ORIGINAL ARTICLE

Surgical Approaches for the Treatment of

Thoracic Disk Herniation
Results of a Decision Analysis
Nikhil R. Nayak, MD,* Joel A. Bauman, MD,w Sherman C. Stein, MD,* Jayesh P. Thawani, MD,*
and Neil R. Malhotra, MD*

Study Design: A decision analysis.

Objective: To perform a decision analysis utilizing postoperative
complication data, in conjunction with health-related quality of
life (HRQoL) utility scores, to rank order the average health
utility associated with various surgical approaches used to treat
symptomatic thoracic disk herniation (TDH).
Summary of Background Data: Symptomatic TDH is an uncommon entity accounting for <1% of all symptomatic herniated disks. A variety of surgical approaches have been
developed for its treatment, which may be classied into 4 major
categories: open anterolateral transthoracic, minimally invasive
anterolateral thoracoscopic, posterior, and lateral. These treatments have varying risk/benet proles, but there is still no
set algorithm for choosing an approach in cases with multiple
surgical options.
Methods: We searched Medline, EMBASE, and the Cochrane
Library for relevant articles on surgical approaches for TDHs
published between 1990 and August 2014. Pooled complication
data and HRQoL utility scores associated with each complication were evaluated using standard meta-analytic techniques to
determine which surgical approach resulted in the highest
average HRQoL.
Results: Posterior surgical approaches resulted in the highest
average HRQoL, followed by thoracoscopic, lateral, and nally
open anterolateral transthoracic procedures. The higher average
HRQoL associated with posterior approaches over all others
was highly signicant (P < 0.001); conversely, the open anterolateral approach resulted in a lower average postoperative
utility compared with all other approaches (P < 0.001).
Conclusions: The results of this decision analysis favor posterior
over lateral approaches, and thoracoscopic over open anterolateral approaches for the treatment of symptomatic TDHs,
Received for publication January 28, 2015; accepted February 25, 2016.
From the *Department of Neurosurgery, Hospital of the University of
Pennsylvania, Philadelphia, PA; and wHartford Healthcare Medical
GroupNeurosurgery, Hartford, CT.
The authors declare no conict of interest.
Reprints: Neil R. Malhotra, MD, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce Street,
3 Silverstein Pavilion, Philadelphia, PA 19104
(e-mail: neil.malhotra@uphs.upenn.edu).
Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.

Clin Spine Surg

Volume 00, Number 00, 2016

which may guide surgeons in cases where multiple surgical options are feasible. Future studies, such as randomized clinical
trials, are necessary to ascertain whether novel surgical strategies
have risk/benet proles that ultimately supersede those of
traditional approaches, and whether enough cases are encountered by the average surgeon to justify their adoption.
Key Words: thoracic disk herniation, decision analysis, qualityof-life, HRQoL, thoracic discectomy
(Clin Spine Surg 2016;00:000000)

ymptomatic thoracic disk herniation (TDH) is an

uncommon pathology accounting for <1% of all
symptomatic herniated disks and occurs most commonly
between the fourth and sixth decades.13 Given the added
stability from the ribs and sternum, TDHs tend to occur
at more caudal segments, where the thoracic spine has
increased mobility.1 Because most providers of spine
careincluding primary care physicians, pain management specialists, and spine surgeonshave limited experience with symptomatic TDHs, the disease is often
difficult to diagnose and treat. Moreover, the low numbers of patients that most providers encounter over a
career have led to small case series and a paucity of
outcomes data aside from standard surgical metrics, such
as blood loss and operative time.
TDHs are usually asymptomatic, incidental ndings, with 10%15% of the population harboring
asymptomatic lesions based on cadaveric and imaging
studies.47 When symptomatic, they most commonly
present with axial back pain, radiculopathy, and/or signs
and symptoms of myelopathy. They may also present
with more insidious, vague symptoms, leading to misdiagnosis or delayed diagnosis. The 2 most common indications for surgery are significant or progressive
myelopathy, and radiculopathy resistant to nonoperative
treatments, although the specific choice of surgical approach has long been a source of debate.
The foremost challenge in the surgical treatment of
TDH is the inability to manipulate the thoracic spinal
cord due to its high susceptibility to mechanical trauma
and ischemic injury. In addition, many TDHs are highly
calcied with signicant adhesions between the disk
www.clinicalspinesurgery.com |

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Nayak et al

material and dura, making dissection and removal of the

calcied disk material technically challenging. Despite the
infrequency of the disease, a variety of surgical approaches have been developed which, for the purposes of
this study, may be classied into 4 major categories: open
anterolateral transthoracic, minimally invasive anterolateral thoracoscopic, posterior, and lateral.
The initial surgical treatment of TDH was through
laminectomy with transdural excision of the herniated
disk, although the procedure has long since been abandoned due to unacceptably high rates of morbidity and
mortality.4,8,9 Since then, posterior and lateral approaches have expanded considerably and now primarily
consist of the transpedicular, costotransversectomy, and
lateral extracavitary techniques.1013 Anterolateral transthoracic-based approaches were developed to improve
visualization of the disk space, particularly for central
TDHs, and minimize direct contact with the spinal cord.
A partial manubriectomy or transsternal approach may
be used to access the upper thoracic spine, and thoracotomy/transpleural techniques are used for mid-thoracic and low-thoracic lesions. To some surgeons, open
transthoracic/transpleural approaches became the gold
standard of TDH surgery.14,15 Finally, in an attempt to
minimize surgical morbidity, video-assisted thoracoscopic
surgery (VATS) was developed as a less invasive alternative to open transthoracic surgery.1620 Although this
approach has reduced complications, it has not eliminated them, and its steep learning curve has remained a
deterrent to widespread adoption.
The 4 broad categories of surgical approaches have
variable risk/benet proles, and it is important to note
that the choice of approach is largely guided by the location and consistency of the TDH. For example, central,
highly calcied TDHs are generally approached through
open transthoracic or thoracoscopic techniques, as these
approaches provide direct visualization of the disk space
and vertebral bodies, and have been perceived to allow
safer removal of the adherent disk material with less
manipulation of the spinal cord. In contrast, soft, paracentral or lateral TDHs are frequently approached
through posterolateral approaches because these approaches are more familiar to most spine surgeons and do
not require the services of an access surgeon.
Although the heterogeneity associated with TDHs
make situations of true clinical equipoise uncertain, there
are certainly cases in which multiple surgical approaches
may be used for a given pathology. Current decision
making is frequently based on an individual surgeons
training and experience, partly because of a lack of reliable data on which to base decisions. Most published
series are either very small or describe the results of a
single surgical approach. Furthermore, the majority of
studies on TDHs have poorly recorded outcome data in
an already rare pathology, particularly with regard to
patient-reported outcomes. In instances where outcome
data are available, typically only 2 approaches have been
directly compared, and despite head-to-head comparison,
there has generally been nonrandom assignment of

2 | www.clinicalspinesurgery.com

Volume 00, Number 00, 2016

patients with regard to surgical approach. In addition,

most series on TDHs report classic surgical metrics such
as blood loss, operative time, and neurologic status rather
than functional outcomes, such as disability (eg, Oswestry
Disability Index) and health-related quality of life
(HRQoL) utility scores, which are highly dependent on
complications and postoperative sequelae not necessarily
reected in most reported metrics.
To provide further evidence for surgical decision
making, the goal of this study was to perform a decision
analysis utilizing postoperative complication data from
the published literature to determine the average HRQoL
associated with the various surgical approaches for
treating symptomatic TDHs.

MATERIALS AND METHODS

We searched Medline, EMBASE, and the Cochrane
online databases for articles containing the key words
intervertebral disk displacement and the word thoracic
in the text. We limited our search to English language articles
published between 1990 and August 2014. We also supplemented the search by using the Related Articles feature of
PubMed and by manually searching the bibliographies of
selected articles. We excluded series involving <10 operated
cases. Articles were divided into those in which the operative
approach was open anterolateral transthoracic (both traditional and mini-open transpleural), anterolateral thoracoscopic, posterior (transpedicular, transfacet, transforaminal,
laminectomy), and lateral (costotransversectomy, lateral extracavitary, other retropleural). At least 2 authors reviewed
each article to obtain pooled data for the evidence tables,
from which we calculated the probabilities of the various
treatment outcomes. We also searched MedLine for articles
on the HRQoL associated with complications of surgery and
other possible outcomes.
We created a decision-analytic model using standard
procedures to compare the open anterolateral transthoracic,
thoracoscopic, posterior, and lateral approaches.21 Our
primary analysis involved calculating likely outcomes following dierent approaches for discectomy. Possible pathways and outcomes after surgery are illustrated in Figure 1.
Separate subtrees (not illustrated) were created to calculate
the expected probabilities and HRQoL scores of patients
suering nonfatal complications. Patients may require reexploration for inadequate discectomy or other complications, such as postoperative spinal instability. The second
operation further impacts HRQoL and may also be associated with additional perioperative complications. Dural
tears were considered to aect HRQoL only if a second
operation was required for repair. For the purposes of
calculating complication rates, articles were included only if
the individual complications were noted. If an article mentioned that no cases of a particular complication had occurred, the incidence was noted as zero for that series.
Observational data were pooled meta-analytically using an
inverse variance-weighted, random eects model.22 Data
pooling followed the guidelines of the meta-analysis of
observational studies in epidemiology group.23
Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Volume 00, Number 00, 2016

FIGURE 1. Decision tree, outlining possible outcomes following surgery for thoracic disk herniation. The probability of
complications varies with operative approach, as do the
overall effects of complications on quality of life.

Analyses of the model used TreeAge Pro 2012 (Tree

Age Software Inc., Williamstown, MA). Sensitivity
analysis was performed using a 2-dimensional Monte
Carlo simulation (expected value for 100 simulated trials,
each made up of 100 microsimulations).24 Outcome
comparisons among the 4 approaches used analysis of
variance (ANOVA) with Bonferroni correction for multiple comparisons. Meta-analytic pooling used the metan
function of Stata (v. 12; StataCorp, College Station, TX).
Dierences for which the probability was <0.05 were
considered signicant.

RESULTS
Our online search of treatment reports yielded 880
abstracts, of which 707 were discarded as unsuitable because of language and topics such as diagnosis or thoracic
disks in animals. This left 173 articles, which we downloaded and reviewed. Figure 2 illustrates the assessment
of the literature that resulted in 39 articles (several of
which report >1 approach), totaling 1319 cases, used to
obtain data listed in Table 1. Multiple operative approaches are included in the Posterior and Lateral
categories. If 1 particular approach was predominant in a
given report, it is listed in the Notes column. We
omitted any article reporting multiple approaches but not
separating outcomes by approach. As none of the series,
including those comparing multiple approaches, involve
randomized trials, they can all be considered level III
evidence.60 For measures of preference-based quality of
Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Thoracic Disk Decision Analysis

FIGURE 2. Summary of literature search. Numbers of articles

found and reasons for elimination of unsuitable reports are
listed.

life, we chose reports covering the various complications

and outcome possibilities, which are detailed in Table 2.
A number of scales are available to quantitatively assess
the preferences of patients or potential patients for various health-related outcomes, including those used in
Table 2.21
Pooled mean estimates of the probabilities of outcomes associated with each of the 4 approaches are
summarized in Table 3. For the purposes of this study, we
dened major respiratory complications as pneumonia,
respiratory failure, chylothorax, hemothorax, or other
complications requiring prolonged endotracheal intubation or prolonged chest tube drainage. Reoperations
were limited to cases in which a second procedure was
needed to address inadequate disk excision, postoperative
spinal instability, persistent CSF stula, etc. Inadvertent
dural or pleural tears repaired during the initial surgery
were excluded from the list of complications or reoperations, as were wound revisions or resuturing.
The expected HRQoL for the average patient for
each procedure is shown in Table 4. These dierences are
highly signicant (F = 911.9, P < 0.001). The higher postoperative HRQoL associated with posterior approaches
over all others was highly signicant (P < 0.001). Similarly,
the open anterolateral approach resulted in a lower average
postoperative HRQoL compared with all other approaches
(P < 0.001). There were no signicant dierences in outcome between the thoracoscopic and lateral approaches
(P = 0.257).
www.clinicalspinesurgery.com |

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Nayak et al

Volume 00, Number 00, 2016

TABLE 1. Thoracic Disk Surgical Series Used in the Analysis

References

Year

Study Type

Approach

Technique

# Cases

Anand and Regan16

Arnold et al25
Arts and Bartels26
Arts and Bartels26
Ayhan et al27
Bilsky28
Borm et al29
Bransford et al14
Cerillo et al30
Chi et al31
Choi et al32
Currier et al33
Delni et al34
Dinh et al35
El-Kalliny et al36
El-Kalliny et al36
El-Kalliny et al36
Fujimura et al37
Gille et al38
Hur et al39
Khoo et al40
Khoo et al40
Korovessis et al41
Le Roux et al11
Levi et al42
Lidar et al43
Moran et al44
Nacar et al45
Nie and Liu46
Nishimura et al47
Ohnishi et al48
Oppenlander et al49
Oskouian and Johnson50
Quint et al51
Regev et al52
Ridenour et al53
Ridenour et al53
Ridenour et al53
Simpson et al54
Singounas et al55
Smith et al56
Stillerman and Weiss57
Uribe et al58
Wait et al20
Wait et al20
Yang et al59

2002
2011
2014
2014
2010
2000
2011
2010
2002
2008
2010
1994
1996
2001
1991
1991
1991
1997
2006
2014
2011
2011
1997
1993
1999
2006
2012
2013
2013
2014
2005
2013
2005
2012
2012
1993
1993
1993
1993
1992
2013
1992
2012
2012
2012
2014

Pro
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Pro
Ret
Pro
Ret
Ret
Pro
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Pro
Pro
Pro
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Ret
Pro
Pro
Ret

Anterior
Posterior
Posterior
Anterior
Anterior
Posterior
Posterior
Posterior
Lateral
Posterior
Posterior
Anterior
Lateral
Lateral
Posterior
Posterior
Anterior
Lateral
Anterior
Anterior
Lateral
Anterior
Anterior
Posterior
Posterior
Lateral
Lateral
Lateral
Posterior
Posterior
Anterior
Posterior
Anterior
Anterior
Posterior
Posterior
Posterior
Lateral
Lateral
Lateral
Posterior
Anterior
Anterior
Anterior
Anterior
Posterior

Thoracoscopy
Posterior transfacet
Posterior transpedicular
Mini-open thoracotomy
Thoracotomy
Transpedicular
Various (mostly transpedicular/transfacet)
Transfacet
Lateral paravertebral retropleural
Transpedicular
Transforaminal endoscopic
Thoracotomy
Lateral extracavitary
Transcostovertebral junction
Transpedicular, transfacet
Costotransversectomy
Thoracotomy
Anterolateral retropleural
Thoracoscopy
Thoracoscopy
Lateral extracavitary
Thoracotomy
Thoracotomy
Transpedicular
Transpedicular
Lateral extracavitary
Lateral retropleural
25 transpleural, 8 retropleural
Posterior MIS endoscopic transforaminal
Posterior transfacet (pedicle sparing)
Thoracotomy
Posterolateral
Thoracoscopy
Thoracoscopy
Posterior MIS transforaminal
Laminectomy
Transpedicular
Costotransversectomy
Costotransversectomy, transpedicular
10 costotransversectomy, 4 lateral
Posterolateral microendoscopic
Thoracotomy
Mini-open thoracotomy
Thoracotomy
Thoracoscopy
Posterior transfacet

117
15
44
56
27
20
27
18
23
11
14
19
20
22
8
5
8
33
18
10
13
11
12
20
35
10
17
33
13
16
12
13
46
167
12
4
12
15
21
14
16
51
60
39
121
29

Pro indicates prospective; Ret, retrospective.

DISCUSSION
Symptomatic TDH is a surgical disease with a
dearth of evidence on which to base decisions in cases
with multiple surgical options. Results of our decision
analysis comparing open anterolateral transthoracic,
anterolateral thoracoscopic, posterior, and lateral approaches suggest posterior approaches result in the
highest HRQoL, as determined by complication data
from the published literature. The thoracoscopic approach results in the next highest HRQoL, closely followed by lateral approaches, and lastly open anterolateral
transthoracic procedures.
The most common posterior approach currently
used is the transpedicular approach. It was rst described
in 1978 to access anterolateral to the thecal sac and is

4 | www.clinicalspinesurgery.com

used primarily for lateral or paracentral TDHs.66 The

approach is appealing to many spine surgeons due to
familiarity with the regional anatomy and techniques for
removal of the herniated disk. Because most TDHs are
central, attempts at central discectomy through the
transpedicular approach is often performed without direct visualization of the disk or thecal sac. A bilateral
transfacet approach has been described to improve visualization anterior to the thecal sac, although some surgeons believe that complete facetectomies may cause
long-term instability, even in the thoracic spine, and
should be treated with upfront instrumented xation/fusion.14 This analysis indicates that rates of neurological
complications using the transpedicular approach are
exceedingly small.
Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Volume 00, Number 00, 2016

Thoracic Disk Decision Analysis

TABLE 2. Preference-based Quality of Life Associated With Various Treatment Outcomes

Outcome

Average QOL

SD

Scale Used

References

1.0
0.928
0.928
0.926
0.95
0.915
0.71
0.695
0.67
0

0
0.179
0.154
0.156
0
0.167
0.23
0.28
0.13
0

Consensus
SG
SG
SG
SG
SG
SG
VAS
EQ
Consensus

Sox et al21
Lega et al61
Lega et al 61
Lega et al 61
Danish et al62
Lega et al 61
King et al63
Sarna et al64
Gautschi et al65
Sox et al21

Successful surgical result

Wound dehiscence/infection
Sepsis
Pulmonary emboli
Deep vein thrombosis
Reoperation
Paraparesis
Postthoracotomy type pain
Paraplegia
Perioperative death

EQ indicates EuroQol; QOL, quality of life; SG, standard gamble, VAS, visual analog scale.

The costotransversectomy is a posterolateral approach originally described to drain a paraspinal abscess,

but has now become a standard technique to treat
TDHs.67 It is performed either in the prone or lateral
decubitus positions, and the transverse process and
proximal segment of the posterior rib are removed to
access the pedicle and disk space. Visualization of the
midline anterior thecal sac is generally improved compared with the transpedicular approach but still limited,
presenting technical challenges for removal of central and
calcied disks. In addition, given the resection of rib, the
pleura and neurovascular bundle, including the radicular
arteries supplying the spinal cord, are placed at risk.
Despite familiar positioning, the extended bony resection
and additional thoracic anatomy may be unfamiliar for
many spine surgeons.
The lateral extracavitary approach represents an
extension of the costotransversectomy and was rst described as a modication of the lateral rhacotomy.68 This
procedure requires further lateral exposure and greater
rib resection than the costotransversectomy, but aims to
provide more midline visualization than the preceding
posterior approaches. Consequently, it is generally perceived to be safer for the removal of central, calcied
disks. However, this approach may be limited at the upper thoracic levels due to a narrowed thoracic inlet, the
mediastinum, and great vessels, as well as at the lower
thoracic spine due to the diaphragm.

To overcome the limited visualization and technical

challenges associated with calcied ventral TDHs, the
transthoracic technique for TDHs was rst described by
Hulme10 in 1960 and revisited by Perot and Munro69 and
Ransoho et al70 in 1969 using a standard anterolateral
thoracotomy with transpleural corridor. While visualization of the disk and vertebral bodies are improved, this
approach also exposes other critical structures such as the
lungs, great vessels, radicular arteries, lymphatic system,
and sympathetic chain, any of which may be damaged
during the procedure. In addition, double-lumen intubation with deation of the ipsilateral lung and postoperative chest tube placement is required. However,
initial published series using the transthoracic/transpleural approach were promising, with low rates of
postoperative neurological deterioration and virtually no
mortality.71
These early surgical outcomes led some surgeons to
recommend the transthoracic approach for virtually all
TDHs.71 However, based on the thoracic surgery literature,
postthoracotomy pain syndrome is a common entity, seen
in approximately 50% of patients postoperatively, including 30% at 45 years of follow-up.72 Hence, modern case
series began to focus attention on complications related to
pain and pulmonary issues, rather than just traditional
surgical metrics. Early meta-analyses found that morbidity
associated with transthoracic procedures were similar
to those for posterior approaches, although aggregate

TABLE 3. Complications and Reoperation Rates (%)

Posterior
Approach/Complications
Number operated
Perioperative death
All nonfatal complications
Paraplegia
Paresis
Neuralgic pain
Wound infection
Sepsis
Pneumonia and other respiratory
Deep vein thrombosis
Pulmonary emboli
Reoperation

Copyright

Mean

Lateral

SD

Mean

327
0
4.0
0.3
1.8
0.0
1.8
0.0
0.0
0.0
0.0
2.4

Anterolateral Transthoracic
SD

Mean

193
0
1.1
0.3
0.7
0.0
0.7
0.0
0.0
0.0
0.0
0.9

0.5
11.5
0.0
2.1
0.5
1.0
0.0
6.3
0.5
0.5
2.1

2016 Wolters Kluwer Health, Inc. All rights reserved.

SD

Thoracoscopic
Mean

335
0.5
2.3
0.0
1.0
0.5
0.7
0.0
1.7
0.5
0.5
1.0

2.1
22.5
0.0
0.7
13.8
0.9
0.0
3.2
0.9
0.7
4.0

SD
464

0.7
2.0
0.0
0.4
1.7
0.5
0.0
0.8
0.5
0.4
0.9

0.0
11.7
0.0
0.4
3.2
0.0
0.0
8.0
0.0
0.0
14.8

0.0
1.5
0.0
0.3
0.8
0.0
0.0
1.3
0.0
0.0
1.7

www.clinicalspinesurgery.com |

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Nayak et al

TABLE 4. Outcome by Approach: Overall Quality of Life

Quality of Life
Approach

Mean

SD

Posterior
Thoracoscopic
Lateral
Anterolateral transthoracic

0.9911
0.9771
0.9744
0.9192

0.0037
0.0049
0.0072
0.0173

numbers of patients for each technique were limited and

many of the cases examined were published before 1990.73
More recently, minimally invasive approaches have
ourished, including thoracoscopic and mini-open transthoracic techniques. Thoracoscopic techniques aim to
minimize surgical morbidity related to pulmonary sequelae and pain, and multiple series have demonstrated
favorable surgical metrics associated with VATS compared with its open counterpart.49 However, these procedures may be unfamiliar to many neurosurgeons,
require the assistance of an access surgeon, and generally
present a steep learning curve. In addition, VATS can be
technically challenging because the skill set applied to
open procedures is not necessarily transposable to VATS
procedures, such as with regard to hemostasis or durotomy repair.
The largest series on VATS for TDHs was published
by Quint et al,51 reviewing 167 patients presenting with
single-level TDHs, the majority of which were soft disk
herniations (58%). They found an overall complication
rate of 15.6%, most of which were related to intercostal
neuralgia lasting up to 6 weeks. However, several patients
required further procedures: 3 patients needed reoperation for incomplete decompression, 2 required reoperation to repair durotomies, 3 required subsequent spinal
fusion for instability, and 4 underwent intervention for
pulmonary complications (2 pneumothoraces requiring
repeat chest tube placement and 2 symptomatic pleural
eusions requiring drainage). The results suggest that
despite the potential advantages of thoracoscopy, the
anterior approach in and of itself may pose inherent
complications that ultimately result in inferior outcomes.
Notably, postthoracotomy pain seems to signicantly
aect quality of life and is not avoided by thoracoscopy.
With respect to respiratory complications, the advantage
of thoracoscopy may be counteracted by the necessity of
double-lumen, single-lung ventilation.
Mini-open approaches include both transpleural
and retropleural techniques. Particularly promising is the
retropleural approach, which does not require an access
surgeon and limits potential complications associated
with traversing the thoracic cavity. This approach retains
the working angles and techniques associated with traditional open approaches and may obviate the need for
double-lumen ventilation, which theoretically decreases
the risk of postoperative pulmonary complications. The
largest series on the mini-open approach was published
by Uribe et al58 in 2012 describing 60 patients, 55% of
whom harbored calcied disk herniations. Seven durotomies were encountered, all of which were repaired in-

6 | www.clinicalspinesurgery.com

Volume 00, Number 00, 2016

traoperatively without further sequelae. About 80% of

patients had good-to-excellent long-term results, and
15% had fair results or no improvement. Of the 4 major
complications, 2 were related to pulmonary issues, 1 was
related to infection, and 1 was related to neurological
deterioration.
The results of our study and the larger series detailed above indicate that pain and/or pulmonary complications are the leading drivers of diminished HRQoL
following surgery for symptomatic TDH. The incidence
of neurological deterioration in modern series is
extremely small, although higher in the posterior and
lateral groups than the open and thoracoscopic anterolateral groups.
There are multiple limitations in the methodology
of the present study. First, the HRQoL data presented in
this study are derived through proxy use of surgical
complications rather than directly from the patient. In
addition, the values assigned to each complication were
obtained from disparate resources and are not specic to
the TDH health state. Therefore, the utility values presented overestimate the overall HRQoL when compared
with the spine surgery literature examining patient-reported outcomes and cannot be compared with those in
the literature derived from HRQoL surveys such as the
EQ-5D and SF-6D.74,75 However, our model assumes
that the HRQoL dierences relative to each other are the
relevant outputs, which is reected in our analysis and
conclusions.
Because complications are reported dichotomously,
the analysis does not reect the duration or severity of
pain, an important metric in postoperative quality of life.
For example, the severity of postthoracotomy pain may
not be equally disruptive in the thoracoscopic approach;
thus, even though the incidence of neuropathic pain in
anterolateral transthoracic surgery may be signicantly
greater than thoracoscopic and lateral approaches (13.8%
thoracotomy, 3.2% thoracoscopy, and 0.5% lateral), the
true debilitation of this pain between the dierent types of
transthoracic approaches may be very dierent. In addition, we did not track which series routinely performed
fusion operations at the time of initial surgery, which has
an impact on complications rates and HRQoL, as well.
Finally, and most importantly, surgery for TDH is
not a one-size-ts-all scenario for determining surgical
approach. Given the heterogeneity among patients and
pathology, it is unclear whether there are situations of
true clinical equipoise. Some series preoperatively stratied surgical approach based on the location and consistency of the TDH, therefore the proportion of more
challenging TDHs may be higher in the transthoracic
cohorts, which would inuence complication rates and
subsequent HRQoL. In contrast, patients with signicant
pulmonary disease may have undergone posterolateral
approaches as a means of avoiding perioperative morbidity, which may skew the neurological and pulmonary
complication rates in the posterior and lateral groups. In
addition, there is heterogeneity among the training and
experience of the surgeons conducting the various studies,
Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Volume 00, Number 00, 2016

which cannot be controlled for and undoubtedly aects

outcomes.
Nevertheless, as much as treatment algorithms have
evolved, larger series have consistently reported a single
or predominant approach, which likely reects surgeon or
institutional practice. Therefore, the results of this study
may help guide decision making in cases where multiple
approaches may be used for a given pathology, such as
open versus thoracoscopic anterolateral approaches for
calcied ventral disks, or posterior versus lateral approaches for soft paracentral disks. Although the results of
this study may not be applicable to all cases of symptomatic
TDHs, they do emphasize the reality that surgical morbidity
plays a signicant role in postoperative HRQoL and that
there is a need for high-quality future studies, such as
randomized controlled trials, geared to specic indications
for symptomatic TDH surgery.16,20,26,57,76

CONCLUSIONS
Quality of life outcome measures have become an
increasingly important aspect of spine surgery. The
present study represents one of the rst applications of
HRQoL research to thoracic disk surgery. The results
of this decision analysis favor posterior over lateral approaches, and thoracoscopic over open anterolateral
approaches for the treatment of symptomatic TDHs,
which may guide surgeons in cases with multiple surgical
options. Symptomatic TDH requiring surgery is an uncommon entity, thus the learning curves associated with
various approaches cannot be ignored and likely play a
major role in outcomes. Future work is necessary to ascertain whether newer approaches, such as the recently
described mini-open and endoscopic posterior techniques,
may have risk/benet proles that ultimately supersede
those of traditional posterior approaches, and whether
enough cases are encountered by the average surgeon to
justify their adoption.
REFERENCES
1. Arce CA, Dohrmann GJ. Thoracic disc herniation. Improved
diagnosis with computed tomographic scanning and a review of
the literature. Surg Neurol. 1985;23:356361.
2. Brown CW, Deffer PA Jr, Akmakjian J, et al. The natural history of
thoracic disc herniation. Spine. 1992;17:S97S102.
3. Love JG, Kiefer EJ. Root pain and paraplegia due to protrusions of
thoracic intervertebral disks. J Neurosurg. 1950;7:6269. Illust.
4. Arseni C, Nash F. Thoracic intervertebral disc protrusion: a clinical
study. J Neurosurg. 1960;17:418430.
5. Awwad EE, Martin DS, Smith KR Jr, et al. Asymptomatic versus
symptomatic herniated thoracic discs: their frequency and characteristics as detected by computed tomography after myelography.
Neurosurgery. 1991;28:180186.
6. Williams MP, Cherryman GR. Thoracic disk herniation: MR
imaging. Radiology. 1988;167:874875.
7. Williams MP, Cherryman GR, Husband JE. Significance of thoracic
disc herniation demonstrated by MR imaging. J Comput Assist
Tomogr. 1989;13:211214.
8. Abbott KH, Retter RH. Protrusions of thoracic intervertebral disks.
Neurology. 1956;6:110.
9. Epstein JA. The syndrome of herniation of the lower thoracic
intervertebral discs with nerve root and spinal cord compression.
A presentation of four cases with a review of literature, methods of
diagnosis and treatment. J Neurosurg. 1954;11:525538.

Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Thoracic Disk Decision Analysis

10. Hulme A. The surgical approach to thoracic intervertebral disc

protrusions. J Neurol Neurosurg Psychiatry. 1960;23:133137.
11. Le Roux PD, Haglund MM, Harris AB. Thoracic disc disease:
experience with the transpedicular approach in twenty consecutive
patients. Neurosurgery. 1993;33:5866.
12. Maiman DJ, Larson SJ, Luck E, et al. Lateral extracavitary
approach to the spine for thoracic disc herniation: report of 23 cases.
Neurosurgery. 1984;14:178182.
13. McCormick PC. Retropleural approach to the thoracic and
thoracolumbar spine. Neurosurgery. 1995;37:908914.
14. Bransford R, Zhang F, Bellabarba C, et al. Early experience treating
thoracic disc herniations using a modified transfacet pedicle-sparing
decompression and fusion. J Neurosurg Spine. 2010;12:221231.
15. Burke TG, Caputy AJ. Treatment of thoracic disc herniation:
evolution toward the minimally invasive thoracoscopic technique.
Neurosurg Focus. 2000;9:e9.
16. Anand N, Regan JJ. Video-assisted thoracoscopic surgery for
thoracic disc disease: classification and outcome study of 100
consecutive cases with a 2-year minimum follow-up period. Spine.
2002;27:871879.
17. Regan JJ. Percutaneous endoscopic thoracic discectomy. Neurosurg
Clin N Am. 1996;7:8798.
18. Regan JJ, Ben-Yishay A, Mack MJ. Video-assisted thoracoscopic
excision of herniated thoracic disc: description of technique and
preliminary experience in the first 29 cases. J Spinal Disord.
1998;11:183191.
19. Rosenthal D, Dickman CA. Thoracoscopic microsurgical excision
of herniated thoracic discs. J Neurosurg. 1998;89:224235.
20. Wait SD, Fox DJ Jr, Kenny KJ, et al. Thoracoscopic resection of
symptomatic herniated thoracic discs: clinical results in 121 patients.
Spine. 2012;37:3540.
21. Sox HC, Blatt MA, Higgins MC, et al. Medical Decision Making.
Philadelphia: American College of Physicians; 2007.
22. Einarson TR. Pharmacoeconomic applications of meta-analysis for
single groups using antifungal onychomycosis lacquers as an
example. Clin Ther. 1997;19:559569. Discussion 38-9.
23. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of
observational studies in epidemiology: a proposal for reporting.
Meta-analysis Of Observational Studies in Epidemiology (MOOSE)
group. JAMA. 2000;283:20082012.
24. Concato J, Feinstein AR. Monte Carlo methods in clinical research:
applications in multivariable analysis. J Investig Med. 1997;45:
394400.
25. Arnold PM, Johnson PL, Anderson KK. Surgical management of
multiple thoracic disc herniations via a transfacet approach: a report
of 15 cases. J Neurosurg Spine. 2011;15:7681.
26. Arts MP, Bartels RH. Anterior or posterior approach of thoracic
disc herniation? A comparative cohort of mini-transthoracic versus
transpedicular discectomies. Spine J. 2014;14:16541662.
27. Ayhan S, Nelson C, Gok B, et al. Transthoracic surgical treatment
for centrally located thoracic disc herniations presenting with
myelopathy: a 5-year institutional experience. J Spinal Disord Tech.
2010;23:7988.
28. Bilsky MH. Transpedicular approach for thoracic disc herniations.
Neurosurg Focus. 2000;9:e3.
29. Borm W, Bazner U, Konig RW, et al. Surgical treatment of thoracic
disc herniations via tailored posterior approaches. Eur Spine J.
2011;20:16841690.
30. Cerillo A, Carangelo B, Bruno MC, et al. Paravertebral retropleuric
microsurgery approach to the treatment of thoracic disc herniation.
Personal experience and consideration of unsatisfactory results.
J Neurosurg Sci. 2002;46:135142.
31. Chi JH, Dhall SS, Kanter AS, et al. The Mini-Open transpedicular
thoracic discectomy: surgical technique and assessment. Neurosurg
Focus. 2008;25:E5.
32. Choi KY, Eun SS, Lee SH, et al. Percutaneous endoscopic thoracic
discectomy; transforaminal approach. Minim Invasive Neurosurg.
2010;53:2528.
33. Currier BL, Eismont FJ, Green BA. Transthoracic disc excision and
fusion for herniated thoracic discs. Spine. 1994;19:323328.

www.clinicalspinesurgery.com |

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

Clin Spine Surg

Nayak et al

34. Delfini R, Di Lorenzo N, Ciappetta P, et al. Surgical treatment of

thoracic disc herniation: a reappraisal of Larsons lateral extracavitary approach. Surg Neurol. 1996;45:517522. Discussion 22-3.
35. Dinh DH, Tompkins J, Clark SB. Transcostovertebral approach for
thoracic disc herniations. J Neurosurg. 2001;94:3844.
36. El-Kalliny M, Tew JM Jr, van Loveren H, et al. Surgical approaches
to thoracic disc herniations. Acta Neurochir (Wien). 1991;111:
2232.
37. Fujimura Y, Nakamura M, Matsumoto M. Anterior decompression
and fusion via the extrapleural approach for thoracic disc herniation
causing myelopathy. Keio J Med. 1997;46:173176.
38. Gille O, Soderlund C, Razafimahandri HJ, et al. Analysis of hard
thoracic herniated discs: review of 18 cases operated by thoracoscopy. Eur Spine J. 2006;15:537542.
39. Hur JW, Kim JS, Cho DY, et al. Video-assisted thoracoscopic
surgery under o-arm navigation system guidance for the treatment
of thoracic disk herniations: surgical techniques and early clinical
results. J Neurol Surg A Cent Eur Neurosurg. 2014;75:415421.
40. Khoo LT, Smith ZA, Asgarzadie F, et al. Minimally invasive
extracavitary approach for thoracic discectomy and interbody
fusion: 1-year clinical and radiographic outcomes in 13 patients
compared with a cohort of traditional anterior transthoracic
approaches. J Neurosurg Spine. 2011;14:250260.
41. Korovessis PG, Stamatakis MV, Baikousis A, et al. Transthoracic
disc excision with interbody fusion. 12 patients with symptomatic
disc herniation followed for 2-8 years. Acta Orthop Scand Suppl.
1997;275:1216.
42. Levi N, Gjerris F, Dons K. Thoracic disc herniation. Unilateral
transpedicular approach in 35 consecutive patients. J Neurosurg Sci.
1999;43:3742. Discussion 42-3.
43. Lidar Z, Lifshutz J, Bhattacharjee S, et al. Minimally invasive,
extracavitary approach for thoracic disc herniation: technical report
and preliminary results. Spine J. 2006;6:157163.
44. Moran C, Ali Z, McEvoy L, et al. Mini-open retropleural
transthoracic approach for the treatment of giant thoracic disc
herniation. Spine. 2012;37:E1079E1084.
45. Nacar OA, Ulu MO, Pekmezci M, et al. Surgical treatment of
thoracic disc disease via minimally invasive lateral transthoracic
trans/retropleural approach: analysis of 33 patients. Neurosurg Rev.
2013;36:455465.
46. Nie HF, Liu KX. Endoscopic transforaminal thoracic foraminotomy and discectomy for the treatment of thoracic disc herniation.
Minim Invasive Surg. 2013;2013:264105.
47. Nishimura Y, Thani NB, Tochigi S, et al. Thoracic discectomy by
posterior pedicle-sparing, transfacet approach with real-time intraoperative ultrasonography. J Neurosurg Spine. 2014;21:568576.
48. Ohnishi K, Miyamoto K, Kanamori Y, et al. Anterior decompression and fusion for multiple thoracic disc herniation. J Bone
Joint Surg Br. 2005;87:356360.
49. Oppenlander ME, Clark JC, Kalyvas J, et al. Surgical management
and clinical outcomes of multiple-level symptomatic herniated
thoracic discs. J Neurosurg Spine. 2013;19:774783.
50. Oskouian RJ, Johnson JP. Endoscopic thoracic microdiscectomy.
J Neurosurg Spine. 2005;3:459464.
51. Quint U, Bordon G, Preissl I, et al. Thoracoscopic treatment for
single level symptomatic thoracic disc herniation: a prospective
followed cohort study in a group of 167 consecutive cases. Eur Spine
J. 2012;21:637645.
52. Regev GJ, Salame K, Behrbalk E, et al. Minimally invasive
transforaminal, thoracic microscopic discectomy: technical report
and preliminary results and complications. Spine J. 2012;12:
570576.
53. Ridenour TR, Haddad SF, Hitchon PW, et al. Herniated thoracic
disks: treatment and outcome. J Spinal Disord. 1993;6:218224.

8 | www.clinicalspinesurgery.com

Volume 00, Number 00, 2016

54. Simpson JM, Silveri CP, Simeone FA, et al. Thoracic disc
herniation. Re-evaluation of the posterior approach using a
modified costotransversectomy. Spine. 1993;18:18721877.
55. Singounas EG, Kypriades EM, Kellerman AJ, et al. Thoracic disc
herniation. Analysis of 14 cases and review of the literature. Acta
Neurochir (Wien). 1992;116:4952.
56. Smith JS, Eichholz KM, Shafizadeh S, et al. Minimally invasive
thoracic microendoscopic diskectomy: surgical technique and case
series. World Neurosurg. 2013;80:421427.
57. Stillerman CB, Weiss MH. Management of thoracic disc disease.
Clin Neurosurg. 1992;38:325352.
58. Uribe JS, Smith WD, Pimenta L, et al. Minimally invasive lateral
approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine. 2012;16:264279.
59. Yang X, Liu X, Zheng Y. Surgical treatment of thoracic disc
herniations using a modified transfacet approach. Indian J Orthop.
2014;48:158162.
60. Harbour R, Miller J. A new system for grading recommendations in
evidence based guidelines. BMJ. 2001;323:334336.
61. Lega BC, Danish SF, Malhotra NR, et al. Choosing the best
operation for chronic subdural hematoma: a decision analysis.
J Neurosurg. 2010;113:615621.
62. Danish SF, Burnett MG, Ong JG, et al. Prophylaxis for deep venous
thrombosis in craniotomy patients: a decision analysis. Neurosurgery. 2005;56:12861292. Discussion 92-4.
63. King JT Jr, Tsevat J, Moossy JJ, et al. Preference-based quality of
life measurement in patients with cervical spondylotic myelopathy.
Spine. 2004;29:12711280.
64. Sarna L, Cooley ME, Brown JK, et al. Symptom severity 1 to 4
months after thoracotomy for lung cancer. Am J Crit Care.
2008;17:455467. Quiz 68.
65. Gautschi OP, Seule MA, Cadosch D, et al. Health-related quality of
life following spinal cordectomy for syringomyelia. Acta Neurochir
(Wien). 2011;153:575579.
66. Patterson RH Jr, Arbit E. A surgical approach through the pedicle
to protruded thoracic discs. J Neurosurg. 1978;48:768772.
67. Benzel EC, Francis TB. Spine Surgery Techniques, Complication
Avoidance, and Management, 3rd ed. Philadelphia, PA: Elsevier/
Saunders; 2012.
68. Larson SJ, Holst RA, Hemmy DC, et al. Lateral extracavitary
approach to traumatic lesions of the thoracic and lumbar spine.
J Neurosurg. 1976;45:628637.
69. Perot PL Jr, Munro DD. Transthoracic removal of midline thoracic
disc protrusions causing spinal cord compression. J Neurosurg.
1969;31:452458.
70. Ransohoff J, Spencer F, Siew F, et al. Transthoracic removal of
thoracic disc. Report of three cases. J Neurosurg. 1969;31:459461.
71. Mulier S, Debois V. Thoracic disc herniations: transthoracic, lateral,
or posterolateral approach? A review. Surg Neurol. 1998;49:599606.
Discussion -8.
72. Karmakar MK, Ho AM. Postthoracotomy pain syndrome. Thorac
Surg Clin. 2004;14:345352.
73. Fessler RG, Sturgill M. Review: complications of surgery for
thoracic disc disease. Surg Neurol. 1998;49:609618.
74. Tosteson AN, Lurie JD, Tosteson TD, et al. Surgical treatment of
spinal stenosis with and without degenerative spondylolisthesis:
cost-effectiveness after 2 years. Ann Intern Med. 2008;149:845853.
75. Tosteson AN, Skinner JS, Tosteson TD, et al. The cost effectiveness
of surgical versus nonoperative treatment for lumbar disc herniation
over two years: evidence from the Spine Patient Outcomes Research
Trial (SPORT). Spine. 2008;33:21082115.
76. Stillerman CB, Chen TC, Couldwell WT, et al. Experience in the
surgical management of 82 symptomatic herniated thoracic discs
and review of the literature. J Neurosurg. 1998;88:623633.

Copyright

2016 Wolters Kluwer Health, Inc. All rights reserved.

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.