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Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.52 no.2 São Paulo June 1994

http://dx.doi.org/10.1590/S0004-282X1994000200013 

A via lateral modificada para a cirurgia da hérnia de disco torácica: nota técnica

 

The modified (extreme) lateral approach to thoracic disc herniation: technical note

 

 

Sandro Rossitti

Departamento de Neurocirurgia, Hospital Sahlgrenska, Göteborg

 

 


RESUMO

A via lateral modificada (extreme lateral approach) para a cirurgia de hérnias de disco torácicas permite a abordagem cirúrgica de discos intervertebrais torácicos sem a mínima retração da medula espinhal e com menor ruptura da anatomia musculo-esquelética, em comparação às técnicas correntes. A técnica cirúrgica é descrita em detalhe. A cirurgia é realizada com o paciente em decúbito ventral. A articulação costotransversal da costela que tem sua inserção ao nível do disco desejado é o ponto de referência para a incisão cutânea. Uma simples incisão cutânea paravertebral transversa de cerca de 5 cm de extensão é suficiente para a operação em um único nível. O disco invertebral é exposto através da remoção de uma extensão de cerca de 5 cm mediais dessa costela, seguida de uma pediculotomia e corpectomia limitada às estruturas ósseas ventrais ao forame intervertebral. As técnicas correntes para a cirurgia de hérnias de disco torácicas são discutidas e comparadas à via lateral modificada. Esta técnica representa um avanço para diminuir a morbidade peroperatória desse tipo de cirurgia, potencialmente com implicações para a estabilidade espinhal a longo termo e prevenção da síndrome dolorosa crônica que por vezes se segue a cirurgia espinhal. Os resultados preliminares em nove pacientes operados com essa técnica são apresentados.

Palavras-chave: coluna torácica, disco intervertebral, doenças espinhais, técnica cirúrgica.


SUMMARY

The thoracic spine may be approached by different ways: posterior, posterolateral, anterolateral and anteriorly, with associated removal of diverse osseous structures as facet joints, costal processes, pedicles and ribs, subsequently imposing the use of diverse fusion procedures in some cases. The extreme lateral approach to the thoracic disc space produces minimum disruption of the normal spinal musculoskeletal anatomy, avoids retraction of the spinal cord and preserves the intercostal neurovascular bundle and the segmental radicular arteries. The operation is carried out with the patient in the prone position, and the patient is rotated away from the surgeon as necessary when the deeper levels are accessed. Radioscopy is used to identify the correct level after positioning of the patient A straight transversal paravertebral incision is recommended in single-level operations. Alternatively an elliptical incision, concave medially and centered at the marked rib, is done and the skin flap is refleted medially. The muscles are partially divided at rigth angles over the rib to be excised and refleted cranial and caudally, exposing the rib and transverse process. The target disc is approached by removal of about 5 cm of the rib which has its insertion at the disc level, if necessary associated with partial removal of the transverse process, followed by partial pediculotomy (exclusively at the base of the pedicle) and a little lateral rachotomy (vertebral body ressection), which permits opening of the spinal canal exclusively ventral to the intervertebral foramen. In this way any kind of hemilaminectomy or facectomy is avoided. The discectomy is then carried out. This is a minimally invasive approach in comparison to the current ones. As the facet joint is preserved and the pedicle just partially removed, a fusion procedure is not necessary. This technique has potentially important consequences for long term spinal stability after multilevel operations. The initial results of nine patients are promising. In this little series up to four disc herniations in the same patient were operated at the same occasion.

Key words: thoracic vertebrae, intervertebral disk, spinal diseases, operative technique.


 

 

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

 

 

REFERÊNCIAS

1. Johnston RA. Neurosurgery of the thoracic spine: a choice of surgical approaches. In Teasdale GM, Miller JD (eds). Current neurosurgery. Edinburgh: Churchill Livingstone 1992, p 185-201.         [ Links ]

2. Rossitti S. The extreme lateral approach to thoracic disc herniations: technique and preliminary results. Neurochirurgia (Stuttgart) 1993, 36:161-163.         [ Links ]

3. Rossitti S. Biomechanics of the pons-cord tract and its enveloping structures: an overview. Acta Neurochir (Wien) 1993, 124: 144-152.         [ Links ]

4. Rossitti S, von Essen C. Den mest laterala approachen vid operation av thorakala diskäck: en beskrivning av operationsteknik. Hygiea 1993,102:259.         [ Links ]

5. Rossitti S, Stephensen H, Ekholm S, von Essen C. The anterior approach to high thoracic (T1-T2) disc herniation. Br J Neurosurg 1993,7:189-192.         [ Links ]

6. Russell T. Thoracic intervertebral disc protrusion: experience of 67 cases and review of the literatura. Br J Neurosurg 1989, 3:153-160.         [ Links ]

 

 

Aceite: 23-novembro-1993.

 

 

Dr. Sandro Rossitti - Neurokirurgiska kliniken, Sahlgrenska sjukhuset - S-413 45 Göteborg - Suécia.