A study published in the European Spine Journal suggests that a new approach for central disc herniation, posterior transdural disectomy, has relative high success rates and is well tolerated by patients.
At present, the optimum surgical technique for central thoracic disc herniation is unknown. Costotransversectomy, posterolateral, and anterolateral approaches have recently been suggested because they allow more direct access to the intervertebral disc and provide good visibility of the operative area of interest. However, Maarten Coppes, Department of Neurosurgery, University Medical Center Groningen, The Netherlands, and his fellow investigators write that one of the disadvantages of these techniques is their more extensive nature, which have the potential for pulmonary and mediastinal complications.
In their study, Coppes et al outlined approach that Coppes developed. With the posterior transdural approach, patients are operated on in the prone position. A unilateral exposure is performed, direct to the side of the most prominent prolaps of the disc herniation, then a hemilaminectomy, a partial facetectomy, and a partial pediculectomy. After these procedures, under microscopic magnification, a posterolateral durotomy is performed followed by the transsection of the denticulate ligament to lift and slightly rotate the spinal cord. The aim of this manoeuvre is to create a corridor to the ventral aspect of the spinal canal. The ventral dura is then opened, providing a direct view of both the spinal cord and disc herniation, allowing a discotomy and herniotomy to be performed. According to Coppes et al, the techniques means the compressed thoracic spinal cord is not touched. They reported: “A ‘no-touch’ strategy is the key to this approach.”
The study reviewed the used of the technique in 13 patients with symptomatic central thoracic disc herniation. After a median follow-up of 18 months, 12 patients had an improvement in symptoms and these included three patients who had reversible complications. Although one patient did not see an improvement in symptoms following surgery, there were no reports of symptoms worsening.
Coppes et al reported that there are several advantages with the novel technique. “The anatomical region is more familiar to spinal surgeons (orthopaedic or neurosurgeons), all types of thoracic disc herinations can be operated on (every thoracic segment and every type of disc herniation, including medial calcified herniation), and it is a relatively straightforward procedure with minimal blood loss and low perioperative morbidity.” They added that patients did not to be admitted to an intensive care unit, a chest tube was not needed, and fixation of the thoracic spine was not required. They concluded: “Although the present series is still small, the posterior transdural approach seems an appealing and promising procedure for the removal of a central thoracic disc herniation.”