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.
- Immediately
upon discharge, contact our office and set up an appointment
for staple removal if one has not already been set up.
- 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.
- 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.
- Lift nothing
heavier than a half gallon of milk until seen by your
doctor.
- 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.
- No jogging
or running.
- After you
get home, you may begin walking up to one mile per day.
- You may
walk up or down steps as often as you like. Please
take them smoothly and slowly.
- 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.
- 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.
- Sexual activities
are permitted.
- 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.
- If you have
any questions, call our office, and for after hours emergencies,
call the medical society.
- Take your
medications prescribed on discharge, as directed.
- It takes
6 - 18 months for a nerve to heal. During that time
you may experience numbness, tingling, fleeting pain,
or creepy/crawly sensations.
- 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.
- 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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