Surgical treatment of thoracic disc herniation: an overview

Abstract

Background Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord. Methods Literature review. Results Symptomatic TDH is a rare condition predominantly localized between T8 and L1. Surgical indications include intractable back or radicular pain, neurological deficits, and myelopathy signs. Giant calcified TDH (> 40% spinal canal occupation) are frequently associated with myelopathy, intradural extension, and post-operative complications. Careful pre-operative planning helps reduce the risk of complications. Pre-operative CT and MRI identify the hernia's location and size, calcifications, and intradural extension. The approach must provide adequate dural sac visualization with minimal manipulation of the cord. Nonanterior approaches are favoured if they provide at least equal exposure than anterior approach owing to higher risk of pulmonary morbidity associated with anterior approach. A transthoracic approach is recommended for central calcified herniated discs. A posterolateral approach is often suitable for non-calcified lateralized TDH. Thoracoscopic approaches are less invasive but have a substantial learning curve. Retropleural mini-thoracotomy is an acceptable alternative. Pre-operative identification of the pathological level is confirmed by intra-operative level check. Intra-operative cord monitoring is preferable but warrant further studies. Magnification and adequate lightening of the surgical field are paramount (microscope, thoracoscopy). Intra-operative CT scan with navigation is becoming increasingly popular since it provides real-time control on the decompression. Indications of fusion consist of pre-operative back pain, Scheuermann's disease, multilevel resection, wide vertebral body resection (> 50%), and herniation at thoracolumbar junction. Neurological deterioration, dural tear, and subarachnoid-pleural fistula are the most severe complications. Conclusion Further improvements are still warranted in thoracic spine surgery despite the advent of minimally invasive techniques. Intra-operative CT scan will probably enhance the safety of the TDH surgery.

Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases

“… 15 – 17 If they provide equal ventral exposure like anterior approach, nonanterior approaches for TDP can be favoured. 30 This is quite evident by all strategies we adopted, adequate ventral exposure can be achieved. Complete 360-degree decompression with restoration of cerebrospinal flow and sphericity of cord was the ultimate goal and achieved in all 18 myelopathic patients.…”

“…5,9,29,30 Postoperative pneumonia, cerebrospinal fluid leakage, pulmonary embolism, deep vein thrombosis, intensive care unit stays, readmissions, longer hospital stay, and intercostal neuralgia have been serious sequelae with anterior approach. 5,9,30 In contrast to cervical and lumbar canal, thoracic canal is smaller and difficult to enter and explore ventrally without a facetectomy. Different variations and extensions of the approach were followed by us to increase the working angle of the surgeon directly to the ventrally located disc (Figure 3).…”

Thoracic Disc Herniation Manifesting as Abdominal Pain Alone Associated with Thoracic Radiculopathy

“…Fusion may be avoided if the lateral portion of the facet joint is preserved. 21 , 22) As reported by Kim et al 27) and Schlenzka et al, 28) an O-arm-based navigation system helped to firmly identify the spinal anatomy. We could determine the extent of the bone resection and muscles dissection with the image guidance technique resulting in preservation of more than half of the facet joint.…”

“…Surgical treatment is indicated in the case of medically refractory pain or progressive myelopathy. 21 , 22) Several surgical approaches have been suggested for the removal of TDH without manipulating the spinal cord. These procedures are classified into posterolateral, posterior, lateral transthoracic approach, and less invasive techniques using image-guided thoracoscopy, endoscope, and novel retractor system.…”

Disc herniation and disc disease: the present and the future of management

“…As for the thoracic region, Bouthors et al [8] remind us that disc herniations (TDH) are a relatively rare occurrence and that their surgical management is technically demanding due to the difficulty of spinal cord dural sac visualization. Nonanterior approaches are favoured owing to higher risk of pulmonary morbidity associated with anterior approach.…”