Surgical Approaches for Various PathologiesSurgical Approaches for Various PathologiesLevels Disc Herniation ApproachesSOFT DISCSOFT DISCT1 to T4 Central, centrolateral Transsternal

Central, centrolateral Medial clavisectomy

Centrolateral, lateral Costoransversectomy

Central, centrolateral, lateral Transthoracic

Central, centrolateral, lateral Thoracoscopy

Centrolateral, lateral Lateral

Central, centrolateral, lateral Costoransversectomy

Lateral Tranpedicular

CALCIFIED DISCCALCIFIED DISCT1 to T4 Central, centrolateral Transsternal

Central, centrolateral Medial clavisectomy

Lateral Costoransversectomy

T4 to T12 Central, centrolateral, lateral TransthoracicLateral Lateral

Lateral, centrolateral CostoransversectomyFrom Mirkovic S: Thoracic disc herniation herniations. In Garfin S R, Vaccaro AR, eds: Orthopaedic knowledge undate: spine, Rosemont III, 1997. American Academy of Orthopaedic Surgeons, pp 87-96.

Thoracic PedicleThoracic Pedicle

• Larger superior-inferior dimensions than transverse widths create oval shape.

• Average height is 8 to 15 mm; average width is 3 to 10mm

• Diameter is less than 5mm in 35%of pedicles.• Transverse plane angulation at T4 is around 15 degrees

medially; it becomes more parallel to sagittal plane T5 to T12, path may be diverged.

• Entry point is 7 to 8 mm medial to lateral edge of superior facet and 3 to 4 mm superior to midline of transverse process of T1 and T2. Between T3 and T12, point lies 5mm medial to lateral edge of superior facet and 5mm superior to midline of transverse process.

PediclePedicle Screw Placement Screw Placement

• Stereotactic guidance

• Fluoroscopically guided

• Manual technique

• CT Scan

How Accurately Do Novice Surgeons Place How Accurately Do Novice Surgeons Place Thoracic Pedicle Screws Thoracic Pedicle Screws

with the Free Hand Technique?with the Free Hand Technique?

Ryan K. Bergeson, et al. Spine Vol 33(15), 2008.

surgeons placing thoracic pedicle screws in cadavers were able to significantly improve by the fourth cadaver practice

Reliability of Three-dimensional Fluoroscopy Reliability of Three-dimensional Fluoroscopy for Detecting Pedicle Screw Violations for Detecting Pedicle Screw Violations

in the Thoracic and Lumbar Spinein the Thoracic and Lumbar Spine

real-time intraoperative imaging, 3-D fluoroscopy may enhance the safety of thoracic transpedicular instrumentation.

Neurosurgery 2004;Vol.54(5), pp 1138–1143 Michael Y. Wang, M.D. et al.

RisksRisks

• Vascular injury

• Spinal cord injury

• Malposition

• Pulmonary injury