Endoscopic thoracic facet debridement

What is endoscopic thoracic facet debridement used for?

Endoscopic thoracic facet debridement is a minimally invasive procedure that is used for patients with upper back pain emanating from the thoracic facet joints. The thoracic facet joint is a paired joint on either side of the disc. The facet joint joins each vertebra with the vertebra above and below it. The facet joint gives stability to the spine in flexion, extension, lateral bending and twisting.

A common cause of thoracic facet injury is whiplash. Whiplash is a mechanism of injury resulting from a rapid flexion and extension of the spine. Usually this occurs in motor vehicle accidents. However, a whiplash mechanism can occur in falls and other types of injuries. Whiplash injuries usually occur in the neck. However, in about 20% of cases there is involvement of the junction of the neck and the upper back (thoracic spine). When there is a thoracic facet injury there is usually injury at multiple levels that are above and below to each other. It is exceedingly rare to see a thoracic facet whiplash injury without a cervical facet whiplash injury.

The diagnosis of thoracic facet mediated pain is a rare diagnosis that requires a conscientious and experienced physician. Thoracic facet pain should always be suspected when the patient has been treated for cervical facet injury and has residual low neck or upper back pain.

How is an endoscopic thoracic facet debridement performed?

Endoscopic thoracic facet debridement is performed utilizing an endoscope. An endoscope is a small tube inserted into the body, allowing the surgeon to look inside the spine. Because the endoscope is small, only a small band-aid like incision is required. The endoscope has a precision lens on one end and a high definition (HD) camera on the other end. Microscopic instruments are passed through the endoscope to perform surgery. The surgeon visualizes the entire operation, from inside the spine, using the endoscope mounted HD camera. The surgical video is projected on a high-resolution monitor or heads up display.

To start the procedure, a small incision is made on the skin at the upper back, right on top of the injured thoracic facet joint. A small tube about 8mm in diameter, (less than half the size of a dime), is then placed into the disc. A small endoscope is placed through the 8mm tube and is used to release the capsule of the injured joint and remove the torn and injured joint components. Using specialized instruments surgery is performed through these tubes. Surgery is guided by real time HD video and x-rays.

What are the advantages of endoscopic thoracic facet debridement?

Endoscopic thoracic facet debridement allows the surgeon to remove damaged tissue from a thoracic facet joint caught between the bones of the joint, causing pain. The surgeon is also able to release the tight capsule of the injured joint, allowing freer movement without pain. Lastly, the surgeon can directly cauterize and remove nerve endings in the joint that sense pain. The tiny opening required means that there is minimal disruption to the facet joints or the muscles and ligaments of the neck. Performing surgery through a tiny skin incision and leaving healthy tissues intact means a same day procedure with a quicker recovery.

Probably the most significant advantage to endoscopic thoracic facet debridement is that it provides a long-term option for patients that have undergone other procedures for thoracic facet pain and have had a return of pain. About one third of patients undergoing a thoracic rhizotomy (the most utilized procedure for thoracic facet pain) will have a return of pain in one year. Occasionally these patients will have to endure several thoracic rhizotomy procedures. Endoscopic thoracic facet debridement provides these difficult patients with a long-term alternative.

Another advantage to endoscopic thoracic facet debridement is that any involved thoracic level can be treated. With thoracic medial branch rhizotomy, the alternative to endoscopic thoracic facet debridement, the thoracic facet joints of the mid to low thoracic spine cannot be treated.

What are the alternatives to endoscopic thoracic facet debridement?

A patient might undergo a thoracic facet injection as an initial treatment for thoracic facet pain. In this procedure, the physician utilizes x-ray guidance to precisely guide a small needle into the actual joint space. A small amount of anesthetic medication and a high potency steroid medication is injected into the joint. Unfortunately, symptoms will commonly return after 4-8 weeks.

Another common treatment for a thoracic facet injury or thoracic facet pain is a thoracic medial branch rhizotomy. In this procedure, a physician places a needle through the skin and, using x-ray guidance, directs the needle to a laterally projecting bony structure of the vertebra called the transverse process. In this region, the medial branch nerve travels. The medial branch is the nerve that senses pain from the facet joint.  Once the needle is in place, the physician inserts a small electrode through the needle. Through this electrode, radiofrequency energy is transmitted. This results in very intense heating in a small area surrounding the electrode.  This heating results in coagulation of the medial branch nerve. As a result, the patient ceases to sense pain from the treated facet joint.

The main disadvantage of this procedure is that there is a moderate rate of recurrence. At 6 months to 1 year one third or greater of patients may have a recurrence of pain, resulting in a need for retreatment.

Another disadvantage of this procedure is that it is dependent on a particular technology to perform medial branch rhizotomy that it is not widely available. This is called "cooled" radiofrequency ablation. This technology is different than what is commonly available and used to perform cervical medial branch rhizotomy.

The last major disadvantage of thoracic medial branch rhizotomy is that there are anatomic limitations. The medial branch nerve can reliably be targeted with x-ray as it travels along the transverse processes of the vertebra from T1-T4 and from T10-T12.  However, the T5-6, T6-7, T7-8, T8-9 and T9-10 thoracic facet joints cannot be reliably treated with thoracic medial branch rhizotomy because of their anatomic location.

How long will the procedure take?

Endoscopic thoracic facet debridement surgery typically takes 15-30 minutes for each joint treated.  You will be in the operating room for an additional hour preparing for surgery and preparing for recovery. After the procedure you will recover for about two hours before going home.

What is the recovery like?

After endoscopic thoracic facet debridement, you will go home the same day with pain medications. In most cases light activity can be resumed the next day. Activity should be tolerably increased over 7 days and should consist of short walks, light exercise and a gradual return to normal daily activities. Avoid strenuous activity and heavy lifting (over 10 to 15 pounds) for the first several weeks. If one’s job is sedentary then work can be resumed in 7

Endoscopic thoracic laminotomy

What is endoscopic thoracic laminotomy used for?

Endoscopic thoracic laminotomy is a minimally invasive procedure that is used for the treatment of thoracic spinal stenosis. Spinal stenosis is a condition where degeneration of the spine results in narrowing of the normal nerve passageways of the spine. Degeneration occurs from repetitive stress to the spine over a long period of time. Degeneration results in overgrowth, called hypertrophy, of some of the stabilizing elements of the spine. This can affect the ligaments of the spine and the facet joints. Along with overgrowth/hypertrophy of these elements, there may be significant disc bulging from wear and tear. Through a combination of these factors, the normal passageways of the nerves of the spine become narrowed and the nerves, or the spinal cord itself, become compressed.  With nerve compression there is pain or weakness. This is called thoracic radiculopathy. With spinal cord compression there is spinal cord malfunction resulting in balance problems, weakness or incontinence. This is called thoracic myelopathy.

How is an endoscopic thoracic laminotomy performed?

Endoscopic thoracic laminotomy is performed utilizing an endoscope. An endoscope is a small tube inserted into the body, allowing the surgeon to look inside the body. Because the endoscope is small, only a small band-aid like incision is required. The endoscope has a precision lens on one end and a high definition (HD) camera on the other end. Microscopic instruments are passed through the endoscope to perform surgery. The surgeon visualizes the entire operation, from inside the spine, using the endoscope mounted HD camera. The surgical video is projected on a high-resolution monitor or heads up display.

To start the procedure, a small incision is made on the skin at the upper back, above the facet joint of the affected thoracic spinal segment. A small tube about 8mm in diameter, (less than half the size of a dime), is then inserted through the tiny incision and placed against the bony ring of the spine. A small endoscope is placed through the 8mm tube. Specialized micro-instruments are used to visualize the thoracic facet joint. A micro drill is then inserted through the endoscope and the middle part of the facet joint is removed. The drilling continues across the back of the vertebra to drill away portions of the lamina. The lamina is a ring of bone surrounding the spinal canal in the back. The lamina are joined together by a ligament call the ligamentum flavum. With drilling of the lamina the ligamentum flavum is removed. By removing the ligamentum flavum, portions of the lamina and the middle portion of the facet joint the nerve and spinal cord passageways are freed up from compression. Surgery is guided by real time HD video and x-rays.

What are the advantages of endoscopic thoracic laminotomy?

Endoscopic thoracic laminotomy allows the surgeon to decompress the affected nerves and spinal cord in cases of spinal stenosis. Because the operation is endoscopic, a small "Band-Aid" incision can be used and smaller surgical tubes can be utilized. These are nearly 3 times smaller than what is utilized for conventional operations. As a result, adequate decompression of the thoracic spine can be performed while minimizing damage to thoracic muscles and minimizing the amount of thoracic vertebral bone that must be removed to achieve an adequate decompression. By preserving normal spinal structures and minimizing the degree of surgery the procedure becomes less invasive, allowing a faster recovery.

What are the alternatives to endoscopic thoracic laminotomy?

Patients with thoracic spinal stenosis might undergo pain injections prior to being considered for surgery. These usually take the form of epidural injections. In these cases, a small needle is placed across the back and into the affected spinal segment. A combination of anesthetics and anti-inflammatory steroid medications are then injected.

In patients that do not respond well to conservative therapy, surgery is considered. The surgical alternative to endoscopic thoracic laminotomy is a thoracic micro–laminotomy. The procedure is very similar to endoscopic thoracic laminotomy. However, the larger surgical retracting tube is utilized. This is nearly 3 times larger. Because the surgical access tube is larger, there is usually a greater degree of bone drilling of the vertebra that is required before the surgeon achieves a satisfactory decompression.

How long will the procedure take?

The endoscopic thoracic laminotomy procedure typically takes one to two hours for each level treated.  You will be in the operating room for an additional hour preparing for surgery and preparing for recovery. After the procedure you will recover for about two hours before going home.

What is the recovery like?

After endoscopic thoracic laminotomy you will go home the same day with pain medications. In most cases light activity can be resumed the next day. Activity should be tolerably increased over 7 days and should consist of short walks, light exercise and a gradual return to normal daily activities. Avoid strenuous activity and heavy lifting (over 10 to 15 pounds) for the first several weeks. If one’s job is sedentary then work can be resumed in 7 days. Recovery time will vary based on individual factors.

Endoscopic thoracic discectomy

What is endoscopic thoracic discectomy used for?

Endoscopic thoracic discectomy is a minimally invasive procedure that is used for the treatment of painful disc herniations in the thoracic spine.

How is an endoscopic thoracic discectomy performed?

Endoscopic thoracic discectomy is performed utilizing an endoscope. An endoscope is a small tube inserted into the body, allowing the surgeon to look inside the body. Because the endoscope is small, only a small band-aid like incision is required. The endoscope has a precision lens on one end and a high definition (HD) camera on the other end. Microscopic instruments are passed through the endoscope to perform surgery. The surgeon visualizes the entire operation, from inside the spine, using the endoscope mounted HD camera. The surgical video is projected on a high-resolution monitor or heads up display.

To start the procedure, a small incision is made on the skin at the upper back, just to the side. A small tube about 7mm in diameter, (less than half the size of a dime), is then placed through a natural opening of the spine called the foramen.  A small endoscope is placed through the 7mm tube. Specialized micro-instruments are used to remove the injured and herniated disc components. Surgery is guided by real time HD video and x-rays.

What are the advantages of endoscopic thoracic discectomy?

Endoscopic thoracic discectomy allows the surgeon to remove the herniated and protruding portion of a thoracic disc that is causing upper back pain or nerve pain. Typically, this is a difficult region to perform a spinal operation. This is because of limited access. The spinal cord blocks access to the disc from the back and the lungs block access from the sides.  The most significant advantage of endoscopic thoracic discectomy is that access to a herniated disc is allowed through natural openings in the spine, without disturbing the spinal cord or the lungs.

How long will the procedure take?

Endoscopic thoracic discectomy surgery typically takes an hour for each disc treated.  You will be in the operating room for an additional hour preparing for surgery and preparing for recovery. After the procedure you will recover for about two hours before going home.

What is the recovery like?

After endoscopic thoracic discectomy you will go home the same day with pain medications. In most cases light activity can be resumed the next day. Activity should be tolerably increased over 7 days and should consist of short walks, light exercise and a gradual return to normal daily activities. Avoid strenuous activity and heavy lifting (over 10 to 15 pounds) for the first several weeks. If one’s job is sedentary then work can be resumed in 7 days. Recovery time will vary based on individual factors.