Retropleural Approach

John M. Gorup and David H. Donaldson

Goals of Surgical Treatment

1. Decompress the spinal canal in the face of myelopathic symptoms or progressive neurologic deficit

2. Relieve mechanical pain after a failure of an appropriate course of nonoperative treatment

Diagnosis

1. Requires a high index of suspicion.

2. Symptoms can vary from profound neurologic deficit to localized back pain with mechanical symptoms.

3. Magnetic resonance imaging (MRI) has supplanted all other imaging studies as the study of choice.

4. Discography is recommended to an asymptomatic, control level when performing a fusion for mechanical back pain.

Indications for Surgery

1. Myelopathy: absolute indication

2. Progressive neurologic deficit: absolute indication

3. Radicular pain unresponsive to an appropriate course of nonoperative treatment

4. One- or two-level degenerative disc disease unresponsive to a prolonged period of nonoperative treatment (> 1 year), working patient, appropriate discographic study.

Contraindications

1. Insufficient pulmonary status: relative contraindication

2. Poor psychological patient profile

3. Unrealistic patient expectations

4. Nonconcordant findings on discography

Advantages

1. Minimal manipulation of spinal cord and nerve roots

2. Improved visualization

3. Decreased blood loss

4. Rarely need chest tube

Disadvantages

1. Learning curve

2. Previous experience with transthoracic approaches mandatory

Procedure

Positioning