Name:
10.3171/2022.3.FOCVID221
Description:
10.3171/2022.3.FOCVID221
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/c7446169-dbfc-4e82-ab60-85628bcb51d6/videoscrubberimages/Scrubber_455.jpg
Duration:
T00H09M07S
Embed URL:
https://stream.cadmore.media/player/c7446169-dbfc-4e82-ab60-85628bcb51d6
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/c7446169-dbfc-4e82-ab60-85628bcb51d6/22-1.mp4?sv=2019-02-02&sr=c&sig=qZ69gPO1L%2FXE1IM0RV0LGctBtlf7RgxnMuTV7Zz08I4%3D&st=2025-05-12T08%3A38%3A48Z&se=2025-05-12T10%3A43%3A48Z&sp=r
Upload Date:
2022-05-24T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This is a video to present an anterolateral transthoracic endoscopic approach for a calcified thoracic disc herniation. This is a 65-year-old woman with a past medical history of asthma, right nephrectomy, and pulmonary embolism. She was diagnosed of a large calcified T5-6 thoracic disc herniation after a test CT done as a follow-up for her pulmonary embolism. The neurological examination was within normal limits without motor or sensitive symptoms.
SPEAKER: On further questionnaire, she described a mild urinary incontinence that she has had for years. And she explained it because of her age and births. This is a sagittal and axial CT without contrast. It shows a calcified TDH at T5-6 with significant stenosis of the spinal canal. We notice the calcification of the thoracic hernias as a common finding. The axial view shows a wide bone implantation.
SPEAKER: The T2-weighted images MRI shows that the firm displaced spinal cord with probable signs of myelopathy. This compressions need to be addressed from anterior approach to achieve a complete decompression reducing the risk of spinal cord injury that a posterior approach could carry. Despite the fact that the compression is mainly the left side, we planned the approach from the right. A simple decompression could have been achieved from the left side.
SPEAKER: But the correct stabilization with screws is very dangerous at this level due to the aorta. This is the reason why we approached the hernia with subsequent osteotomy from the right side. It is important to make sure that the osteotomy is long enough to achieve a sufficient decompression. The patient is right lateral position. The surgeon is in her ventral side. We do not usually use intraoperative neuromonitoring, as we need sufficient relaxation of the diaphragm just in case it had to be retracted.
SPEAKER: A 30-degree endoscope is used. Given the size and depth of the thoracic cavity, long spine surgical instruments were also utilized. Usually, we place intramuscular needles to count vertebras with x-ray. We also use a lumbar puncture needle to localize the exact intrathoracic space, leaving it inside as a reference to find with the endoscope. We approach the patient using portals at the middle and interior axillary lines.
SPEAKER: The first portal is for the camera. We try to find the needle we placed perfectly to localize the correct rib. We follow it medially to reach the exact intervertebral space. You can also count the ribs to ensure the level. With this first portal we can see from inside how we open the others.
SPEAKER: We use a lung retractor to make her feel more comfortable. Once we reach the rib, subperiosteal dissection is performed. In this case, the corresponding rib we aim is the sixth. Next step is to remove a piece of bone from the head of the rib, which we will use as autologous bone graft to achieve the fusion posteriorly.
SPEAKER: Then we direct our attention to the main field and start to make small, thin osteotomes with the bone scalpel. This is a very useful instrument for this kind of surgery, because it can make thin slices of the bone and help us to decompress securely from the side of the bone. We use the bone scalpel, osteotomes, and rongeurs. It is important to make small bone osteotomies in order to minimize the likelihood of neural damage.
SPEAKER: The bone scalpel allows making straight cuts specifically in the bone with a very low risk of harming the spinal cord and/or other soft tissues. We finally arrive to the epidural space and make it wider following the dura.
SPEAKER: Here, during the decompression, we notice a possible durotomy that we are capable to seal it temporarily with Surgicel and a cottonoid patty while we keep opening the space with rongeurs.
SPEAKER: Now we are removing the last bone fragment that is compressing the spinal cord to achieve, finally, a complete decompression. We confirm the decompression with hook. To prevent a CSF leak due to the questionable durotomy, we use TachoSil, Spongostan, and Surgicel.
SPEAKER: We place the bone graft in the intervertebral space. Then we use the bone scalpel to make the initial hole for the screws and tapping. And finally, we put the screws.
SPEAKER: The rod is placed carefully to avoid this loss in the durotic space. If that happens, it can become an issue, as it would be very difficult to find it. The nuts are positioned and adequately torqued. Topic glucose solution is used to create a controlled and localized pleuritis and increase the ceiling of the leak. We insert the drain tube under the direct endoscope vision, keeping in mind not to place it too cranial, as it could cause more pain and cough during postoperative course.
SPEAKER: The postoperative CT scan revealed a complete resection of the hernia and a good decompression. We confirmed that the osteotomy was accurate and sufficient to decompress the spinal cord as we planned at the beginning. The fragment of the rib that was used as a bone graft was correctly placed to achieve fusion. The patient woke with paresthesia in the left leg as a new symptom that almost completely disappeared in the next month.
SPEAKER: The chest tube was removed in the second day. We usually remove it in the first day, but the use of topic glucose can carry a subsequent pleuritis that can lead to a significant pleural effusion-- reason why we kept it for an additional one more day. The patient was discharged on the fifth postoperative day. In the next month after surgery, she also noticed an improvement of her urinary continence.
SPEAKER:
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