Circumferential dural resection technique and reconstruction for the removal of giant calcified transdural herniated thoracic discs

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The authors report a novel paradigm for resection of the disc or dural complex to treat giant calcified transdural herniated thoracic discs, and they describe a technique for the repair of dural defects. These herniated thoracic discs are uncommon, complicated lesions that often require a multidisciplinary team for effective treatment. The intradural component must be removed to effectively decompress the spinal cord. The opening of the friable dura mater, which frequently adheres to the extradural component of the disc, can result in large defects and difficult-to-manage CSF leaks.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The authors performed a retrospective study of the technique and outcomes in patients with a transdural herniated disc treated at St. Joseph’s Hospital and Medical Center within a 4-year period between 2012 and 2015.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>During the study period, 7 patients (mean age 56.1 years) presented to the department of neurosurgery with clinical symptoms consistent with myeloradiculopathy. In all cases, 2-level corpectomies of the involved levels were combined with circumferential resection of the dura and complete decompression of the spinal cord. The dural defect was repaired with an onlay dural patch, and a large piece of AlloDerm (LifeCell Corp) graft was sewn to close the pleural defect. Every patient had a perioperative lumbar drain placed for CSF diversion. No patient suffered neurological decline related to the surgery, and 3 patients experienced clinically significant improvement in function. Two patients developed an early postoperative CSF leak that required operative revision to oversew the defects.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>This novel technique for decompression of the spinal cord by dural resection for the removal of giant calcified transdural herniated thoracic discs is safe and results in excellent decompression of the spinal cord. The technique becomes necessary when primary repair of the dura is not possible, and it can be used in cases in which the resection of pathology includes the dura.</jats:p></jats:sec>

Reliability of a Novel Classification System for Thoracic Disc Herniations

“…Alternative surgical corridors to the ventral aspect of the thoracic spine use anterior and anterolateral approaches, including open thoracotomy, thoracoscopy, and minimally invasive lateral retropleural approaches. [4][5][6][7][8]10 These treatment approaches focus on ventral bone removal (partial or complete corpectomies) via transthoracic or retropleural corridors.…”

“…These TDHs are typically calcified and therefore fit in types 3C or 4C categories. In 2018, Walker et al 6 described an anterolateral treatment approach with circumferential dural resection for patients with these lesions via open thoracotomy. After corpectomies above and below the segment, the transgressed dura was sharply dissected around the TDH and a dural graft was placed.…”

“…These TDHs are typically calcified and therefore fit in types 3C or 4C categories. In 2018, Walker et al 6 . described an anterolateral treatment approach with circumferential dural resection for patients with these lesions via open thoracotomy.…”

“…Treatments have previously included traditional posterior or posterolateral surgical approaches, 2 as well as anterolateral approaches such as open thoracotomy, thoracoscopy, and minimally invasive lateral retropleural approaches. [4][5][6][7][8] To standardize the characterization of patients with TDHs, we propose a comprehensive novel classification system. We also sought to confirm the reliability of this system by surveying a panel of expert spine surgeons.…”

“…However, pertinent characteristics may dictate treatment approaches and influence clinical outcomes. Treatments have previously included traditional posterior or posterolateral surgical approaches, 2 as well as anterolateral approaches such as open thoracotomy, thoracoscopy, and minimally invasive lateral retropleural approaches 4–8 …”