Indications
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Thoracoscopic diskectomy is employed for treatment of herniated disks in the thoracic spine anterior to the spinal cord using a minimally invasive anterior approach.
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Patients typically present with spinal myelopathy and cord compression.
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This approach can be used to treat thoracic radicular pain, diskitis, and other similar conditions best treated from the front of the spine.
Planning and positioning
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It is essential to confirm the pathologic level. Surgeons should have all magnetic resonance imaging (MRI) studies available in the operating room to identify relevant anatomy. Preoperative imaging must confirm the level of the operation using anatomy that can be replicated in the operating room—typically including the disk levels down to the sacrum for mid-thoracic and lower thoracic disk herniations.
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In addition to MRI, we typically obtain plain films and frequently a computed tomography (CT) scan to identify the location of the cervicothoracic or the thoracolumbar junction, the number of ribs present, and the location of the last visible rib. Imaging studies also serve to ascertain whether the disk is calcified.
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The patient is intubated with a dual lumen endotracheal tube and is given appropriate antibiotic prophylaxis.
Figure 83-1:
Place the patient in a standard lateral position with an axillary roll placed below the arm, which should be flexed; this helps protect the brachial plexus from injury.
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Secure the patient with three-point or four-point restraints on the patient’s chest and pelvis, or tape the patient down to the surgical bed to ensure that the patient does not move during the procedure.
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Scrub the patient as if preparing to complete a true thoracotomy in case the need arises to convert to an open procedure. Scrub from dorsally around the mid-back to ventral, including the navel and axilla.
Procedure
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Place the first portal at the posterior axillary line, two disk spaces above the pathologic disk when using a 30-degree scope; when using a 0-degree scope, place it directly above the posterior aspect of the pathologic disk space. This posterior portal is an ideal initial guide because it is posterior, away from the lung, which is superior and anterior, and the diaphragm, which is anterior and inferior. Make an incision over the rib, and use a hemostat to puncture the pleura and dilate the tract. Use the trocar introducers to dilate the tract progressively to the appropriate portal size.
