Percutaneous Laser Discectomy In Thoracic Disc Herniation

Read printer friendly
 Subscribe in a reader

Share with others

 

P.P.M. Menchetti M.D., F.R.C.S. (US)
Orthopaedic Surgeon
Florence University

Address:
Italy

W. Bini M.D., F.R.C.S. (US)
Neurosurgeon


Address:
Seligenstadt
Germany

F. Menotti M.D.
Orthopaedic Surgeon


Address:
Florence
Italy

Citation: P. Menchetti, W. Bini & F. Menotti : Percutaneous Laser Discectomy In Thoracic Disc Herniation . The Internet Journal of Minimally Invasive Spinal Technology. 2008 Supplement I - to IJMIST Vol 1 No 2

Introduction

The symptomatic thoracic disc herniation is a quite rare pathology; one person per million per year suffers for this desease, and it's only 0.25-0.75% of all disc herniations; the most common affected levels are T9- T12, with a male predominance, the average age is 40-60 and the 37% of patiences have a past trauma in their history.¹,². Several treatments like open surgery and mininvasive procedures have been performed during the years. In order to minimize the invasive approach to the thoracic spine, permitting the best preservation of the anatomy, Percutaneos Laser Discectomy has been performed in thoracic disc herniation. The possibility to treat percutaneously thoracic spine under CT-Scan, appears to give the best resolution of the pathology, avoiding general anesthesia with a lower risk of potential respiratory, neurological and infective complications³,⁴,⁵,⁹. A 980 nm Diode (Biolitec AG™) Laser energy introduced via a 21G needle under CT-Scan guidance and local anesthesia, vaporizes a small amount of nucleous polposus with a reduction of volume of the disc (closed hydraulic space) by a shrinkage and a relief of pressure on nerve root with disappearance of pain due to the disc protrusion pressing against the nerve root ⁶.

Material And Method

Eight patients, six males and two females, affected by an image documented and symptomatic thoracic disc herniation, have been treated. They were unresponsive to conservative treatment for at least 3-6 months on average. The level involved in 3 cases was T10-T11 (38%), in 2 cases T11-T12 (24%) and in 3 cases T12-L1 (38%), and the average age was 45 (35 – 56). The exclusion criteria have been a free disc fragment, cause disc herniation must be in contact with the parent disc in order to obtain a reduction of pressure on the nerve root, peridural scar entrapment by previous surgical approach (even if a previous surgery does no t contraindicate the treatment), severe spondylosis with osteophytes and calcifications of the posterior spinal ligament. Finally very important the patient involvement in surgical decision, according with the north American spine society clinical guidelines.

The procedure, approved by International Society of Laser Assisted Spine Surgery (ISLASS, www.islass.org ) protocol, has been performed under multi slices CT-Scan guidance (64 Slices)⁷ (fig.1). Laser Decompression has been performed via a 21 G needle inserted percoutanousely into the herniated disc under a e.v sedation, local anesthesia and antibiotical profilaxis. The total Laser energy delivered was of an average of 1000 Joules, in pulsed - 3 sec – wave, 8 Watt powered. A specific Diode Laser 980nm (Biolitec AG), and a dedicated 400 µm optical fiber (NA 0.22) has been used. A smoke evacuation system specifically designed and worldwide patented (Menchetti's handpiece) connected to the needle permits to eliminate the gas formation during the treatment, by reducing the postoperative muscle contracture with relative pain.

Results

A retrospective clinical evaluation at an average follow up of 12 months, have been performed by applying the Macnab's criteria ⁸(tab. 1). The Excellent/Good results (according to Mcnab) were 82%, the Fair results were 14% and Poor were 4%. No significant difference (p < 0.05) related to sex, age, disc level and symptoms duration was found. No postoperative treatment was delivered into the discs Laser Decompressed and no disc has been treated in a second step surgical way. Under CT-Scan guidance no complication occurred.

Figure 1: The procedure under CT scan guidance

Figure 2: CT scan view in three different planes with a 3D reconstrucion

Conclusions

In conclusion percutaneous Laser Discectomy under multi slices CT-Scan, is a valid surgical choice in the management of symptomathic thoracic disc herniations.

It's a safe alternative to microsurgery or endoscopy, permitting a minimal invasive approach to thoracic spine with a better preservation of the anatomy, avoiding general anesthesia and potential infective, neurological an pulmonary complications in thoracic spine surgery.

Moreover, a secondstep microsurgery is not precluded, if needed.

Corresponding Author

Pier Paolo M. Menchetti, M.D., F.R.C.S. (US)
Villa Cherubini Clinic, Via Cherubini, 8 – 50132 Florence – Italy
Fax : +39 055 2347266; e-mail: [ppm.menchetti@libero.it]

References

1. Stillerman et al. Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg. 1998 Apr;88(4):623-33. (s)

2. Morgan et al. herniation at T1-2. Report of four cases and literature review. J Neurosurg. 1998 Jan;88(1):148-50. (s)

3. Watanabe et al. Complications of endoscopic spinal surgery: a retrospective study of thoracoscopy and retroperitoneoscopy. J Orthop Sci. 2007 Jan;12(1):42-8. Epub 2007 Jan 31. (s)

4. Ozgen et al. Treatment of the subarachnoid-pleural fistula. Case report. Neurosurg Focus. 2000 Jul 15;9(1):ecp1 (s)

5. Takeuchi et al. Thoracic paraplegia due to missed thoracic compressive lesions after lumbar spinal decompression surgery. Report of three cases. J Neurosurg. 2004 Jan;100(1 Suppl Spine):71-4 (s)

6. Case R.B.C., Choy D.S., Altman P., : Intervertebral disc pressure as a function of fluid volume infused. J.Clin. Laser Med. Surg., 13, 143-147, 1985 (s)

7. Yonezawa T., Onomura T., et al.: The system and procedures of percutaneous intradiscal laser nucleotomy. Spine; 15(11): 1175-85, 1990. (s)

8. Black et al. : Percutaneous laser disc decompression in treatment of discogenic back pain. Photo Med Laser Surgery; 22(5): 431-3 2004 oct. (s)

9. Choy et al.: Percutaneous laser disc decompression: a 17 yrs experience. Photo Med Laser Surgery; 22(5): 407-10 2004 (s)

This article was last modified on Fri, 13 Feb 09 13:44:14 -0600

This page was generated on Sun, 21 Mar 10 06:18:10 -0500, and may be cached.