Endoscopic Trans-Costovertebral Approach to Thoracic Discectomy for Central Calcified Disc Herniations: A Technical Note.

Abstract

Thoracic disc herniations are rare but can cause severe myelopathy, particularly when centrally located and calcified. Their ventral position and limited operative corridor make surgical management challenging. A 46-year-old male presented with progressive gait instability, a T5 sensory level, and upper motor neuron signs. Imaging revealed a large, centrally located, partially calcified T5-6 disc herniation with rostral migration causing significant cord compression. Given the morphology and ventral displacement of the cord, an endoscopic trans-costovertebral approach was selected to access the pathology safely. The endoscopic trans-costovertebral approach offers an effective minimally invasive corridor for the resection of large, centrally located, calcified thoracic disc herniation when careful technique is applied. Critical factors include selecting an entry point at least 10 cm off midline and referencing the dorsal rib border for trajectory planning. Swimmer's arm positioning can lateralize the scapula when needed, though the approach may be limited to very thin patients. Superficial lateral facet docking is the first step. Foraminoplasty should then be performed under endoscopic visualization, establishing key anatomical landmarks including the rib head and neck and identifying the rib anatomy by tracing back from the foramen/disc space.