA) using laser-assisted spinal endoscopy (LASE, Clarus Medical, LLC, Minneapolis, MN) [9]. CT fluoroscopy, which is one of the newest advances in interventional radiology, provides accurate spatial and real-time information. The LASE, which integrates an Ho:YAG laser, endoscopy, illumination, and irrigation, allows vaporization and shrinkage of disc tissue through a small cannula. The LASE is especially developed for targeted posterior decompression and posterior anuloplasty.

The major advantages of these minimally invasive thoracic discectomy are as follows:

Minimized muscular and bony damage

No manipulation of dural sac and roots

Less risk of neurologic compromise and infection

Little bleeding

An excellent cosmetic effect and reduced operation time and hospital stay, which allow the patient to return to normal daily activity more rapidly

Indications and contraindications

Indications

Table 25.1 lists the indications for PETA and PETD, which can be summarized as follows:

Soft thoracic disc herniations

Pain refractory to conservative therapy

Table 25.1 Indications, Patient Complaints, and Physical Findings Identifying Need for Percutaneous Endoscopic Thoracic Disc Procedures

	Percutaneous Endoscopic Thoracic Discectomy Using Rigid Spinal Endoscopy	Percutaneous Endoscopic Thoracic Anuloplasty Using Laser-Assisted Spinal Endoscopy
Indications	Thoracic disc herniation paramedian to foraminal disc	Thoracic degenerative disc disease Foraminal disc
Patient complaints	Unilateral sensory change, pain, or weakness below the lesion; it may be leg, trunk or both	Back pain and/or thoracic radicular pain Usually also interscapular central thoracic pain and/or radiating anterior chest pain The patient usually reports interscapular, thoracolumbar, anterior chest radiating, midspine, intercostal, flank, and low back pain
Physical findings	Careful examination reveals mild Brown-Séquard syndrome (lateral cord syndrome)	Minimal sensory change or slightly increased deep tendon reflex Usually patient reports pain on compression of the spinous process around the lesion