Anterior transthoracic approach

Anterior transthoracic approaches, including thoracoscopic microdiscectomy (TMD), are the preferred techniques for central, broad-based, calcified thoracic disc herniations (TDHs). Dural defects due to manipulation or transdural extension may create a potentially life-threatening subarachnoid-pleural fistula. We evaluate a fast, sutureless technique for reconstructing the dura.

METHODS: We analyzed 476 anterior transthoracic approaches for TDHs (437 TMDs, 31 mini-thoracotomies, 7 transaxillary approaches, and 1 sternotomy). Dural defects were closed using an onlay dura substitute, fibrin glue, an autologous fat graft, and another layer of fibrin glue topped by an absorbable gelatin sponge. A chest tube was used to provide a water seal, and the use of external lumbar drains (ELDs) was discontinued in recent years.

RESULTS: We encountered 35 dural defects (7.35%), including 27 in 279 procedures (9.67%) in the first 10 years and 8 in 197 (4.06%) in the past 6 years. Five defects were large, 23 were relatively small, and 5 had an intact arachnoid layer, likely preventing cerebrospinal fluid (CSF) egress. Two CSF leaks in the early series were overlooked intraoperatively; 1 patient died following widespread cortical venous thrombosis, whereas the other merely had a headache that disappeared within 1 week. Overall, an ELD was inserted in 3 of 5 large defects and in 17 of 23 small defects; however, in the past 6 years, an ELD was inserted in no large defects and in only 1 of 5 small defects. The technique was successful in all but 1 patient, who underwent reoperation using a larger fat graft.

CONCLUSIONS: Dural defects encountered during anterior transthoracic approaches to TDHs can be reconstructed endoscopically, while avoiding the use of an ELD in most cases 1).

Cornips EMJ. Multilayer Dura Reconstruction After Thoracoscopic Microdiscectomy: Technique and Results. World Neurosurg. 2018 Jan;109:e691-e698. doi: 10.1016/j.wneu.2017.10.056. Epub 2017 Oct 20. PubMed PMID: 29061456.
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