Name:
Outpatient endoscopic resection of large calcified thoracic disc herniation with caudal displacement
Description:
Outpatient endoscopic resection of large calcified thoracic disc herniation with caudal displacement
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Duration:
T00H09M00S
Embed URL:
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Upload Date:
2021-11-22T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SANJAY KONAKONDLA: This is a case of a large calcified thoracic disc herniation with caudal displacement, all resected with an outpatient endoscopic procedure. I'm Sanjay Konakondla. And I'll be explaining how we did that. The patient is a 32-year-old female, BMI 54, who was suffering from 6 months of midthoracic back pain, progressive gait abnormalities, and heaviness and weakness in the legs.
SANJAY KONAKONDLA: At the time of surgery, she was using a walker to assist with ambulation. The imaging included an MRI and subsequently, a CT scan of the thoracic spine, which showed a large calcified thoracic disc at the level of T9-10, preferential to the right side with caudal migration and significant spinal cord compression. A surgery was felt necessary for this patient due to her significant clinical and radiographic findings.
SANJAY KONAKONDLA: To appreciate the intraoperative view and anticipate the amount of bony resection necessary, 3D models were digitally reconstructed from the patient's CT scans and MRIs. Areas were subtracted to allow the best possible view of the disc and to plan trajectories for complete removal of the calcified disc and the caudally migrated fragment. 3D printed models were fashioned to facilitate operative planning.
SANJAY KONAKONDLA: We often use these 3D models for patient education and surgical discussion, and they really help with true, full, informed consent. Patient positioning is typical. As with any discectomy, with the patient in a prone position on a Wilson frame to facilitate opening of the neural foramen, marking levels intraoperatively as always is done carefully with specific reference to preoperative imaging when comparing to intraoperative fluoroscopic images.
SANJAY KONAKONDLA: Due to the patient's body habitus, the calcified disc was unable to be unambiguously seen, contrary to what we would have predicted. We counted up from the 12th rib, but also from the sacrum to mark the level of T9-10. Key anatomical landmarks are identified and lines are drawn on the patient to mark the midline, the disc level, and trajectories. In a typical endoscopic transdermal approach, the guide needle is docked on the posterior superior apex of the inferior vertebral body on the lateral view and just medial to the ipsilateral pedicle on the AP view.
SANJAY KONAKONDLA: Due to the large, calcified, caudal migration of this disc, it would not have been helpful to dock in this area, so we proceeded with a modified transforaminal approach. The ideal trajectory as determined by our 3D model suggests that a more acute angle aimed inferiorly, which could be better categorized as a combined transforaminal and ventrolateral transpedicular approach. The needle, as seen, is docked just lateral to the pedicle at the pedicle, superior articulating process, and transverse process junction of T10.
SANJAY KONAKONDLA: A subcentimeter incision was made around the needle. A guidewire was placed into the needle before the needle was removed and sequential dilators were advanced over the guidewire to protect the surrounding tissue. The working channel was advanced over the final dilator, and the endoscope was introduced. And in this case, the tubular retractor had an inner diameter of 6.5 mm facilitating the 6.3-mm outer diameter of the endoscope, which has a working channel diameter of 3.7. The surrounding tissue was removed and cauterized to reveal the underlying bony anatomy.
SANJAY KONAKONDLA: The inferior articulating process of T9, the superior articulating process, transverse process, and proximal pedicle of T10 is visualized. An instrument can then be placed lateral to the pedicle of T10 on the superior border and an intraoperative fluoroscopic image can be taken. A high-speed 3.5-mm round diamond burr was used to begin the planned bony resection, including the partial superior articulating process, transverse process, and pedicle of T10.
SANJAY KONAKONDLA: And the T9 inferior articulating process. The T9-10 joint space can be visualized here easily after minimal drilling. The pedicle is identified anatomically and confirmed again with fluoroscopic imaging. After trajectory of the bony drilling was verified, drilling continued to the medial surface of the pedicle. The medial cortical surface of the T10 pedicle can be visualized here, labeled in the still image.
SANJAY KONAKONDLA: Intraoperative fluoroscopy was taken to confirm these anatomical landmarks. We continued drilling in the cephalad direction to remove the remaining T10 superior articulating process. Bleeding from the epidural veins allows for appreciation of entrance into the epidural space.
SANJAY KONAKONDLA: These veins are carefully cauterized with bipolar electrocautery. A full-length view from top to bottom of the disc and the medially displaced spinal cord can be seen here. The epidural fat is seen pulsating through the newfound space created by this approach.
SANJAY KONAKONDLA: The cautery device can be used again dually this time as a dissector to carefully palpate the dorsal and medial aspects of the disc herniation. We can now appreciate the inferior border of the T10 pedicle and the disc fragment along with its hard shell, some soft disc material in the center, and a severely compressed spinal cord.
SANJAY KONAKONDLA: As most of the disc was calcified, a significant amount of drilling was completed to thin out the outer layer that was closest to the spinal cord for easier removal at the later portion of the case. Straight and slightly up-angled graspers remove the thin rim closest to the spinal cord. Epidural bleeders ventral to the spinal cord were cauterized carefully and attention was placed on the most cephalad portion of the disc herniation Kerrison Rongeurs and graspers remove the medial rim of this disc.
SANJAY KONAKONDLA: The severely compressed spinal cord can clearly be seen here almost folded over the last remaining calcified disc, which is apparent at the approximately 3- o'clock position on the screen. A dissector can be seen here mobilizing the free fragment. Graspers were again used to remove the final compressive components of the disc.
SANJAY KONAKONDLA: After the removal of the final compressive disc components, we can appreciate the now decompressed spinal cord and its natural morphology. The less than 1-cm incision was closed with absorbable sutures and dressed with glue.
SANJAY KONAKONDLA: The postoperative MRI revealed complete resection of the thoracic disc and the caudally migrated fragment. The patient was discharged to home 83 minutes after her surgery without the need for narcotic medications. Conclusively, we should also note that although these novel techniques can result in favorable outcomes, complex cases such as migrated large calcified thoracic discs can be challenging.
SANJAY KONAKONDLA: The importance of training in full-endoscopic procedures should be emphasized. And these cases are likely best reserved for surgeons with sufficient clinical experience and volume in full- endoscopic spine procedures.
