1. science
2. medicine
3. surgery

Neurosurg Focus 9 (4):E9, 2000
Treatment of thoracic disc herniation: evolution toward the
minimally invasive thoracoscopic technique
TIMOTHY G. BURKE, M.D., AND ANTHONY J. CAPUTY, M.D.
Department of Neurosurgery, The George Washington University, Washington, DC
Thoracic disc herniation has always carried with it the potential for serious adverse neurological consequences if
not treated appropriately. The authors review the historical evolution of treatment for thoracic disc herniation from the
early surgical series using dorsal approaches (which were known to involve a significant risk of paraplegia) to later
surgical series in which lateral and then ventral approaches to the disc were increasingly emphasized, with significant
improvement in patient outcome.
The evolution of minimally invasive thoracoscopic techniques is discussed, together with the results of several surgical series demonstrating significant reductions in morbidity compared with more traditional methods. The technique
of thoracoscopic discectomy is presented in detail.
KEY WORDS • thoracic spine • herniated disc • thoracoscopic surgery • endoscopy •
minimally invasive surgery
Few disorders have undergone more dramatic changes
in neurosurgical management than thoracic disc herniation and its evolving diagnosis and treatment. A relatively
unusual diagnosis for the neurosurgeon to make, this disorder accounts for approximately five of every 1000 disc
herniations encountered in the clinical setting. The natural history can vary from a chronic pain disorder to sudden
catastrophic neurological compromise.12,13 In 1911, the
first surgical procedure for a herniated thoracic disc was
reported by Middleton and Teacher (as described in Benjamin1); it involved a patient with paraplegia who subsequently died. This dismal outcome was unfortunately not
uncommon for patients with this disorder as recognition
of the disease evolved.
The diagnosis of thoracic disc herniations had always
presented a challenge, especially when based solely on
history and clinical findings. Imaging this region of the
spine, which is contained within the surrounding chest
cavity within a plethora of different tissue densities, is also difficult. Before the introduction of MR imaging, clinicians were limited to the use of plain x-ray film and CT
scanning. Plain films were useful when a calcified protrusion was present; however, although thoracic discs do
have a higher tendency to become calcified than herniated
discs in other vertebral locations, fewer than one half of
these calcifications are evident on plain film studies.1 The
Abbreviations used in this paper: CT = computerized tomography; LECA = lateral extracavitary approach; LPEA = lateral parascapular extrapleural approach; MR = magnetic resonance; VATS =
video-assisted thoracoscopic surgery; 3D = three-dimensional.
Neurosurg. Focus / Volume 9 / October, 2000
advent of myelography and CT myelography dramatically improved the clinician's ability to recognize thoracic
disc disease radiographically. Overall, however, MR imaging is still the first-line modality for imaging the thoracic spine (Fig. 1). In the modern era of diagnostic MR
imaging, the CT myelogram remains an indispensable adjunct in both the diagnosis of herniated disc material and
is equally important in determining exactly which vertebral segment is involved. The risk of performing surgery
at the wrong spinal level is ever present and obliges the
surgeon to be vigilant and definitive in identifying the appropriate surgical level.2,35
As stated earlier, the treatment of herniated thoracic
discs has undergone significant changes since the first surgeries were attempted. Early cases were treated solely via
a dorsal approach and involved a significant risk of causing irreversible paraplegia,12,13 with operative mortalities
approaching 10%.13 As surgeons began to explore alternative techniques that allowed the lateral and ventral surface
of the thecal sac to be exposed, the risk of neurological
injury was reduced dramatically. The last decade has seen
the application of minimally invasive methods to the treatment of thoracic disc herniation; these procedures have
brought about a significant change in the postoperative
care of these patients: critical care requirements and discharge times have been reduced dramatically.14,26,27,29,30,34
The purpose of this report is to review the evolution that
has taken place in the treatment of thoracic disc herniation, with special attention to improvements in anatomical
approaches and advances in technology. Special emphasis
will be given to the technique of thoracoscopic surgery for
disc herniation.
1
T. G. Burke, and A. J. Caputy
niation was thought to be due to a combination of vascular insufficiency and microcontusions secondary to spinal
cord manipulation.37
Posterolateral Approaches
Fig. 1. Sagittal T2-weighted MR image of a herniated thoracic
disc with spinal cord compression at T-7. Note that the identity of
the spinal level cannot be absolutely confirmed from this study; it
is inferred by the marking. A myelogram is usually obtained to
confirm the level precisely.
HISTORY OF SURGERY FOR THORACIC DISC
HERNIATION
Dorsal Approaches
Early treatment options for spinal cord compression
from disc herniation were limited to simple laminectomy.
The first known case of a surgically treated disc herniation
was reported in 1922 by Adson (as described by Zeidman,
et al.,37) who performed laminectomy and disc removal.
Mixter and Barr25 reported three cases of ruptured thoracic disc herniations in 1934. Two of these patients developed postoperative transverse myelopathy, and the other
was only mildly improved after some time (see Zeidman,
et al.,37 for historical review). The results of many other
early dorsal approach procedures for herniated discs were
typical equally dismal.12,13 In a pivotal paper published in
1952, Logue19 reported the results of surgery in a series of
11 patients: three postoperative cases of paraplegia, two
deaths, and two cases of mild improvement after a temporary increased motor weakness. In 1969, Perot and Munro29 reviewed 91 cases from the literature on herniated
thoracic discs, all treated by dorsal approaches. Exceptionally, Horwitz, et al.,14 reported good outcomes in five
consecutive cases of herniated thoracic discs treated using
a dorsal approach.
Many variations in surgical technique were applied in
these early cases. Some surgeons advocated simply performing a decompression without disc removal to avoid
the potentially harmful effects of spinal cord manipulation
required to reach the ventrally located disc herniation. The
opposite extreme was to attempt to reach the disc material via an intradural approach that involved sectioning the
dentate ligaments with adjunctive rhizotomy.13,14 It was
believed that this approach permitted improved ventral
visualization. The significant rate of postoperative neurological deficits after laminectomy for thoracic disc her2
To avoid spinal cord manipulation, many surgeons began to look for approaches that would allow a more direct
approach to the disc space.
As with many of the surgical techniques that have been
applied to the thoracic spine, the costotransversectomy
bears its roots in the treatment of Pott's disease. In 1894,
Ménard24 first described the use of this technique to reach
the vertebral body via an expleural route. In 1958 Hulme15
used costotransversectomy to treat thoracic disc herniation. The use of rib resection and removal of the transverse
process in this approach provides a significantly more
ventral window than that of laminectomy or later transpedicular techniques.
In 1978, Patterson and Arbit (as mentioned in Zeidman,
et al.,37) described an approach involving removal of the
entire pedicle and facet, which provided a more direct line
of exposure to the ventrally located disc space. This transpedicular approach evolved from recognition of the high
morbidity rates associated with treating thoracic discs by
using laminectomy, along with pulmonary and various
other complications found with the alternative lateral and
ventral surgical approaches to the thoracic spine. It should
be noted that the degree of anterolateral exposure afforded by the transpedicular approach, although much improved over that of simple laminectomy, is still limited
compared with the more extensive lateral and ventral exposures. This exposure is particularly important when
treating a disc that is calcified or located in the midline. In
the original series of Patterson and Arbit,28 all patients presented with myelopathy and reportedly made uniformly
good recoveries.
A potential advantage to the transpedicular approach
over costotransversectomy, transthoracic, and LECAs is
that it entails no damage to the radicular vessels. The possible adverse effect of sectioning these vessels has long
been a concern for many surgeons. It is well established
that the thoracic spinal cord is a watershed vascular zone.
The artery of Adamkiewicz (arteria magna radicularis)
usually arises on the left side at T8–L2.31 Based on this
anatomical fact, some surgeons have suggested obtaining
an angiogram if the possibility exists for any division of
left-sided thoracic radicular vessels.5,14,21 Mansour, et al.,22
reported an interesting case in which a patient suffered
from a Brown–Séquard syndrome from a left-sided lateral disc herniation at T9–10, with only radicular compression. The site happened also to be the location of the artery
of Adamkiewicz in this patient, and thus the disc herniation was presumed to be the cause of a vascular event.
Continuing efforts to improve the exposure of the
ventral surface of the spinal cord led to use of the LECA
for herniated thoracic discs. Capener4 first developed this
technique for the treatment of tuberculous spondylitis;
it was later applied to thoracolumbar fractures. This approach provided the following advantages over other
methods for accessing the thoracic and thoracolumbar
spine. 1) It afforded excellent ventral exposure of the cord.
2) It was a completely extrapleural procedure. 3) It proNeurosurg. Focus / Volume 9 / October, 2000
Surgical treatment of thoracic disc herniation
vided surgeons with the ability to span both the thorax and
abdomen without taking down the diaphragm. Maiman, et
al.,21 used the LECA for thoracic disc herniation in 23
cases, and none of their patients experienced new deficits
postoperatively. On the other hand, this approach has significant shortcomings. It requires exceptionally extensive
soft-tissue dissection and manipulation. More seriously,
the paraspinous muscles are mobilized medially, thus denervating and devascularizing these structures. This may
contribute to poor wound healing and an increased risk for
postoperative kyphosis. With this approach it may still
be very difficult to remove intradural disc fragments, although in their series, Maiman, et al., did not find this to
be the case.
The LPEA, developed by Fessler and colleagues9 provides exposure of the upper thoracic spine comparable to
that provided by the LECA. The major additional risk entailed by this procedure compared with the LECA is that
of significant shoulder girdle problems, due to the fact the
scapula is mobilized in a lateral direction.
Ventral Approaches
Use of a transpleural approach to the thoracic spine for
disc herniation dates to 1958, when Crafoord, et al.,6 reported the use of this technique in a patient with a herniated disc. In 1969, Perot and Munro29 reported the use of
this technique for thoracic disc herniation in two patients.
In that same year, Ransohoff and Spencer30 reported on
three patients with thoracic disc herniations treated with a
transthoracic approach. Since the appearance of these two
pivotal reports, there have been several series3,26,27 supporting the efficacy of this approach. Anatomically, it provides unparalleled ventral exposure of the spinal cord,
which not only creates a safe working channel adjacent to
the spinal cord but also provides the optimal angle for
removal of intradural discs and for dural repair. It also permits multiple levels to be addressed via the same approach
if required. The obvious disadvantage to the transpleural
approach is the risk of pulmonary morbidity. Risk of
injury to major vascular vascular and visceral structures
is also present. The initial postoperative days are also
marked by a considerable amount of pain secondary to the
thoracotomy approach and presence of a chest tube. It
should also be noted that this technique is limited to treatment of the T-5 disc space or below.
techniques (see biographical articles by Gow10,11 and Jennings16). Thoracic surgeons recognized the potential advantages of a minimally invasive technique for biopsy and
drainage procedures compared with the currently available open technique, which involved significant risk of
morbidity to the patient. In 1991 Lewis18 reported the use
of VATS, which quickly proved to be a viable approach.
Soon various centers were attempting increasingly complex procedures, including lung-lesion resections. Landreneau, et al.,17 reported on 106 such cases in 1993, in which
he compared VATS with thoracotomy. The patients who
underwent VATS suffered less pain and had improved pulmonary function and superior shoulder girdle function
compared with thoracotomy patients. In the same year,
Mack, et al.,20 published a report demonstrating the potential of VATS to provide a reliable route to the ventral
surface of the thoracic spine. In 1995 Caputy, et al.,5 demonstrated the successful use of VATS in performing a thoracic discectomy in both a cadaver and porcine model. In
that same paper a clinical case of a thoracoscopic discectomy was also reported. Although thoracoscopy was well
established in the field of thoracic surgery, the practicality
of its use in spine surgery remained in question. The rapid
development and availability of special long instruments
has facilitated the application of thoracoscopic spine techniques (Fig. 2).
Several large series have since been published demonstrating the efficacy of VATS and the reduced morbidity
associated with its use when compared with traditional
open approaches.8,23,32,36 Note that although the benefit of
VATS is usually compared only with the alternative of
thoractomy, some data suggest that it is also a less morbid procedure than costotransversectomy. Rosenthal and
Dickman32 reported on a series of 55 patients who underwent thoracoscopic discectomy; they compared the rate
of complications between thoracotomy patients and costotranversectomy patients with thoracic disc herniation.
There were no instances of postoperative neurological
deterioration in either the thoracoscopy or thoracotomy
groups, but of those patients undergoing costotransversectomy, 7% experienced neurological deficits after surgery.
Intercostal neuralgia, both temporary and permanent, has
long been a significant problem associated with thoracotomy. The use of VATS has significantly reduced the incidence of this painful disorder, which frequently prevents
Thoracoscopic Approach
The advantages of a minimally invasive ventral approach to the treatment of thoracic disc herniations
seemed obvious. Today, most spine surgeons would agree
that a ventral approach is most appropriate for anything
other than a far-lateral disc herniation.1,29,30,33 The main
obstacle to using the ventral approach was the associated
morbidity of a thoracotomy. Patients were obliged to
spend several days in the intensive care unit, undergo thoracostomy drainage, and experience significant postoperative pain. Intercostal neuralgia, both temporary and permanent, is also a potential drawback associated with this
technique.
The dramatically improved optics and lighting of rigid
glass endoscopes, developed by physicist Harold Hopkins
in 1970, nurtured the rapid growth of endoscopic surgical
Neurosurg. Focus / Volume 9 / October, 2000
Fig. 2. Photograph of three types of endoscopic drills. Cutting
and rough-diamond burrs (bottom) are displayed. Long protective
outer shafts minimize the risk of injury to other tissues.
3
T. G. Burke, and A. J. Caputy
Fig. 3. Artist's illustration showing the proposed setup of the
operative suite for a thoracoscopic discectomy. The spine and cardiothoracic surgeons stand to the ventral side of the patient while
the assistant is positioned on the dorsal side. Two video monitors
are always used. The patient is in the lateral decubitus position.
patients from resuming their normal levels of activity. In
the series reported by Rosenthal and Dickman, there was
a 16% rate of intercostal neuralgia in the VATS group
compared with 50% in those patients who had a thoracotomy. In all patients in the thoracoscopic groups with intercostal neuralgia, the condition was temporary and resolved completely within 1 to 2 weeks. In those patients
undergoing a costotransversectomy there was a 20% rate
of intercostal neuralgia.
A major criticism of minimally invasive surgery is the
increase in the total amount of time that usually is involved in such procedures. Although it is certainly true
that VATS takes longer than the transpedicular approach,
this is not necessarily the case when compared with the
alternative ventral approach, that is, the thoracotomy. In
our experience with the performance of VATS for thoracic
disc herniations, the mean operation time has been 260
minutes (unpublished data). In their group of 55 patients,
Rosenthal and Dickman32 reported a mean operation time
of 205 minutes. In thoracotomy patients the mean surgical
time was 268 minutes, and those undergoing costotranversectomy spent an average of 280 minutes in the operating room. An additional concern regarding the current
trend toward minimally invasive procedures is that the
overall effectiveness of the procedure is jeopardized. If the
patient is spared a painful and potentially morbidity-inducing thoracotomy only to undergo an endoscopic technique that leaves the pathology unresolved, then treatment
has certainly failed. Rosenthal and Dickman examined the
rate of retained disc fragments in those patients undergoing VATS, thoracotomy, and costotranversectomy, and
found that in the thoracotomy group there were no instances of retained fragments, whereas in the thoracoscopy group 4% of patients retained incompletely removed fragments. Costotranversectomy yielded a retained
disc fragment rate of 13%. In 1999, Dickman, et al.,8 reported on a group of 15 patients who had undergone surgery for herniated thoracic discs and were found to have
4
Fig. 4. Photograph showing the operative suite setup during a
case of thoracoscopic discectomy. A 3D endoscopic system is
shown in this paricular case. Note the liquid crystal display 3D
glasses.
retained fragments. Eleven of these patients had previously undergone a posterolateral approach, one had undergone a thoracotomy, and three had undergone VATS. The
vast majority of these lesions were calcified. Thoracoscopic techniques were used for reoperation in all but one
patient, who required a thoractomy.
From the above information, it appears that VATS provides a very effective method of treating thoracic disc disease, including reoperative situations.8 Although the data
suggest that thoracotomy may provide a slight decrease in
the rate of retained disc fragments, the significant difference in postoperative morbidity between these two procedures seems to support the use of a thoracoscopic approach.
Description of Endoscopic Technique
Patient Position and Operating Room Setup. The lateral decubitus position is used with the operative side up,
unless the pathology is distinctly to the right; in that case
the left side of the thorax is preferred due to the location
of the inferior vena cava on the right. The patient is secured to the operating table with three-in tape; security is
tested by rolling the table from side to side before the
patient is prepared and draped. The spine surgeon and cardiothoracic assistant work on the ventral side of the patient, while the second assistant is positioned at the dorsal
side. Two video monitors are positioned, one on each side
of the patient's head (Figs. 3 and 4).
Localization of Operative Level. An x-ray film may be
obtained after patient positioning is completed to assist in
optimal port placement. Alternatively, the ports may be
positioned followed by placement of a long bovie tip in
the estimated disc space by counting from the first rib,
which lies adjacent to the subclavian artery and underneath a pad of fat (Fig. 5). Proper placement of the operative ports is particularly important to ensure that awkward
angles are not created for the surgical instruments. It is
also important to avoid placing ports too close together;
Neurosurg. Focus / Volume 9 / October, 2000
Surgical treatment of thoracic disc herniation
Fig. 5. Endoscopic intrathoracic view in a cadaver demonstrating the rib-counting method to identify the operative level. The first
rib is typically hidden under the subclavian fat pad (SC). The second rib (2) is usually easily identified.
this creates a frustrating situation in which the surgeon's
instruments tend to make contact with the shaft of either
the endoscope or the suctioning device.32
Port Placement and Exploratory Thoracoscopy. A
small skin incision is made toward the superior border of
the caudal rib at the desired level to avoid damaging the
neurovascular bundle of the cephalad rib. A Kelly clamp
is used to enter the pleural cavity, being careful not to injure the underlying lung. The first port is placed, and this
helps the surgeon visualize additional port placement. For
a standard discectomy, three ports are typically used. The
use of soft rubber ports has recently become popular, in
the belief that they have less tendency to traumatize the
intercostal nerve. It is not yet known whether the incidence of postoperative intercostal neuralgia has actually
been reduced by the use of these devices. At this point, the
chest surgeon explores the thoracic cavity and takes down
any pleural adhesions. The patient is then rolled ventrally
to allow the lung to fall away from the vertebral column.
If this maneuver is not adequate to expose the vertebral
structures, the anesthesiologist may be asked to attempt
further deflation of the ipsilateral lung. Lung retraction
may need to augmented by the use of a special fan retractor, although we frequently find that the aforementioned
techniques suffice (Fig. 6).
Rib Resection. Once the operative level has been confirmed with certainty, the pleura over the disc space and
proximal rib is incised. The segmental vessels are typically dissected and ligated with hemoclips, then cut with special endoscopically-guided cautery scissors. The pleura is
then mobilized from the rib head by an endoscopic Cobb
Fig. 6. Photograph of a thoracoscopic lung fan retractor, which
is used to facilitate exposure of the spinal column if lung deflation
is not sufficient.
Neurosurg. Focus / Volume 9 / October, 2000
Fig. 7. Intraoperative photograph demonstrating the use of the
rough-cutting diamond burr to remove the rib head. The action of
the diamond burr is to minimize bleeding while still providing a
cutting burr for more aggressive bone removal. Only the very end
of the rotating shaft and burr are exposed from the protective sheath.
elevator. During our early experience with the procedure,
the rib was typically removed in a 2- to 3-cm en bloc segment and saved for potential grafting. The current technique involves drilling the proximal 2 cm of the rib head
with a rough-cut diamond burr (Midas Rex, Fort Worth,
TX) (Fig. 7 and Video Clip 1). The diamond bit serves to
control bone bleeding significantly, thereby improving
visualization.
Click here to view Video Clip 1.
Video Clip 1. Thoracoscopic view of removal of the T-9 pedicle for a heavily calcified T8–9 herniated disc. The rib head has
already been removed with the use of a drill. The use of the roughcutting diamond bit can be seen to minimize the amount of bone
bleeding encountered. A medium-sized hemoclip can be seen at the
bottom of the screen on a previously divided segmental vessel. The
pulsations of the heart can also be seen.
Pedicle Removal. The next step is to view a normal segment of the thecal sac. This is accomplished by a combination of drilling and application of Kerrison rongeurs.
Bleeding from the epidural plexus is frequently encountered at this point, but is easily controlled with bipolar
cautery or Avitene (Davol, Kalamazoo, MI).
Creating a Working Trough. To prevent causing anatomical deformity or vascular compromise in the spinal
cord, a pyramid-shaped space is created ventral to the spinal cord by removing a portion of both the cephalad and
caudal vertebral body with the drill (Fig. 8). Once this
space is created, the disc material is pulled away from the
thecal sac into this cavity (Video Clip 2). Throughout the
procedure the disc is pulled away from the spinal cord and
thus no instruments are placed in the canal. The amount of
bone removed is dictated by the extent of the disc herniation. One must always remove enough of the vertebral
body to be able to visualize normal dura on both sides of
the disc herniation. For large calcified discs, something
akin to a partial corpectomy is performed. Generous vertebral body resection is also performed when an intradural fragment is found. Instability has not been a problem
in this procedure, and a graft is usually not placed.
5
T. G. Burke, and A. J. Caputy
Fig. 9. Intraoperative photograph of a thoracoscopic procedure
demonstrating the exposed and decompressed thecal sac (white
arrow).
Fig. 8. Postoperative 3D CT scan demonstrating bone removal
needed to perform adequately a thoracic discectomy. The rib head
has been removed. It can also be seen that the cephalad portion of
the caudal pedicle has been removed to expose the lateral aspect of
the thecal sac. A significant cavity has been created in the vertebral
bodies of the two adjacent levels. This cavity provides a working
trough that allows the surgeon to pull disc material away from the
spinal canal, thus avoiding compression of the spinal cord.
Click here to view Video Clip 2.
Video Clip 2. A partial corpectomy, or working trough, has
been previously created with the use of the drill. A portion of the
calcified disc material has been decompressed from the spinal canal by pulling the disc away from the cord into the trough. An endoscopically-guided pituitary rongeur is used to remove a remaining
disc fragment. The decompressed thecal sac is seen.
Discectomy. After the vertebral body is fully resected,
the disc material may be safely pulled away from the spinal cord into the working trough (Video Clip 3). The decompressed canal must be palpated along the contralateral pedicle with a long probe (Fig. 9 and Video Clip 4) to
check for any residual intradural fragment; if found, this
should be carefully removed while dissecting the disc
from the pia and arachnoid with a microdissector. The dura is then sealed with a tissue patch and fibrin glue. A lumbar drain is placed postoperatively. It is also recommended that the chest tube be placed on water seal, rather than
suctioned.32
Click here to view Video Clip 3.
Video Clip 3. A thoracoscopic curette is seen being used to pull
remaining calcified disc material into the working trough. The exposed lateral portion of the dura is clearly seen. This exposure is
obtained by previous removal of the rib head and pedicle.
Click here to view Video Clip 4.
Video Clip 4. A straight probe is used to palpate across to the
contralateral pedicle along the ventral surface of the decompressed
thecal sac. This is done to assure that no remaining portion of herniated disc material is left behind. Again the motion of the heart
can be seen in the bottom portion of the screen.
Any remaining bleeding is then controlled by Gelfoam
with thrombin and Avitene. The pleural cavity is then irrigated with a copious amount of antibiotic solution, which
is then suctioned out. A single chest tube is implanted; in
most cases this remains in place for 24 hours.
6
The Learning Curve
The procedure used to access and treat lesions of the
thoracic spine with the aid of endoscopic guidance entails
the use of techniques that may be foreign to most spine
surgeons. Becoming familiar with the hand–eye coordination required to manipulate the endoscope takes many
hours before real agility is achieved. Becoming comfortable with the use of extremely long instruments also requires practice.
The authors believe strongly that it is the duty of academic programs to take the initiative in teaching both residents in training and surgeons in the surrounding community the new and evolving techniques, as well as to
provide an environment for continued development of
competency. At the George Washington University, for
example, the neurosurgical residency program has developed structured training sessions in the endoscopic laboratory using live porcine models to train residents in thoracosopic techniques before they attempt them in the
clinical environment (Fig. 10). This has provided an invaluable experience for the safe and effective teaching of a
demanding surgical technique. The authors hope that others will emulate this model for the education of others in
the field.
CONCLUSIONS
The surgical treatment of few disorders has undergone
as dramatic an evolution as that of thoracic disc herniation. From an era in which surgery incurred significant
mortality and dramatic morbidity rates, the field has progressed to the point where effective procedures are viewed
as routine, with significant improvements in patient
outcome.
Continued advances in technique, surgical instrumentation, and endoscopic technology have suggested that the
future may hold continued improvements for the treatment of this potentially devastating disorder. There are
now many published reports of minimally invasive endoscopic surgery for the treatment of other disorders of
the thoracic spine and neuraxis, such as tumors, as well as
for placement of instrumentation.7 While such advances
Neurosurg. Focus / Volume 9 / October, 2000
Surgical treatment of thoracic disc herniation
Fig. 10. Photograph of the porcine endoscopic surgical laboratory at The George Washington University. This facility is dedicated to the education of surgeons in various endoscopic surgical
techniques. It provides an invaluable resource for teaching thoracoscopic spine surgery in a safe and effective manner.
should be viewed as welcome, their safety and efficacy
must also be subjected to critical review before they can
be accepted into the spine surgeon's armamentarium.
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Manuscript received August 17, 2000.
Accepted in final form September 11, 2000.
Address reprint requests to: Timothy G. Burke, M.D., Department of Neurosurgery, The George Washington University, 2150
Pennsylvania Avenue, NW, Suite 7-450, Washington, DC 20037.
email: timburke@gwu.edu.
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