If you have a thoracic disc herniation, you are very unique. The frequency of symptomatic thoracic disc herniation is between one in a thousand to one in a million people.
If the disc herniation occurs in the thoracic spine, it either compresses the nerve, the spinal cord or both. If the disc fragment pinches a spinal nerve, it typically causes pain that spreads from the spine towards the chest or abdomen (belly). This condition is frequently called a thoracic radiculopathy. If the disc fragment compresses the spinal cord, this leads to spinal cord dysfunction, most typically hallmarked by loss of function in the legs, and, in rare conditions, bowel and bladder dysfunction. When this occurs, it is called thoracic myelopathy.
When these conditions are severe, and there is clear compression on imaging (such as MRI or CT), surgery often is the best solution. Unfortunately, because of the position of the thoracic spine in between the lungs and protected by the ribs, traditional (open) surgical approaches to the thoracic spine are particularly challenging and often destructive. Even worse, many of the disc herniations in the thoracic spine calcify, or turn into bone. Many surgeons frequently decline to perform thoracic surgery because of these challenges.
Fortunately, endoscopic techniques reduce the invasiveness of the surgery. By miniaturizing the surgical approach, we are able to maximize the discectomy while reducing the collateral damage of the approach to the thoracic spine. This is the case even with calcified thoracic disc herniations.
Reasons for Thoracic Discectomy Surgery
A thoracic discectomy is primarily recommended for patients with a symptomatic herniated disc in the mid-back that has not responded to conservative treatments like medication, physical therapy, or injections.
- Thoracic Disc Herniation: Herniated or protruded discs in the thoracic spine can compress nerve roots or the spinal cord, resulting in pain, numbness, weakness, or even paralysis.
- Thoracic Radiculopathy: Compression of thoracic nerve roots leads to radiating pain along the rib cage, chest, or abdomen.
- Thoracic Myelopathy: Compression of the spinal cord can cause gait disturbances, lower limb weakness, numbness, and bowel or bladder dysfunction.
- Progressive Neurological Deficits: Worsening neurological symptoms or loss of function may necessitate surgical intervention.
Symptoms Indicating a Need for Surgery:
Endoscopic discectomy is a cutting-edge surgical technique aimed at treating herniated or damaged discs in the spine. The procedure involves the use of an endoscope, a thin tube equipped with a light and camera, which is inserted through a small incision to access the affected disc. We remove the herniated portion of the disc, relieving pressure on the spinal nerves and alleviating pain, weakness, or numbness.
Benefits of Endoscopic Thoracic Discectomy Surgery
- Ultra-Minimally Invasive: Small incisions (typically 6–8 mm) minimize tissue disruption, blood loss, and scarring.
- Less Postoperative Pain: The small incision and minimal access reduces trauma to the spinal muscles, which is the most common and obvious source for surgery-related pain.
- Outpatient Procedure: Many cases are performed in an outpatient setting, allowing for same-day discharge or short, overnight stays.
- Faster Recovery: Patients usually experience less postoperative pain and quicker return to normal activities compared to traditional open surgery. Open surgeries for thoracic disc herniations may involve a chest splitting procedure known as a thoracotomy -which requires extensive recovery.
- Preservation of Spinal Stability: The approach avoids destabilizing the spine, so fusion and instrumentation are often unnecessary.
- Reduced Complications: Lower risk of infection, blood loss, and other complications associated with open thoracic surgery.
- Precise visualization: Advanced endoscopic equipment provides enhanced visualization for precise removal of disc material.
Details of the Endoscopic Thoracic Discectomy Procedure
The primary goal of the surgery is to create more space for the spinal cord and nerve roots, thereby relieving the compression that is causing the symptoms.
Anesthesia: Because the surgery is located in the thoracic spine and requires very fine, detailed and meticulous surgical steps, it is generally a requirement for the surgery to be performed under general anesthesia.
Preparation: You are positioned comfortably lying face down. Imaging, which refers to X-rays or fluoroscopy, is used to correctly locate the spinal level (vertebrae) where the stenosis is located. Because the endoscopic approach solely focuses on the problem (and is not exploratory), we are ultra-precise in planning.
Incision: A small incision (about 6-7 mm, for approximately width of your pinky fingernail) is made in the skin at the level of the affected spinal level. A tube is inserted through this incision, and the endoscope is carefully navigated to the narrowed spinal level.
Visualization: The endoscope provides beautiful images of the spinal elements, including the nerves, joints, ligamentum flavum and lamina. The edge of the spinal joint and often some of the vertebral body is carefully sculpted away using a very small drill. The thoracic disc fragments are pushed down and away from the spinal cord and then removed.
Closure: The instruments and endoscope are removed, and the skin is closed with tiny dissolving sutures.
Risks and Potential Complications
Like any surgical procedure, endoscopic decompression carries risks, though these are generally lower than those associated with open surgery. Some of the potential complications include:
Incomplete relief of symptoms: Sometimes, particularly with severe spinal cord compression or longstanding symptoms, the spinal cord does not recover. Often, in these situations, our goal is to prevent further worsening -rather than reverse the consequences of time. Nevertheless, some individuals are disappointed that we cannot resolve all pain, weakness, or numbness that occurred from spinal cord injury.
Need for revision surgery: Sometimes thoracic discs can recur (reherniate). We discuss this risk upfront, as every patient is unique. Sometimes, larger surgeries are necessary, particularly when there are larger anatomical problems leading to the spinal cord compression.
Infection: Although rare, infection at the incision site or deeper in the spine can occur. In our series, only 1 patient of approximately 1,200 patients had an infection2 , which occurred after swimming. We therefore recommend avoiding submersion, including pools, hot tubs, and bathtubs, until 1 month after surgery
Bleeding: While the endoscopic approach minimizes bleeding3 , there is still a small risk of bleeding after the surgery -which may also require revision surgery.
Dural tear: The use of irrigation and endoscopy reduces the incidence (frequency of occurrence) of inadvertent tears of the spinal fluid membrane, also known as dura mater. In certain cases, there are adhesions to the dura, such as calcified thoracic disc, which greatly increases the likelihood of an unavoidable and unintentional tearing of the dura (incidental durotomy). Because the tools are smaller with an endoscopic approach, durotomies tend to be smaller.
Spinal cord or nerve Injury: Because this is a technically complex surgery, there is a remote risk of damaging the compressed spinal cord or nerves during the surgery, which could result in weakness, numbness and/or new pain. Fortunately, in most cases, any worsening in function usually recovers with time.
Anesthesia-related complications: Adverse reactions to the anesthesia. The risks of your anesthesia are reviewed with you by our anesthesia team immediately prior to surgery. In some cases, when individuals have multiple medical problems, we may ask you to see our anesthesiologists prior to surgery to make the best plans.
Need for Conversion to Another Surgery: In unforeseen circumstances, our team may need to convert to a traditional open surgical approach during the procedure. This is exceptionally rare.
Medical complications: These are problems that are independent of the surgery, but may occur because in association with surgery. For example, blood clot may form in the legs (deep vein thrombosis – DVT) or lungs (pulmonary embolism – PE) if you are not moving much after surgery. Other examples include: opioid or other pain medication problems, such as drug dependence or addiction, bowel obstruction, etc.
It is important to understand risk factors are often patient-specific, and that we will provide our best estimate of your risks – not generalized estimates.
What to Expect After Surgery
After the procedure, you will spend a short period in a recovery area to allow the sedating medications to wear off, and most can go home the same day.
Postoperative Care: You may experience mild discomfort or soreness at the incision site, which is typically managed with anti-inflammatory pain medications.
Activity Restrictions: Initially, you may be advised to avoid strenuous activities, such as lifting heavy objects or excessive neck activity, for a few weeks to allow your body to heal.
Physical Therapy: A physical therapy program may be recommended to strengthen the muscles around the spine and improve mobility. Everyone tends to do well with a coach helping them out to achieve their goals.
Follow-up Appointments: a 6 week follow-up appointment is set prior to surgery. Additional follow-up appointments are established to assess the success of the surgery, additional needs or other considerations. Imaging tests, such as MRI or X-rays, may be used to confirm that the stenosis has been adequately removed and that no further issues are present.
Recovery and Long-Term Outlook
Recovery from endoscopic decompression is typically quicker compared to traditional open spinal surgery. Many patients report a significant reduction in pain and an improved ability to perform daily activities within a few weeks. However, full recovery may take several months as the body continues to heal.
While most patients achieve lasting relief, it’s important to maintain a healthy lifestyle, engage in regular exercise, and avoid activities that could strain the spine to reduce the risk of future problems.
