Thoracic Disc Herniation Research Articles

Full Endoscopic Surgery for Thoracic Pathology: Next Step after Mastering Lumbar and Cervical Endoscopic Spine Surgery?

Thoracic disc herniation and stenosis are relatively rare, and various symptoms make them difficult to diagnose. Due to the complexity of neural and vascular structure, surgical treatment of thoracic pathology is challenging. Endoscopic spine surgery is an emerging minimally invasive surgical option. Based on wide experience on the cervical and lumbar spine, an endoscopic approach for the thoracic pathology can be performed beyond the learning curve. Transforaminal approach for thoracic disc herniation, endoscopic unilateral approach, and bilateral decompression for thoracic stenosis have been reported as favorable and safe surgical options. In the present study, the authors described the detailed surgical procedure as well as tips and tricks.

Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance.

Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs. A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores. A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade. The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon's arsenal for the confident tackling of all TDHs.

Surgical management of giant calcified thoracic disc herniation and the role of neuromonitoring. The outcome of large mono centric series

PurposeGiant thoracic disc herniations (GTDH) are considered a subgroup of TDHs with worse functional outcomes, a high calcification rate, and a considerable risk of complications. We aimed to determine whether there is a relationship between the extent of calcification of GTDH and outcomes concerning the risk of complications, the surgical technique, and changes in neuromonitoring signals. MethodsWe present a retrospective analysis of 76 patients undergoing surgery for calcific GTDH. We introduced and defined a radiological definition of the calcified disc into“fully calcified” and “partially calcified.” We performed a statistical analysis between clinical and radiological variables, type of surgical procedure, the extent of excision, neuro-monitoring signals, and outcome, comparing a group of 58 “fully-calcified TDH” patients and 18 “partially-calcified TDH” patients. ResultsFully calcified TDHs, compared with partially calcified TDHs, do not have significant differences in outcome (worse outcome 4/58–6.9% versus 0/18, p = 0.25) and complications (10/58–17.24% versus 4/18–22.2%, p = 0.63); Fully calcified TDH is associated with a higher risk of alterations in neurophysiological potentials (14/58–24.1% versus 0/18, p = 0.02) and subtotal excision (18/58–31% versus 2/18–11%, p = 0.15), without significant differences between the approaches used. ConclusionFully calcified TDH group has a similar outcome and complication rate as the partially calcified TDH group, but they are associated with higher intraoperative neuromonitoring signal changes. We introduced a new classificationsystem that guides the approach and helps tocounsel the patients.

DISCECTOMÍA TRANSTORÁCICA EXTRAPLEURAL SIN FUSIÓN PARA RESECCIÓN DE HERNIA DISCAL DORSAL CALCIFICADA GIGANTE: REPORTE DE CASO

Introduction: Calcified thoracic disc herniations are rare and their approach represents a surgical challenge when they are giant and symptomatic Surgery is indicated in cases of intractable back pain with medical management persistent intercostal neuralgia or progressive neurological deficit with the transthoracic extrapleural approach being the one of choice because it has advantages regarding the best view of the operative field We present the case of a patient with a giant calcified thoracic hernia who was successfully operated on in our hospital using an extrapleural transthoracic approach. Clinical case: A 53-year-old male with dorsal pain in the medial region radiating to the inframammary region and progressive difficulty walking moderate proximal paraparesis T8 sensory level and urinary retention CT and MRI images showed a large calcified T6-7 disc herniation causing severe compression of the spinal cord The patient underwent a T6-7 extrapleural transthoracic discectomy plus a T6 partial corpectomy without fusion The patient tolerated the procedure well with no complications and the postoperative images one month after surgery demonstrated spinal cord decompression At follow-up irradiated back pain sensory level paraparesis and urinary retention improved. Conclusion: Extrapleural transthoracic discectomy can be considered a safe approach in the case of giant calcified thoracic hernias since it allows resection of the calcified disc fragment and decompression of the spinal cord. Keywords: Intervertebral Disc Displacement, Diskectomy, Spinal Cord, Decompression (Source: MeSH NLM)

Full Endoscopic Thoracic Discectomy: Is the Interlaminar Approach an Alternative to the Transforaminal Approach? A Technical Note.

Various approaches are used for decompressive surgeries in the thoracic spine depending on the location and consistency of the pathology, always avoiding manipulation of the thoracic spinal cord. Recently, there has been an effort to achieve adequate results and reduce morbidity with minimally invasive surgeries. Good outcomes and the advantages of full endoscopic spine surgery (FESS) have been proven for surgerical correction of herniated discs and stenoses in the lumbar and cervical spine. Similar evidence has recently been described for the thoracic spine, but it has not previously been reported in Brazil. Although the transforaminal approach is already established for the thoracic spine, the newly described interlaminar approach is equally efficient, and both techniques must be considered when treating thoracic spine diseases. The objective of the present article was to present the full endoscopic interlaminar and transforaminal techniques in patients with symptomatic disc herniation of the thoracic spine, discuss the rationality for implementing FESS in thoracic spine, and discuss the rationality in choosing between both approaches. Two patients were submitted to thoracic FESS. A transforaminal approach was chosen for a T10-T11 foraminal disc herniation; an interlaminar approach was selected for a paramedian T7-T8 disc extrusion. Data regarding operating time, intraoperative images, hospital stay, visual analog scales before and after FESS, course of recovery, and surgery satisfaction were evaluated. The patients had eventless surgeries, improved from preoperative pain without morbidity. Both were satisfied and recovered well. Hospital stay was less than 6 hours after surgery. Transforaminal and interlaminar FESS for thoracic disc herniation are safe, efficient, and minimally invasive alternatives. Despite being an innovative technique with evident advantages, it should be carefully considered along with conventional technique for the treatment of thoracic spine diseases, since its clinical relevance is yet to be determined.

Spinal surgery for gallstones disease - Case report of a rare differential diagnosis.

Introduction and importanceAbdominal pain in the right upper quadrant is very common for patients to present in the emergency department. Finding the correct diagnosis seems straightforward in most cases but can be challenging.Case presentationWe present the case of a 75-year-old male with a rare differential diagnosis for right upper quadrant and back pain, initially diagnosed as symptomatic cholelithiasis. After referral to an abdominal surgeon, detailed history taking prior to planned cholecystectomy revealed a record of back pain due to spinal degeneration and fusion surgery, as well as a bulb of the right abdominal wall with hypesthesia in a dermatomal area in the right upper quadrant. Considering these “new” facts, a spinal surgeon was consulted and a foraminal disc hernia of the thoracic vertebrae 11/12 was identified as the cause of symptoms. Instead of the initially planned cholecystectomy, a right-sided facetectomy Th11/12, sequestrectomy and unilateral transpedicular stabilization to decompress the nerve root was successfully performed.Clinical discussionAlthough, symptomatic cholelithiasis is one of the most common diagnoses for patients presenting with right upper quadrant pain in the presence of gallstones, other differential diagnoses have to be considered. Thoracic disc herniations can present with atypical symptoms that mimic other non-spinal causes and may pose a diagnostic challenge, sometimes even leading to unnecessary surgery.ConclusionThis case highlights a rare differential diagnosis for one of the most common diseases seen by emergency physicians. It emphasizes the risk of working under time pressure, especially in an emergency setting, which may lead to premature diagnostic error and treatment, endangering patient's care and safety.

444 Partial Transpedicular Thoracic Discectomy With Ultrasonic Aspiration and Ultrasound Guidance for Every Thoracic Disc Herniation: A 43-Patient Case Series and Technical Note Demonstrating Safety and Efficacy

INTRODUCTION: Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. METHODS: A retrospective review was performed of patients who underwent a thoracic discectomy through the partial transpedicular approach between January 2014 and 2020 by a single surgeon. Variables reviewed included demographics, peri-operative imaging, and functional outcome scores. RESULTS: 43 patients (53% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 9 ± 8.86 months. 23 (42.5%) of discs were fully calcified on imaging and 18 (33.3%) were partially calcified. 33 (61.1%) were giant TDH (&gt;40% canal compromise). Average operative time was 197 ± 77.1 minutes with an average blood loss of 238 ± 250 cc. 6 patients required ICU stays. Hospital length of stay was 4.37± 3.42 days. Of patients with follow-up MRI, 38 of 40 disc-levels (95%) demonstrated &lt;20% residual disc. Post-operative Frankel scores (&gt;3 months) were maintained or improved for all patients with 28 (65.1%) patients having an increase of 1 or greater on their Frankel score. 6 (14%) patients required repeat surgery, 2 of which were due to re-herniation, 2 were from adjacent level herniation and 2 others from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intra-operative neuromonitoring was associated with a greater improvement in Frankel grade. CONCLUSION: Here we demonstrate a minimally invasive, posterior approach that utilizes intraoperative ultrasound and ultrasonic aspiration with great outcomes and a complication profile similar or better than other reported case series. This posterior approach is a great complement to the spine surgeon’s arsenal for the confident tackling of all TDHs.

A Case of Thoracic Disc Herniation Effectively Treated with Interventional Radiology Computed Tomography- Guided Percutaneous Endoscopic Radiofrequency Annuloplasty Using a Disc-Fx®

A Case of Thoracic Disc Herniation Effectively Treated with Interventional Radiology Computed Tomography- Guided Percutaneous Endoscopic Radiofrequency Annuloplasty Using a Disc-Fx®

Single-stage C6-7 ACDF with T1-2 Oblique Keyhole Transcorporeal Disectomy to Treat Cervico-thoracic Tandem Disc Herniation: A Case Report

Symptomatic cervico-thoracic tandem disc herniation occurs very rarely. On the other hand, cervical disc herniations are common and may be treated via a variety of surgical procedures. Symptomatic upper thoracic disc herniations are extremely rare, and use of a surgical approach in their treatment is controversial due to the narrow operative space within which surgical procedures must be performed. We report an extremely rare case of symptomatic tandem C6-7 and T1-2 disc herniation successfully treated via single-stage, single-incision, C6-7 anterior cervical decompression and fusion, and T1-2 oblique keyhole transcorporeal discectomy. This is the first symptomatic cervico-thoracic tandem disc herniation with its treatment.

Symptom distribution and development in thoracic disc surgery – A retrospective case series of 664 patients

ObjectiveThe incidence of surgically treated thoracic disc herniations in the U.S. is estimated to be 1:116,338 [1]. The disease poses 2 main challenges: 1) Surgical removal and 2) early and correct diagnosis. It is without doubt that herniated thoracic discs can be difficult to remove; Equally difficult is often enough attributing the correct symptoms to the disease that lead to the diagnosis, because there is a great variability and supposedly low specificity of the clinical symptoms, especially concerning pain related symptoms, which are often attributed to muscular or joint related causes.The series published so far are comparatively small (up to a maximum of 200) to give a good and valid overview of the symptoms that the disease can cause.The aim of this study was therefore to verify and falsify the previously published data that were obtained with small series on the basis of a much larger series. MethodsWe used our practice's own database that was designed to included only patients with thoracic disc herniations since the senior author focused on this disease about 25 years ago. The patient's symptoms were initially recorded descriptively on the basis of the medical record. Then the patients were contacted and the development of symptoms after surgery and new symptoms were recorded. Results664 patients were included in the study. Mean follow-up period was 57.89 months. 151 (22.74%) patients reported neurological motor deficits, 313 (47.13%) reported neurological sensory deficits, 542 (81.62%) thoracic back pain, 125 (18.82%) bladder and rectal dysfunction and 46 (6.92%) atypical symptoms. 137 (20%) of the patients were completely symptom-free. The rate of improvement/ symptom stability was about 90% for neurological symptoms, pain-improvement 40%, 65% improvement in bladder and rectal dysfunction, and 80% improvement in atypical symptoms. ConclusionThe results of this largest series to date of patients who were operated on for a thoracic disc herniation show that not only neurological but also algetic symptoms are dominating in patients harboring this disease. The postoperative results primarily help to advise the patient on their prognosis.

Thoracoscopic Microdiscectomy with Preservation of Rib and Costovertebral Joint.

Thoracic disc herniations (TDH) may cause major morbidity. While thoracoscopic microdiscectomy (TMD) is an excellent technique, postoperative band-like pain is an important drawback. We performed 181 consecutive TMDs (including 39 high-risk cases) with preservation of rib and costovertebral joint (CVJ). We shave a few mm of the rib, drill straight to target, and avoid opening the canal before the TDH is completely free and (in case of giant TDHs) internally debulked, creating initial decompression and limiting epidural venous oozing. Subsequently, we gently mobilize and remove the residual TDH while avoiding leverage. Skin-to-skin time was <90' in 64, 90-120' in 48, >120' in 20, unknown in 10, and 162' mean in 39 high-risk procedures. Blood loss was <100mL in 76, <250mL in 48, and 537mL mean in 39 high-risk procedures. The technique was successfully applied in all (including nine dural repairs) without a single conversion. We observed an increased neurological deficit in two (1.1%) and inadequate decompression in merely one (wrong level). Complications (mainly pulmonary) were few and managed conservatively, except for a segmental artery pseudoaneurysm treated endovascularly. We observed a substantial decrease in acute and chronic postoperative pain. The technique is fast, straightforward, minimizes bone resection and blood loss, improves orientation, safely and effectively deals with any TDH, and prevents postoperative band-like pain as the CVJ is preserved. We hope this technique will find broader acceptance among a new generation of spine surgeons to benefit patients suffering TDH-related myelopathy or merely intractable pain.

High thoracic disc herniation: a case-based discussion with a review of literature

Aim This article aims to describe a case of a 28-year-old male patient with progressively worsening of myelopathic symptoms owing to a large T4-5 thoracic disc herniation with severe cord compression. Background A 28-year-old male patient was referred to the clinic by a neurologist for worsening of bilateral lower extremity numbness, tingling, and progressive weakness over a period of few months with a clinical examination significant for severe myelopathy and imaging confirming a large thoracic disc herniation. Procedure T4-5 left hemilaminectomy and transfacet discectomy with unilateral right T4/T5 fixation and fusion were done. Outcomes The patient experienced delayed postoperative paraplegia that was reversible despite negative imaging studies, suggesting intraoperative incidental trauma to the cord or progressive postoperative cord edema. Scientific message Literature review of similar cases is presented as well as learning points from this challenging case. If the posterior approach is to be used, complete thorough decompression of the cord is advisable to minimize the risk of complications.

Surgical treatment of herniated thoracic discs using transthoracic extrapleural approach

To analyze the results of herniated thoracic disc resection via transthoracic extrapleural approach. The study included 16 patients with 18 symptomatic herniated thoracic discs wo underwent transthoracic extrapleural surgery. In 11 cases, clinical pattern of disease was represented by myelopathy with radicular or axial pain syndrome. Five patients had radiculopathy alone. Median localization of hernias was observed in 8 (44.4%) cases, paramedian hernias - in 10 (55.6%) cases. There were 10 (55.6%) ossified hernias, 5 (27.7%) giant, 10 (55.5%) large and 3 (16.6%) medium hernias. In most patients, VAS score of pain syndrome decreased by 2-6 points (mean 3.6). In 4 patients, this value remained the same. Among 11 patients with myelopathy, regression of conduction disorders in 1 year after surgery was achieved in 9 (82%) cases including complete recovery in 6 (55%) patients (Frankel E, Nurick - 0-I). In 2 patients, neurological status was equal to preoperative one. In all cases, the follow-up examination confirmed total removal of compressive substrate and found no signs of spine instability. Surgery time varied from 80 to 210 min (mean 161), blood loss - from 300 to 800 ml (mean 378 ml). Two patients had transient neurological deterioration. There was damage to dura mater in 4 cases. Intercostal neuralgia was observed in 3 patients. While retaining the advantages of open thoracotomy, transthoracic extrapleural approach is less traumatic, allows complete spinal cord decompression, minimizes the risk of iatrogenic spinal cord injury and avoids certain postoperative complications.

Outpatient endoscopic resection of large calcified thoracic disc herniation with caudal displacement.

Thoracic disc herniations can cause radiculopathy and myelopathy from neural compression. Surgical resection may require complex, morbid approaches. To avoid spinal cord retraction, wide exposures requiring extensive tissue, muscle, and bony disruption are needed, which may require instrumentation. Anterior approaches may require vascular surgeons, chest tube placement, and intensive care admission. Large, calcified discs or migrated fragments can pose additional challenges. Previous literature has noted the endoscopic approach to be contraindicated for calcified thoracic discs. The authors describe an ultra–minimally invasive, ambulatory endoscopic approach to resect a large calcified thoracic disc with caudal migration and avoidance of conventional approaches.The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID2112

Posterior Transdural Discectomy for Thoracic Disc Herniation.

Thoracic disc herniation is a challenging condition with severe neurological sequelae. Surgical management is still a matter of debate. Medical records of seven patients who underwent a posterior transdural discectomy for thoracic disc herniation was retrospectively evaluated. Between years 2012 and 2020, 7 patients (5 male and 2 female) with age ranged between 17 and 74 were operated with posterior transdural discectomy Numbness is the most common presenting symptom and 2 patients were complaint with urinary incontinance. T10-11 was the most effected level. All the patients underwent at least 6 months follow-up. There were no postoperative CSF leak and neurological complications due to the surgery. All the patients were remained at their baseline neurological status or improved after surgery. None of the patients experienced a secondary neurological deterioration or a need for further surgical treatment. The posterior transdural approach is a safe procedure that should be kept in mind in lateral and paracentral thoracic disc herniations providing a more direct approach.

Transdural approach for giant calcified herniated thoracic disc: a case report

Transdural approach for giant calcified herniated thoracic disc: a case report

T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach

To describe a cohort of T3-T4 thoracic disc herniations (TDHs), their clinical and radiologic characteristics, and unique thoracoscopic transaxillary approach (TAA). All patients operated on for a T3-T4 TDH with minimal follow-up of 1 year were selected. Eight TAA procedures (6 males and 2 females) were included (1.4%). Six patients reported axial pain, irradiating in 2, 4 sensory changes, 1 objective and 1 merely subjective motor weakness. Only 1 TDH was calcified, none was giant, 2 were accompanied by myelomalacia, and 2 by a small segmental syrinx. A cardiothoracic surgeon helped with exposure through a curved axillary incision using anterior cervical and more recently double-ring wound retractors. All patients were operated on using a 10-mm 30° rigid (three-dimensional) high-definition scope. There were no major complications and a good outcome with symptomatic relief in 7 of 8 patients. T3-T4 TDHs are infrequent but may be underdiagnosed because they tend to be small and their signs and symptoms may mimic a cervical problem involving the shoulders and even the arms. There may be a male predominance. The TAA is straightforward, safe, efficacious, and well tolerated despite the supposed vulnerability of the upper thoracic spinal cord. Dissection between large crowded subpleural veins characteristic for the upper thoracic spine and ensuring adequate dura decompression when the steep angle may partially obscure the tip of the instruments does require some extra time. Thorough knowledge of the unique anatomy of the upper thorax is mandatory and the assistance of a cardiothoracic surgeon is highly recommended.

Posterior-only approach for the treatment of symptomatic central thoracic disc herniation regardless of calcification: A consecutive case series of 30 cases over five years

PurposeTo report the safety and efficacy of posterolateral approach for thoracic disc herniation (TDH) via a consecutive clinical case series of 30 central thoracic disc herniations that were all operated through a posterolateral approach. MethodsA retrospective review was conducted of all patients with symptomatic TDH who underwent surgical intervention from 2016 to 2021. A total of 23 patients comprising 30 central TDH were included in the study. Age, gender, location of the lesion, preoperative and post-operative Frankel and Nurick scores, surgical approach and instrumented vertebrae, and length of stay were recorded. Findings23 patients with an average age of 62 were included in the study. 30 of the 32 symptomatic TDH were centrally located. 8/32 TDH were calcified while 24/32 TDH were non-calcified. Unilateral and bilateral transpedicular approach was used in the treatment of 12/32 and 10/32 disc herniations respectively. A transfacet-pedicle sparing approach was used in 10/32 disc herniations. 19/23 (82.6%) of the patients had improvement in Nurick score while 12/23 (52.2%) patients had improvement in their Frankel scores. The average length of stay was 4.5 days. No major complications were encountered. All patients underwent a short-segment instrumented construct with no need for revision surgery for thoracic disc herniation, worsening myelopathy, or instrumentation failure. Conclusions83% of the patients who underwent a transfacet or transpedicular decompression for the treatment of symptomatic TDH had improvement in their myelopathy with no neurological deterioration in any of the patients. Given the familiarity and low morbidity associated with a transfacet or transpedicular approach, posterolateral-based approaches remains an excellent alternative for surgical management of majority of the patients with thoracic disc herniations

Letter to the Editor Regarding “Prevalence and Distribution of Incidental Thoracic Disc Herniation, and Thoracic Hypertrophied Ligamentum Flavum in Patients with Back or Leg Pain: A Magnetic Resonance Imaging−Based Cross-Sectional Study”

Letter to the Editor Regarding “Prevalence and Distribution of Incidental Thoracic Disc Herniation, and Thoracic Hypertrophied Ligamentum Flavum in Patients with Back or Leg Pain: A Magnetic Resonance Imaging−Based Cross-Sectional Study”

Management of Thoracic Disc Herniation Using the Mini-Open Retropleural Approach: Technique Illustration and Clinical Outcomes of 33 Patients From a Single Academic Center

Noureldine, Mohammad Hassan A MD, MSc; Pressman, Elliot MD; Krafft, Paul R MD; Molcanyi, Marek MD, PhD; Tran, Nam D MD, PhD; Greenberg, Mark S MD; Alikhani, Puya MD