Thoracic Endoscopic Discectomy

What it is and why we do it

The thoracic spine is the part attached to the ribs. Disc herniations there are far less common than in the neck or low back, and many cause no symptoms at all. When they do, they cause a band of pain around the chest or belly that follows a rib, or, if the disc presses on the spinal cord, numbness, stiffness, or weakness in the legs and changes in balance or bladder control. Pain alone is usually treated without surgery. Pressure on the spinal cord with symptoms is a reason to operate.

The difficulty has always been the route. The spinal cord sits directly behind the disc and cannot be moved aside, so surgeons traditionally reached thoracic discs through the chest, by removing a rib, or by cutting away part of the vertebra from the back. Those are large operations with long recoveries. An endoscopic transforaminal approach reaches the disc from the side, through the natural opening beside the nerve, with an incision about 1 centimeter wide, without entering the chest cavity and without disturbing the cord.

What happens during surgery

Under general anesthesia, lying face down, X-ray guides a needle to the side of the disc along a path planned on your MRI and CT scan. A tube is placed and the endoscope shows the disc and the edge of the spinal canal. The herniated fragment is removed piece by piece, often with a small burr to widen the opening, and the cord is checked to be free. Nerve monitoring runs throughout. The incision is closed with a stitch.

Your recovery

Most people go home the same day or the next morning. Pain at the incision is mild. Band-like pain usually improves quickly; leg symptoms from cord pressure recover more slowly, over weeks to months, and the earlier the pressure is relieved the better they recover. Walking starts the day of surgery. Desk work often restarts in one to two weeks. No brace is needed.

Activity and restrictions

Walk from the first day. For four weeks, no heavy lifting, deep bending, or twisting. Driving once you are off opioids and comfortable. Physical therapy for balance and leg strength if the spinal cord was involved. See my playbook after lumbar decompression or endoscopic surgery, which applies to this procedure as well.

Who is not a good fit

Soft herniations that sit off to one side suit the endoscope best. A large, calcified herniation that is stuck to the lining of the spinal cord, or one sitting in the exact center and pressing on the cord broadly, may still need a larger operation, and sometimes a fusion. I plan this from the CT scan and tell you which situation you are in. This is a specialized procedure, and I perform it only when the anatomy is right for it.

The science: for the curious

The transforaminal corridor passes between the rib head and the facet joint, under the exiting nerve, into the back of the disc from the side. From there the endoscope looks across the back of the disc space toward the canal, so the fragment can be removed without retracting the cord at all, which is the step that caused the most harm in older operations. Pooled results from published series of full-endoscopic thoracic discectomy show low rates of spinal fluid leak, new nerve symptoms, and recurrence, with most patients discharged within a day. The procedure is technically demanding, and results depend on careful case selection.

Learn more

OrthoInfo, Herniated Disk in the Lower Back: orthoinfo.aaos.org (opens in a new tab)

My overview of endoscopic spine surgery compares every endoscopic procedure I offer.

Watch

Thoracic transforaminal endoscopic discectomy2:57

This handout is general education about this procedure and does not replace the specific plan, risks, and consent discussion we have together. Your own situation may differ: if anything here does not match what we talked about, what we talked about wins, so please ask me.