Technical modifications and decision-making to reduce morbidity in thoracic disc surgery: An institutional experience and treatment algorithm

• Thoracic disc herniation is a rare condition with significant treatment risks.
• We review our complications the past decade as approach and technique have evolved.
• Several strategies were effective at preventing and managing complications.
• Tubular retractors facilitated safe dissection with low access-related morbidity.
• Thoracoscopy protected the lung and great vessels during retractor placement.

BackgroundSymptomatic thoracic disc herniation (TDH) is an uncommon condition with significant treatment risks.ObjectiveTo evaluate strategies to avoid and manage complications from thoracic disc surgery.MethodsAll TDH cases by the senior author were retrospectively reviewed from 2000 to 2012. Complications were recorded, together with avoidance and management strategies. To reduce access-related morbidity, a thoracoscopic-tubular retractor approach was developed later in the series.Results64 patients were treated for TDH, the majority undergoing an anterior minimally-invasive approach. Complications occurred in 15 patients (23%). Three patients with intercostal neuralgia persisting for >3 months had pain resolution after intercostal nerve blocks and radiofrequency lesioning. Five of the six patients with dural tears during anterior surgery had no further events following dural repair, lumbar drain insertion, and placement of chest tube to water seal. One case of persistent CSF leakage was successfully treated with a laparoscopically-mobilized omental flap. Preoperative metallic marker placement was effective at guiding correct-level surgery. For anterior operations, no pneumothorax occurred with routine chest tube placement. Our approach and techniques evolved based on early experience, allowing us to reduce surgical morbidity. The thoracoscopic-tubular retractor approach was associated with low morbidity (no complications among 13 cases other than temporary intercostal neuralgia).ConclusionsSeveral strategies may reduce morbidity from thoracic disc surgery: careful approach selection, preoperative level marking, use a tubular retractor with thoracoscopic guidance, rib resection at the mini-thoracotomy site, routine chest tube placement for anterior operations, and routine lumbar drain insertion in the event of a dural tear. Prospective comparative studies are needed to assess the efficacy of these techniques.