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Computer-guided Endoscopic Neurosurgery in the Thoracic Spine

Published Online: June 4th 2011
Authors: Daniel L Farkas, J Patrick Johnson, Wesley A King
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There seems to be broad agreement that the brightest hope for delivering enhanced patient care and better outcomes in surgery relies on technological advances, in the right hands. Some of the more promising approaches, emphasizing imaging and robotics, were recently reviewed.< UP>1 Neurosurgery, due to its special challenges, has always been at the forefront of new technology adoption. Thoracic spinal surgery is an excellent example, since it often has both technical and anatomic challenges due to the need to intervene within the farthest reaches of the chest cavity. Recent endoscopic surgical techniques have resolved many old problems while creating others, mainly due to difficult orientation utilizing a 2-D imaging-based endoscopic procedure within a complex 3-D structure.

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The application of computer-assisted image guidance technology to these surgical procedures allows creation of new methods to address these challenges by providing the needed 3-D orientation that ultimately improves accuracy, efficiency, and safety. The concepts described below represent the initial step of combining computer-assisted image guidance technology with standard endoscopic surgical procedures, which may ultimately change many of the customary methodologies for performing current surgical procedures.

Thoracic Spinal Disorders
The treatment of thoracic disc herniation remains a difficult clinical challenge, particularly when it is located anterior to the spinal cord. Many thoracic disc herniation problems are small and laterally located, causing only chest-wall pain; they are not a threat to causing paralysis, are self-limited, and resolve.

However, some of these disc herniations remain problematic primarily when they are in a strategically difficult location directly ventral to the spinal cord (see Figure 1). These previously necessitated a highly invasive operative procedure through an anterior or anterior-lateral approach; this required a large surgical incision through the chest wall (i.e. thoracotomy) resulting in a long painful recovery period.

Thoracic Endoscopy Development
Recent interest in endoscopic procedures emerged due to technological advances with endoscopic imaging and improved surgical instruments and techniques in the late 1980s. The addition of digital video technology to endoscopy further advanced the field, with precision images displayed on brilliant video monitors providing the surgeon with a clear view of the surgical field. Thoracic endoscopic procedures have developed in recent years in other disciplines, such as pulmonary surgery involving the lungs and related structures, from basic, less difficult procedures; they have now evolved significantly, with the ability to perform most complex procedures using less invasive endoscopic techniques.2–5 The efficacy of these procedures is equivalent to open procedures, but with significantly less post-operative pain and shortened hospital stay.

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