Tag: Posterior approach

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The posterior approach for removal of all thoracic disc herniations

J Neurosurg Spine 44:876–883, 2026

his single-surgeon series evaluates a posterior partial transpedicular approach for symptomatic thoracic disc herniation augmented by intraoperative ultrasound (IOUS) and ultrasonic aspiration (UA). Over 108 patients (137 discs) treated from 2012–2024, the technique produced significant neurological improvement with an acceptable complication and reoperation profile.

The report details patient selection, operative steps, radiographic grading, neuromonitoring use, outcomes (Frankel grade improvements), and multivariate predictors, highlighting the method’s versatility for giant and calcified herniations and its accessibility to general spine surgeons.

Clinical problem Thoracic disc herniation is surgically challenging due to ventral location, frequent calcification, and risk of severe neurologic compromise; anterior/lateral approaches can be effective but carry substantial morbidity and technical demands.

Study aim Evaluated safety, efficacy, and versatility of a posterior partial transpedicular discectomy augmented with intraoperative ultrasound (IOUS) and ultrasonic aspiration (UA) for symptomatic TDH.

Cohort & design Retrospective single-surgeon series of 108 consecutive patients (137 TDHs) treated from 2012–2024; outcomes tracked with Frankel grades preop, 3–6 months, and final follow-up; multivariate regression used to identify predictors of improvement.

Key technique Posterior midline exposure with laminectomy, <50% medial facetectomy, and superomedial caudal pedicle removal using UA to create a corridor; IOUS used after laminectomy, during ventral work, and after resection to confirm decompression and detect residual/migrated fragments; IONM used in all cases.

Case mix severity Most patients presented with myelopathy (86.1%); many discs were giant (>40% stenosis, 68.6%) and frequently calcified (complete 38.7%, incomplete 21.2%).

Neurologic outcomes Mean Frankel grade improved from 3.77 preop to 4.54 at last follow-up (p < 0.001); 61.1% improved by ≥1 Frankel grade; follow-up for the primary outcome was 100%.

Safety & complications IOUS and UA enabled safe decompression in all cases; reoperation-requiring complications occurred in 9.3% (most commonly reherniation 4.6%); no postoperative CSF leaks through the wound were reported.

Predictors & conclusion Less neurologic improvement was associated with diabetes and obesity (and heart disease); overall conclusion: posterior partial transpedicular approach with IOUS and UA is safe, effective, and broadly applicable for TDH (including large/calcified lesions) and can be adopted by general spine surgeons.

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Is achieving optimal spinopelvic parameters necessary to obtain substantial clinical benefit?

J Neurosurg Spine 30:833–838, 2019

It is now well accepted that spinopelvic parameters are correlated with clinical outcomes in adult spinal deformity (ASD). The purpose of this study was to determine whether obtaining optimal spinopelvic alignment was absolutely necessary to achieve a minimum clinically important difference (MCID) or substantial clinical benefit (SCB).

METHODS A multicenter retrospective review of patients who underwent less-invasive surgery for ASD was conducted. Inclusion criteria were age ≥ 18 years and one of the following: coronal Cobb angle > 20°, sagittal vertical axis (SVA) > 5 cm, pelvic tilt (PT) > 20°, or pelvic incidence to lumbar lordosis (PI-LL) mismatch > 10°. A total of 223 patients who were treated with circumferential minimally invasive surgery or hybrid surgery and had a minimum 2-year follow-up were identified. Based on optimal spinopelvic parameters (PI-LL mismatch ± 10° and SVA < 5 cm), patients were divided into aligned (AL) or malaligned (MAL) groups. The primary clinical outcome studied was the Oswestry Disability Index (ODI) score.

RESULTS There were 74 patients in the AL group and 149 patients in the MAL group. Age and body mass index were similar between groups. Although the baseline SVA was similar, PI-LL mismatch (9.9° vs 17.7°, p = 0.002) and PT (19° vs 24.7°, p = 0.001) significantly differed between AL and MAL groups, respectively. As expected postoperatively, the AL and MAL groups differed significantly in PI-LL mismatch (-0.9° vs 13.1°, p < 0.001), PT (14° vs 25.5°, p = 0.001), and SVA (11.8 mm vs 48.3 mm, p < 0.001), respectively. Notably, there was no difference in the proportion of AL or MAL patients in whom an MCID (52.75% vs 61.1%, p > 0.05) or SCB (40.5% vs 46.3%, p > 0.05) was achieved for ODI score, respectively. Similarly, no differences in percentage of patients obtaining an MCID or SCB for visual analog scale back and leg pain score were observed. On multivariate analysis controlling for surgical and preoperative demographic differences, achieving optimal spinopelvic parameters was not associated with achieving an MCID (OR 0.645, 95% CI 0.31–1.33) or an SCB (OR 0.644, 95% CI 0.31–1.35) for ODI score.

CONCLUSIONS Achieving optimal spinopelvic parameters was not a predictor for achieving an MCID or SCB. Since spinopelvic parameters are correlated with clinical outcomes, the authors’ findings suggest that the presently accepted optimal spinopelvic parameters may require modification. Other factors, such as improvement in neurological symptoms and/or segmental instability, also likely impacted the clinical outcomes.

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Surgical consideration of cervical dumbbell tumors

Surgical consideration of cervical dumbbell tumors

Acta Neurochir (2013) 155:1907–1910

Nineteen patients with cervical dumbbell tumors treated surgically were analyzed retrospectively.

Methods Surgical strategies for dumbbell tumor were discussed from the perspective of safe, less-invasive surgery.

Results Patients included 6 men and 13 women, with a mean age at the time of surgery of 48.3 years (range, 25–70 years). Underlying pathologies included 16 schwannomas, 2 neurofibromas, and 1 double tumor (schwannoma and meningioma). According to Eden’s classification, one patient was classified as Type 1, 5 as Type 2, 8 as Type 3, and 5 as Type 4. In 13 cases, tumors were excised through the posterior approach alone, compared to five cases using the anterior approach. One case was excised using combined anterior and posterior approaches. Facetectomy was not performed in 18 cases. In one case, the facet joint on one side had already destroyed and needed instrumentation. Tumors were totally excised in all cases. Postoperatively, the patients did not display any further neurological deficit, with the exception of transient radiculopathy in two patients. Major surgical complications and cerebrospinal fluid leakage were not seen. Tumor recurrence and spinal segmental instability were not found during follow-up period (mean, 41.6 months).

Conclusions Dumbbell tumor surgery requires sufficient debulking of the epidural and paravertebral mass, using intraoperative nerve stimulation and Doppler ultrasonography to detect the vertebral artery. When using a posterior approach, recapping laminoplasty using an ultrasonic bone curette is very useful to remove tumor without sacrificing facet joints.

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