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Transthoracic removal of herniated disc

Procedure description

A transthoracic removal of a herniated disc is an operation which requires the assistance of a cardiothoracic surgeon.  Thoracic discs account for only  0.5% of all herniated discs, due to the rigidity of the thoracic spine and rib cage.  These can be linked to a history of trauma in only 25% of cases.  We focus here on the transthoracic approach (an approach from the side, often with the removal of a rib, to facilitate approach to the spine).  Generally, a thoracic surgeon makes the approach (unless the neurosurgeon is very familiar with the thoracic anatomy).  The patient is brought to the operating room, and placed in a lateral position (on the patient's side).  Care is taken to ensure that all "bony" areas are well protected, to prevent pressure sores.  The thoracic surgeon will incise over the side of the chest, parallel to the ribs.  Often, a rib will need to be removed, in order to provide exposure.  A "rib spreader" retractor is placed within the wound, and opened.  The lung is now seen, and it must be "collapsed" intentionally, in order to allow the surgeon an unobstructed view of the spine.  The anesthesiologist may use an endotracheal tube which can selectively pass oxygen to each lung independently, allowing him to collapse a lung.  Retractors are gently placed over the lungs, with wet sponges to protect the lung.  After removing the pleura (membrane lining the chest cavity) overlying the spine, the neurosurgeon now takes over the operation.  He will incise into the disc, and remove the portion pressing on the nerve root or spinal cord.  If necessary, some or all of the vertebral body above and below will also be removed.  Depending on the amount of bone removed, the stability of the spine, and the intraoperative judgement of the surgeon, a fusion may or may not be performed, with bone graft and instrumentation.  Often, spinal cord monitoring may be used during the case, depending upon the degree of spinal cord compression and the judgement of the surgeon.  After this portion of the procedure is accomplished, the thoracic surgeon will generally closed the chest cavity.  A drain will usually be placed to help re-expand the  lung, and this will remain in for one or more days. 

 

Procedure Risks

Transthoracic discectomy is quite an involved surgery, performed much less frequently than lumbar or cervical discectomies.  Although great care is taken by the team of experienced neurosurgical and cardiothoracic experts, there are risks.  These can be broken down into two categories, 1) those related to the operative site, and 2) those related to the risks of anesthesia. 

Risks related to the operative site: 

Surgical Exposure:  The patient is placed in a lateral position (on their side).  The cardiovascular surgeon performs the approach to the spine, through the chest cavity, by opening up the rib cage.  There are risks of injury to the lungs, the heart, the esophagus, the trachea ( windpipe), as well as the great vessels (large arteries and veins, such as the aorta and vena cava).  There may be injury to the intercostal nerves (sensory nerves which lie between the ribs), resulting in rib pain. 

Spinal Cord/Nerve Root injuries: If there is any injury to the spinal cord in the thoracic area, this  could result in paralysis of the lower extremities, as well as loss of bowel, bladder and sexual function.     There may be a spinal fluid leak, which could occur after a tear of the covering of the spinal cord or nerve roots.  If this persisted, it could result in the chest cavity filling with spinal fluid, and it  may necessitate additional surgery.  If instrumentation such as screws, rods, and plates are placed, these have a small chance of breaking or pulling out.    There is a small chance of causing instability with the discectomy. 

General Risks:  These include such general difficulties, such as bleeding, infection, stroke, paralysis, coma and death.  Incisions on chest cavity generally heal well, but if could   be tender, or may heal in an unpleasant manner, with scarring.  There is also the possibility that the surgery may not relieve the symptoms for which the procedure was performed.  The problem for which the surgery was performed may recur, requiring additional surgery in the future.  In addition, although every attempt is made to protect all areas of the body from pressure on nerves, skin and bones, injuries to these areas can occur, particularly with prolonged cases.

Risks of Anesthesia: Blood clots in the legs, heart attacks, reaction to the anesthetic, reaction to blood transfusion, if  given.

 

Post-operative care:

There shall be no bending, twisting, or heavy lifting for several weeks after surgery.  Physical therapy may or may not be implicated.  Your doctor will gradually ease your work restrictions, depending on your progress. 

Remember to keep the wound dry and clean.  Notify your surgeon of any drainage or temperatures greater than 101 Fahrenheit.

The goal of this surgery was to relieve the pressure on the nerves and/or spinal cord  in your back.  The healing process is a long one, particularly if a fusion with a bone graft was performed.    Some continuuing back  pain is not unusual during the first few days and weeks following surgery.  Hurt does not necessarily mean harm.   The following is a list of suggestions that should help speed your recovery and give you every possible chance for the best results from your surgery.

  1. Immediately upon discharge, contact our office and set up an appointment for staple removal if one has not already been set up.
  2. Take it easy until seen by the physician.  This does not mean bed rest, but athletic activities during this period are definitely not recommended.  Please give your incision a chance to heal.  Avoid bending.
  3. If your surgeon has prescribed for you a brace or corset, make sure to wear it when you are out of bed.  It will help to support your spine while your own bone is healing.
  4. Lift nothing heavier than a half gallon of milk until seen by your doctor.
  5. Avoid sitting for periods of time longer than 45 minutes.  It is OK to sit in a lounge chair which is laid back, for as long as you wish.
  6. No jogging or running.
  7. After you get home, you may begin walking up to one mile per day.
  8. You may walk up or down steps as often as you like.  Please take them smoothly and slowly.
  9. No driving until OK with your physician.  Do not ride further than  50 miles at a time.  This applies during the first month after surgery.
  10. You may shower after you go home unless otherwise instructed.  Cover the incision with plastic wrap before the shower and remove it afterward.  Change dressing immediately.  Tub baths are not advisable.  You may shower without covering the incision one week after the staples are out.  Follow instructions concerning care of tapestrips, stitches or staples.  Your surgeon or his nurse clinician will explain the techniques used in the closure of your incision.
  11. Sexual activities are permitted.
  12. If you notice swelling, redness or opening of the incision, or if there is any clear fluid draining from it, please contact your surgeon immediately!  If you develop a fever, stiff neck or chills, contact the office immediately.  Take your temperature at 4:00 PM daily until the clips are removed.  Call in greater than 101 degrees Fahrenheit.
  13. If you have any questions, call our office, and for after hours emergencies, call the medical society.
  14. Take your medications prescribed on discharge, as directed.
  15. It takes 6 - 18 months for a nerve to heal.  During that time you may experience numbness, tingling, fleeting pain, or creepy/crawly sensations.
  16. If there has been spinal cord damage due to long term spinal cord compression, it may take 1-2 years for an improvement, and often, improvement will be very limited, if it does occur at all.
  17. If you have had a fusion, make sure you don't smoke, as this decreases the likelihood of a successful fusion

 

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