Kerezoudis Panagiotis, Rajjoub Kenan R, Goncalves Sandy, Alvi Mohammed Ali, Elminawy Mohamed, Alamoudi Abdullah, Nassr Ahmad, Habermann Elizabeth B, Bydon Mohamad
Mayo Clinic Neuro-Informatics Laboratory, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
Mayo Clinic Neuro-Informatics Laboratory, Rochester, MN, USA; George Washington University School of Medicine, Washington, District of Columbia, USA.
Clin Neurol Neurosurg. 2018 Apr;167:17-23. doi: 10.1016/j.clineuro.2018.02.009. Epub 2018 Feb 6.
Thoracic disc herniations (TDH) represent 1.5-4% of all intervertebral disc herniations. Surgical treatment can be divided into anterior, lateral and posterior approaches and is an area of contention in the literature. Available evidence consists mostly of single-arm, single-institutional studies with limited sample sizes. The objective of this study is to investigate 30-day surgical outcomes following excision of TDH utilizing a national surgical registry.
The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) was queried for cases that underwent anterior (thoracotomy or thoracoscopy), lateral (extracavitary or costotransversectomy) or posterior (transpedicular or laminectomy) surgery for a primary diagnosis of TDH between 2012 and 2015.
A total of 388 patients (48% females) were included in the analysis. An anterior approach was used in 65 patients, lateral approach in 34, transpedicular approach in 90 and laminectomy in 199. Overall, baseline demographics and clinical characteristics were similarly distributed between the four procedure groups. Patients undergoing an anterior approach spent, on average, 2-3 more days in the hospital compared to the other groups (p < .001). Furthermore, they were more likely to have developed a major complication (27%) compared to the lateral (8%), transpedicular (18%) or laminectomy group (14%) (p = .13). Unplanned 30-day readmission and return to the operating room occurred in 5-8% of patients (p = .69 and 0.63, respectively). Lastly, the majority of the patients were discharged to home or a home facility (anterior-74%; lateral-81%; transpedicular-68% and laminectomy-74%, p = .58).
Anterior approaches had longer LOS and higher, although not statistically significant, complication rates. No difference was found with regard to discharge disposition. In light of these findings, surgeons should weigh the risks and benefits of each surgical technique during tailoring of decision making.
胸椎间盘突出症（TDH）占所有椎间盘突出症的1.5%-4%。手术治疗可分为前路、侧路和后路入路，这是文献中存在争议的领域。现有证据主要包括样本量有限的单臂、单机构研究。本研究的目的是利用国家外科登记处调查TDH切除术后30天的手术结果。
查询美国外科医师学会-国家外科质量改进计划（ACS-NSQIP）中2012年至2015年间因TDH原发性诊断而接受前路（开胸手术或胸腔镜手术）、侧路（腔外手术或肋骨横突切除术）或后路（经椎弓根手术或椎板切除术）手术的病例。
共有388例患者（48%为女性）纳入分析。65例采用前路入路，34例采用侧路入路，90例采用经椎弓根入路，199例采用椎板切除术。总体而言，四个手术组之间的基线人口统计学和临床特征分布相似。与其他组相比，接受前路手术的患者平均住院时间多2-3天（p<0.001）。此外，与侧路组（8%）、经椎弓根组（18%）或椎板切除术组（14%）相比，他们发生严重并发症的可能性更高（27%）（p=0.13）。5%-8% 的患者发生了计划外的30天再入院和返回手术室（p分别为0.69和0.63）。最后，大多数患者出院后回家或回家护理机构（前路-74%；侧路-81%；经椎弓根-68%；椎板切除术-74%，p=0.58）。
前路手术住院时间更长，并发症发生率更高，尽管无统计学意义。出院处置方面未发现差异。鉴于这些发现,外科医生在制定决策时应权衡每种手术技术的风险和益处。
