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08.05.2020 | How I Do it - Spine degenerative | Ausgabe 9/2020

Acta Neurochirurgica 9/2020

How I do it: posterior transdural approach for central soft thoracic disk herniation

Zeitschrift:
Acta Neurochirurgica > Ausgabe 9/2020
Autoren:
Carlo Mandelli, Alfio Spina, Francesco Calvanese, Pietro Mortini
Wichtige Hinweise

Electronic supplementary material

The online version of this article (https://​doi.​org/​10.​1007/​s00701-020-04387-6) contains supplementary material, which is available to authorized users.
Carlo Mandelli and Alfio Spina contributed equally to this work.
This article is part of the Topical Collection on Spine degenerative

Key Points

1. Due to its rarity, make sure to determine the correct diagnosis of TDH through different examinations, such as careful neurological testing, thoracic CT and MRI imaging studies, and neurophysiological studies.
2. The PTA seems less invasive than other described techniques.
3. We do not recommend PTA for calcified TDH.
4. In this technical variant, the drilling of the omolateral caudal pedicle and transverse process allows a more lateral displacement of the dural flap gaining a wider intradural surgical corridor.
5. The PTA for central soft TDH avoids tractions over a “closed” dural sac. During extradural posterolateral thoracic approaches, mild traction to the dural sac can reduce spinal cord blood flow in an already suffering tissue, increasing morbidity.
6. Plenty cerebrospinal fluid drainage after dural opening in PTA is a key point for spinal cord protection.
7. Adequate blood pressure control during surgery is mandatory to reduce the risk of further spinal cord hypoxia due to hypotension.
8. It is not necessary to close the anterior portion of the dura mater after TDH removal because of its natural tight adhesion to the anterior anatomic structures and the consequent low risk of leak [4]. Spinal fusion is usually not needed.
9. Neurosurgeons are more confident with transdural approaches, and a short learning curve is required [2].
10. Compared with other techniques, in transdural approaches to TDH, a lower rate of postoperative severe complications has been reported, and patients are able to start the rehabilitation program few days after surgery [2, 4].

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Abstract

Background

Thoracic disc herniation (TDH) is a rare condition with severe neurological sequelae. Surgical management is still a matter of debate and challenging.

Method

We present a modification of the transdural approach for TDH. The approach has been described in a stepwise fashion, analysing pre-, peri-, and postoperative strategies to improve patients’ management and reduce approach-related morbidity.

Conclusion

The modified posterior transdural approach represents an effective technique for TDH, minimizing the risk of spinal cord damages, which can dramatically affect the outcome.

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