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Paper title The image guided transtubular extracavitary costo-trasversectomy (TECT) for the treatment of giant thoracic disk herniations: description of the technique and results.
Paper code P29
Authors
  1. Rodolfo Maduri Swiss Medical Network Speaker
  2. Juan Barges Coll CHUV - University Hospital
  3. Gabriel A Castillo-Velásquez Centro Médico Puerta de Hierro
  4. John Michael Duff CHUV Lausanne
Form of presentation Poster
Topics
  • SSNS-Neurosurgery
Abstract text Aims
Thoracic disc herniations (TDH) are a rare clinical entity. Giant TDH (occupying > 40% of the canal) constitute a surgical challenge. Available literature about GTDH favors anterior transthoracic, or in some cases open costotransversectomy approaches, both with a complication rate ranging from 28.4 % of 36.7 %. The transtubular extracavitary costo-transversectomy (TECT) avoids these complications, with a direct lateral trajectory to the disc space. Here we present our results of a series of 5 patients with GTDH operated using a a TECT approach.


Material and methods
From November 2006 to February 2018, 14 patients with TDH were operated using a TECT approach. 6/14 were GTDH, 4 of which were calcified. All patients presented with myelopathy.
The surgical procedure consisted as follows: in prone position. Image guidance using 2D fluoroscopy for 4 cases and 3D fluoroscopic guidance for 2 cases. Optimal trajectory is chosen on preoperative MR images. The skin incision and the tubular retractor are placed under image guidance. The index rib is skeletonized and detached from the vertebral body. The inferior vertebral facet, the transverse process and the pedicle of the upper vertebra are carefully drilled. After division of the thoracic nerve root, partial vertebrectomies of the upper and lower vertebra allow the decompression of the thoracic disk herniation.

Results
6 GTDH patients presented a mean age of 27.6 (range 35-87), 4 female, 2 male.
4 over 6 presented preoperatively with myelopathy (2 Nurick score=2, 2 Nurick score=3). 1 patient presented with a right T7 radiculopathy.
Postoperatively, all patients with giant thoracic disk herniation were neurologically improved. After mean follow up was 20 months (range 1-67), 5 patients have a Nurick score 0, one patient a Nurick score 1. One patient developed a right T5 neuropathic pain controlled under pregabalin. No patient required fusion.

Conclusion
The principal drawback of transthoracic approaches to the thoracic spine is the morbidity related to the thoracotomy access and the steep learning curve (thoracoscopy).
Here we describe an alternative surgical technique for most, if not all TDH, including GTDH. TECT allows us good access to the ventral spinal canal with direct vision past the midline. The potential advantages of TECT are the familiarity with the anatomy, increased precision particularly using 3D fluoroscopic navigation and minimization of approach related morbidity.