1
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Sofoluke N, Leyendecker J, Barber S, Reardon T, Bieler E, Patel A, Kashlan O, Bredow J, Eysel P, Gardocki RJ, Hasan S, Telfeian AE, Hofstetter CP, Konakondla S. Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis. Neurosurgery 2024:00006123-990000000-01222. [PMID: 38899868 DOI: 10.1227/neu.0000000000003034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/25/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Surgical treatment for symptomatic thoracic disc herniations (TDH) involves invasive open surgical approaches with relatively high complication rates and prolonged hospital stays. Although advantages of full endoscopic spine surgery (FESS) are well-established in lumbar disc herniations, data are limited for the endoscopic treatment of TDH despite potential benefits regarding surgical invasiveness. The aim of this study was to provide a comprehensive evaluation of potential benefits of FESS for the treatment of TDH. METHODS PubMed, MEDLINE, EMBASE, and Scopus were systematically searched for the term "thoracic disc herniation" up to March 2023 and study quality appraised with a subsequent meta-analysis. Primary outcomes were perioperative complications, need for instrumentation, and reoperations. Simultaneously, we performed a multicenter retrospective evaluation of outcomes in patients undergoing full endoscopic thoracic discectomy. RESULTS We identified 3190 patients from 108 studies for the traditional thoracic discectomy meta-analysis. Pooled incidence rates of complications were 25% (95% CI 0.22-0.29) for perioperative complications and 7% (95% CI 0.05-0.09) for reoperation. In this cohort, 37% (95% CI 0.26-0.49) of patients underwent instrumentation. The pooled mean for estimated blood loss for traditional approaches was 570 mL (95% CI 477.3-664.1) and 7.0 days (95% CI 5.91-8.14) for length of stay. For FESS, 41 patients from multiple institutions were retrospectively reviewed, perioperative complications were reported in 4 patients (9.7%), 4 (9.7%) required revision surgery, and 6 (14.6%) required instrumentation. Median blood loss was 5 mL (IQR 5-10), and length of stay was 0.43 days (IQR 0-1.23). CONCLUSION The results suggest that full endoscopic thoracic discectomy is a safe and effective treatment option for patients with symptomatic TDH. When compared with open surgical approaches, FESS dramatically diminishes invasiveness, the rate of complications, and need for prolonged hospitalizations. Full endoscopic spine surgery has the capacity to alter the standard of care for TDH treatment toward an elective outpatient surgery.
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Affiliation(s)
- Nelson Sofoluke
- Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA
| | - Jannik Leyendecker
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Sean Barber
- Department of Neurosurgery, Houston Methodist Neurological Institute, Houston, Texas, USA
| | - Taylor Reardon
- Kentucky College of Osteopathic Medicine, University of Pikeville, Pikeville, Kentucky, USA
| | - Eliana Bieler
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
| | - Akshay Patel
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Osama Kashlan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
- University Hospital Cologne, Cologne, Germany
| | - Jan Bredow
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
- Department of Orthopedics and Trauma Surgery, Krankenhaus Porz am Rhein, University of Cologne, Cologne, Germany
| | - Peer Eysel
- Department of Orthopedics and Trauma Surgery, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Raymond J Gardocki
- Department of Orthopedic Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Saqib Hasan
- Golden State Orthopedics and Spine, Oakland, California, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Warren Alpert School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Christoph P Hofstetter
- Department of Neurological Surgery, The University of Washington, Seattle, Washington, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Geisinger Neuroscience Institute, Danville, Pennsylvania, USA
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2
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Rujeedawa T, Mowforth OD, Davies BM, Yang C, Nouri A, Francis JJ, Aarabi B, Kwon BK, Harrop J, Wilson JR, Martin AR, Rahimi-Movaghar V, Guest JD, Fehlings MG, Kotter MR. Degenerative Thoracic Myelopathy: A Scoping Review of Epidemiology, Genetics, and Pathogenesis. Global Spine J 2024; 14:1664-1677. [PMID: 38146739 DOI: 10.1177/21925682231224768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
STUDY DESIGN Literature Review. OBJECTIVE Myelopathy affecting the thoracic spinal cord can arise secondary to several aetiologies which have similar presentation and management. Consequently, there are many uncertainties in this area, including optimal terminology and definitions. Recent collaborative cervical spinal research has led to the proposal and subsequent community adoption of the name degenerative cervical myelopathy(DCM), which has facilitated the establishment of internationally-agreed research priorities for DCM. We put forward the case for the introduction of the term degenerative thoracic myelopathy(DTM) and degenerative spinal myelopathy(DSM) as an umbrella term for both DCM and DTM. METHODS Following PRISMA guidelines, a systematic literature search was performed to identify degenerative thoracic myelopathy literature in Embase and MEDLINE. RESULTS Conditions encompassed within DTM include thoracic spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, calcification of ligaments, hypertrophy of ligaments, degenerative disc disease, thoracic osteoarthritis, intervertebral disc herniation, and posterior osteophytosis. The classic presentation includes girdle pain, gait disturbance, leg weakness, sensory disturbance, and bladder or bowel dysfunction, often with associated back pain. Surgical management is typically favoured with post-surgical outcomes dependent on many factors, including the causative pathology, and presence of additional stenosis. CONCLUSION The clinical entities encompassed by the term DTM are interrelated, can manifest concurrently, and present similarly. Building on the consensus adoption of DCM in the cervical spine and the recent proposal of degenerative cervical radiculopathy(DCR), extending this common nomenclature framework to the terms degenerative spinal myelopathy and degenerative thoracic myelopathy will help improve recognition and communication.
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Affiliation(s)
- Tanzil Rujeedawa
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Oliver D Mowforth
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Benjamin M Davies
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Cylene Yang
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Aria Nouri
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Jibin J Francis
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | | | - Brian K Kwon
- Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - James Harrop
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Allan R Martin
- Department of Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - James D Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Michael G Fehlings
- Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mark R Kotter
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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3
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Pojskić M, Bopp MHA, Nimsky C, Saß B. Surgical Treatment of Calcified Thoracic Herniated Disc Disease via the Transthoracic Approach with the Use of Intraoperative Computed Tomography (iCT) and Microscope-Based Augmented Reality (AR). MEDICINA (KAUNAS, LITHUANIA) 2024; 60:887. [PMID: 38929504 PMCID: PMC11206109 DOI: 10.3390/medicina60060887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: The aim of this study is to present our experience in the surgical treatment of calcified thoracic herniated disc disease via a transthoracic approach in the lateral position with the use of intraoperative computed tomography (iCT) and augmented reality (AR). Materials and Methods: All patients who underwent surgery for calcified thoracic herniated disc via a transthoracic transpleural approach at our Department using iCT and microscope-based AR were included in the study. Results: Six consecutive patients (five female, median age 53.2 ± 6.4 years) with calcified herniated thoracic discs (two patients Th 10-11 level, two patients Th 7-8, one patient Th 9-10, one patient Th 11-12) were included in this case series. Indication for surgery included evidence of a calcified thoracic disc on magnet resonance imaging (MRI) and CT with spinal canal stenosis of >50% of diameter, intractable pain, and neurological deficits, as well as MRI-signs of myelopathy. Five patients had paraparesis and ataxia, and one patient had no deficit. All surgeries were performed in the lateral position via a transthoracic transpleural approach (Five from left side). CT for automatic registration was performed following the placement of the reference array, with a high registration accuracy. Microscope-based AR was used, with segmented structures of interest such as vertebral bodies, disc space, herniated disc, and dural sac. Mean operative time was 277.5 ± 156 min. The use of AR improved orientation in the operative field for identification, and tailored the resection of the herniated disc and the identification of the course of dural sac. A control-iCT scan confirmed the complete resection in five patients and incomplete resection of the herniated disc in one patient. In one patient, complications occurred, such as postoperative hematoma, and wound healing deficit occurred. Mean follow-up was 22.9 ± 16.5 months. Five patients improved following surgery, and one patient who had no deficits remained unchanged. Conclusions: Optimal surgical therapy in patients with calcified thoracic disc disease with compression of dural sac and myelopathy was resectioned via a transthoracic transpleural approach. The use of iCT-based registration and microscope-based AR significantly improved orientation in the operative field and facilitated safe resection of these lesions.
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Affiliation(s)
- Mirza Pojskić
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
| | - Miriam H. A. Bopp
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35032 Marburg, Germany;
| | - Christopher Nimsky
- Marburg Center for Mind, Brain and Behavior (MCMBB), 35032 Marburg, Germany;
| | - Benjamin Saß
- Department of Neurosurgery, University of Marburg, 35039 Marburg, Germany; (M.H.A.B.); (B.S.)
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4
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Farber SH, Walker CT, Zhou JJ, Godzik J, Gandhi SV, de Andrada Pereira B, Koffie RM, Xu DS, Sciubba DM, Shin JH, Steinmetz MP, Wang MY, Shaffrey CI, Kanter AS, Yen CP, Chou D, Blaskiewicz DJ, Phillips FM, Park P, Mummaneni PV, Fessler RD, Härtl R, Glassman SD, Koski T, Deviren V, Taylor WR, Kakarla UK, Turner JD, Uribe JS. Reliability of a Novel Classification System for Thoracic Disc Herniations. Spine (Phila Pa 1976) 2024; 49:341-348. [PMID: 37134139 DOI: 10.1097/brs.0000000000004701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/14/2022] [Indexed: 05/04/2023]
Abstract
STUDY DESIGN This is a cross-sectional survey. OBJECTIVE The aim was to assess the reliability of a proposed novel classification system for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA TDHs are complex entities varying substantially in many factors, including size, location, and calcification. To date, no comprehensive system exists to categorize these lesions. METHODS Our proposed system classifies 5 types of TDHs using anatomic and clinical characteristics, with subtypes for calcification. Type 0 herniations are small (≤40% of spinal canal) TDHs without significant spinal cord or nerve root effacement; type 1 are small and paracentral; type 2 are small and central; type 3 are giant (>40% of spinal canal) and paracentral; and type 4 are giant and central. Patients with types 1 to 4 TDHs have correlative clinical and radiographic evidence of spinal cord compression. Twenty-one US spine surgeons with substantial TDH experience rated 10 illustrative cases to determine the system's reliability. Interobserver and intraobserver reliability were determined using the Fleiss kappa coefficient. Surgeons were also surveyed to obtain consensus on surgical approaches for the various TDH types. RESULTS High agreement was found for the classification system, with 80% (range 62% to 95%) overall agreement and high interrater and intrarater reliability (kappa 0.604 [moderate to substantial agreement] and kappa 0.630 [substantial agreement], respectively). All surgeons reported nonoperative management of type 0 TDHs. For type 1 TDHs, most respondents (71%) preferred posterior approaches. For type 2 TDHs, responses were roughly equivalent for anterolateral and posterior options. For types 3 and 4 TDHs, most respondents (72% and 68%, respectively) preferred anterolateral approaches. CONCLUSIONS This novel classification system can be used to reliably categorize TDHs, standardize description, and potentially guide the selection of surgical approach. Validation of this system with regard to treatment and clinical outcomes represents a line of future study.
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Affiliation(s)
- S Harrison Farber
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Corey T Walker
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - James J Zhou
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jakub Godzik
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Shashank V Gandhi
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Bernardo de Andrada Pereira
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Robert M Koffie
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - David S Xu
- Department of Neurosurgery, Baylor University, Houston, TX
| | - Daniel M Sciubba
- Department of Neurosurgery, Zucker School of Medicine at Hofstra University, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Brigham and Women's Hospital, Boston, MA
| | | | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami Hospital, Miami, FL
| | | | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA
| | - Dean Chou
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Frank M Phillips
- Department of Neurological Surgery, Rush University, Chicago, IL
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | | | - Roger Härtl
- Department of Neurosurgery, Weill Cornell Medicine, New York, NY
| | | | - Tyler Koski
- Department of Neurological Surgery, Northwestern University, Chicago, IL
| | - Vedat Deviren
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA
| | - William R Taylor
- Department of Neurosurgery, University of California San Diego, San Diego, CA
| | - U Kumar Kakarla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
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5
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D'Aliberti G, Villa F, Giorgi P, Crisà FM, Gribaudi G, Mastino L, Auricchio AM, Cenzato M, Talamonti G. Giant calcified thoracic disk herniations: ossification of PLL or autonomous entity? J Neurosurg Sci 2024; 68:70-79. [PMID: 32734747 DOI: 10.23736/s0390-5616.20.04938-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of ossified posterior longitudinal ligament (OPLL) with a possible common pathophysiology consisting in the dural violation. METHODS Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital, Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed. RESULTS There was no mortality, whereas permanent morbidity consisted of 1 case of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL. CONCLUSIONS GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.
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Affiliation(s)
| | - Fabio Villa
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
| | - Pietro Giorgi
- Department of Orthopedics and Traumatology, ASST Niguarda Hospital, Milan, Italy
| | - Francesco M Crisà
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy -
- University of Milan, Milan, Italy
| | - Giulia Gribaudi
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
- University of Milan, Milan, Italy
| | - Lara Mastino
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
- Sapienza University, Rome, Italy
| | - Anna M Auricchio
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
- Sacred Heart Catholic University, Rome, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Niguarda Hospital, Milan, Italy
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6
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Davidar AD, Hersh AM, Theodore N. Abra-ka-diskus: Vanishing Calcified Herniated Thoracic Disk. World Neurosurg 2023; 180:146-148.e1. [PMID: 37778626 DOI: 10.1016/j.wneu.2023.09.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/22/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
Herniated thoracic disk has an incidence of 1/1 million. Treatment options for a calcified herniated disk include conservative management or diskectomy with or without fusion. We describe a patient who presented a year ago with a 5-month history of back pain, thoracic radiculopathy, and normal physical examination. Imaging revealed a giant calcified herniated thoracic disk at T10-T11. She underwent epidural steroid injections and chiropractic manipulation. Imaging obtained at 1-year follow-up showed near-complete resorption of the calcified thoracic disk.
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Affiliation(s)
- A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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7
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Yuan L, Chen Z, Liu Z, Liu X, Li W, Sun C. Comparison of Anterior Approach and Posterior Circumspinal Decompression in the Treatment of Giant Thoracic Discs. Global Spine J 2023; 13:17-24. [PMID: 33511881 PMCID: PMC9837516 DOI: 10.1177/2192568221989964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The treatment of giant thoracic disc herniation (gTDH)remains challenging for surgeons worldwide because of its large volume and calcified or ossified nature and the limitations of the prior small-sample-size, single-center studies reporting comparative effectiveness. We aim to compare the anterior decompression and spinal fusion (ASF) and posterior circumspinal decompression and spinal fusion (PCDF) for patients with myelopathy due to gTDH in the largest study to date by sample size. METHODS Preoperative and postoperative functional status, surgical details, and complication rates were compared between the 2 groups. RESULTS A total of 186 patients were included: 63 (33.9%) ASF and 123(66.1%) PCDF. The PCDF group had significantly shorter operation duration (163.06 ± 53.49 min vs. 180.78 ± 52.06 min, P = 0.032) and a significant decrease in intraoperative blood loss(716.83 mL vs. 947.94 mL, P = 0.045), and also a shorter hospital length of stay (LOS) and postoperative LOS (6 vs. 7, P = 0.011). The perioperative complication rate (13.8% vs. 28.6%, P = 0.015) and surgery-associated complication rate(13.0% vs. 27.0%, P = 0.018) were significantly higher in the ASF group. A higher rate of complete decompression was achieved in the PCDF group. There were no observed significant differences in changes in functional status between the 2 groups. CONCLUSION PCDF for central or paracentral gTDHs is a highly effective and reliable technique. It can be performed safely with a low complication rate. If either procedure can adequately excise a central or paracentral gTDH, a PCDF approach may be a better option.
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Affiliation(s)
- Lei Yuan
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Zhongqiang Chen
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China,Zhongqiang Chen, MD, Department of
Orthopedics, Peking University Third Hospital, No 49, North Garden Street, Hai
Dian District, Beijing 100191, China.
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
| | - Chuiguo Sun
- Department of Orthopedics, Peking University Third Hospital, Beijing, China,Beijing Key Laboratory of Spinal Disease
Research, Peking University Third Hospital, Beijing, China,Engineering Research Center of Bone and
Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, Beijing, China
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8
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Gaddikeri MB, Srivastava SK, Patil P, Naseem A, Agrawal H. Long-term operative outcome of giant calcified thoracic disc herniation – A retrospective analysis of 24 patients. Surg Neurol Int 2022; 13:526. [DOI: 10.25259/sni_798_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background:
Thoracic disc herniations (TDHs) are rare (0.15–4%) and often cause significant myelopathy (70–95%). They are defined as “Giant” if they occupy >40% of the spinal canal. Further, they are ossified/calcified in 42% of cases, with a 70% incidence of intradural extension. Here, we reviewed our experience resecting 24 giant thoracic discs utilizing a posterolateral surgical approach.
Methods:
Over a 2-year period, we evaluated the outcomes for 24 patients averaging 40 years of age undergoing posterolateral resections of giant ossified/calcified TDH. We evaluated multiple clinical and radiographic parameters; demographics, Frankel grades, surgical time, perioperative complications, and number of levels involved. In addition, utilizing magnetic resonance/computed tomography studies, we documented that the most commonly involved level was T11–T12, and the average canal occupancy ratio (i.e., degree of canal encroachment) was 58.2 ± 7.72%.
Results:
Neurological improvement was seen in 22 of the 24 patients; none experienced neurological deterioration over the average 2-year post-operative period. Six complications occurred; three dural tears and three suture site infections.
Conclusion:
The posterolateral approach proved to be safe and effectively for resecting 24 giant ossified/calcified TDH with minimum complications.
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Affiliation(s)
- Manojkumar B. Gaddikeri
- Department of Orthopaedics, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India,
| | | | - Praveen Patil
- Department of Orthopaedics, Diana, Princess of Wales Hospital, Grimsby, United Kingdom,
| | - Atif Naseem
- Department of Orthopaedics and Spine Surgery, Bharat Ratna Dr. Babasaheb Ambedkar Memorial Hospital, Mumbai, Maharashtra, India
| | - Harsh Agrawal
- Department of Orthopaedics and Spine Surgery, Bharat Ratna Dr. Babasaheb Ambedkar Memorial Hospital, Mumbai, Maharashtra, India
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9
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Mukaihata T, Shiga Y, Inage K, Eguchi Y, Ohtori S, Orita S. Anterior Spinal Surgery Requiring Thoracotomy for Post-Operative Hematoma Removal: Two Case Reports. J Orthop Case Rep 2022; 12:75-78. [PMID: 36659895 PMCID: PMC9826674 DOI: 10.13107/jocr.2022.v12.i07.2924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/20/2022] [Indexed: 01/22/2023] Open
Abstract
Introduction We report two cases that required revision surgery with thoracotomy for massive hematoma after anterior kyphorectomy surgery. Case Report A woman with significant thoracolumbar kyphosis due to L1 vertebral fracture showed associated vertebral instability and pain resistant to conservative treatment.She underwent surgery for a one-stage anterior kypholectomy with spinal fusion. We performed an extrapleural approach. On the 4th post-operative day, the patient developed respiratory distress with decreased SpO2. Contrast-enhanced computed tomography (CT) revealed a left hemothorax with active bleeding. Revision surgery was performed to arrest the bleeding, and a large hematoma in the thoracic cavity was observed around the intercostal artery just below the skin incision, not around the surgical site.A man suffered from impaired activities of daily living caused by postural abnormalities due to severe kyphosis from vertebral fractures at the L1 and L2 vertebrae. Thus, we performed two-stage kypholectomy surgery. First, we performed posterior fixation with posterior facet resection. Then, corpectomy of the 1st and 2nd lumbar vertebrae through an anterior extrathoracic approach was performed. A CT scan on the 2nd post-operative day showed a massive hemopneumothorax, indicating persistent bleeding, and we performed a revision surgery to open the chest for additional hemostasis. Intraoperative findings showed a large hematoma, including reactive pleural effusion in the subcutaneous, retroperitoneal, and intrathoracic cavities. Conclusion We experienced two patients who required thoracotomy hematoma removal after anterior spinal surgery. Intraoperative patronage and adequate hemostasis are necessary to avoid post-operative complications such as hemothorax and hemopneumothorax.
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Affiliation(s)
- Tomohito Mukaihata
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan,Address of Correspondence: Dr. Tomohito Mukaihata, Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan. E-mail:
| | - Yasuhiro Shiga
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kazuhide Inage
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yawara Eguchi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Seiji Ohtori
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sumihisa Orita
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan,Department of Orthopaedic, Chiba University Center for Frontier Medical Engineering 1-33 Yayoi-cho, CFME room#B201, Inage-ku, Chiba, 263-8522, Japan
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10
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Feigl GC, Staribacher D, Kuzmin D. Minimally invasive dorsal approach in the surgery of giant thoracic disc herniation: technical note and clinical case report. World Neurosurg 2022; 165:154-158. [PMID: 35768057 DOI: 10.1016/j.wneu.2022.06.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 06/19/2022] [Accepted: 06/20/2022] [Indexed: 11/28/2022]
Abstract
Giant thoracic disc herniations are calcified hernias that fill more than 40% of the spinal canal and result in myelopathy with associated neurological symptoms. This is a fairly rare abnormality that requires surgical treatment. Currently, there is no unambiguous opinion about the surgical approach to the treatment this pathology. It is believed that the most effective method is the anterior approach (mini-thoracotomy or thoracoscopic approach), which reduces the risks of spinal cord injury, but is associated with the risks of damage to the lungs, pleura and major vessels. It is also quite large. We describe the case of a 60-year-old female patient with a giant thoracic disc herniation. Complete removal of the hernia through a minimally invasive dorsal approach was performed, followed by stabilization. No complications have been registered after the surgery. In this case, surgery resulted in a curative treatment outcome for the patient.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany; Department of Neurological Surgery, Houston Methodist Hospital, Houston, Texas, USA; Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany.
| | | | - Dzmitry Kuzmin
- Department of Neurosurgery, General Hospital Bamberg, Bamberg, Germany.
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11
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Cong M, Si M, Hou Y, Ma H, Nie L. Foot drop as the initial symptom caused by thoracic disc herniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1795-1801. [PMID: 35598203 DOI: 10.1007/s00586-022-07254-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/14/2022] [Accepted: 04/30/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Foot drop is a syndrome resulting from weakness or paralysis of the tibialis anterior muscle. Some patients with thoracic disc herniation seek medical help complain of foot drop as the initial symptom. The study investigated the clinical characteristics of these patients and clarified the clinical efficacy after treatment. METHODS A total of 13 patients with foot drop as the initial symptom arising from thoracic disc herniation were collected from January 2015 to December 2020. The average follow-up period was 20.5 months. We recorded neurological functions, the tibialis anterior muscle strength, Japanese Orthopedic Association score (JOA), location of the lesion, and occupation rate of herniation in the spinal canal preoperatively and at the final follow-up. RESULTS None pathological reflex was found in the patients. Surgical treatment was performed in 12 of the 13 patients, and tibialis anterior functional recovery was observed in 83.4% (10/12) of the cases, with an average recovery rate of 52.8 ± 18.5%. The mean JOA score increased from 6.8 ± 1.9 points preoperatively to 8.9 ± 1.3 points postoperatively (p < 0.05), achieving a mean recovery rate of 52.3 ± 13.1%. The MRI showed the conus medullaris was obviously compressed at the level of T11-L1, and the occupation rate of herniation was more than 40% in all patients, with an average of 65.4 ± 16.3%. CT indicated that 84.6% of the cases had calcification in intervertebral discs. CONCLUSION Foot drop can be the initial symptom caused by thoracic disc herniation at the T11-L1 level, especially for the calcified disc herniation. A satisfactory recovery rate can be achieved by surgical decompression with fixation.
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Affiliation(s)
- Menglin Cong
- Department of Spine Surgery, Qilu Hospital of Shandong University, Shandong University, Jinan, 250012, China
| | - Meng Si
- Department of Spine Surgery, Qilu Hospital of Shandong University, Shandong University, Jinan, 250012, China
| | - Yong Hou
- Department of Spine Surgery, Qilu Hospital of Shandong University, Shandong University, Jinan, 250012, China
| | - Hecheng Ma
- Department of Spine Surgery, Qilu Hospital of Shandong University, Shandong University, Jinan, 250012, China.
| | - Lin Nie
- Department of Spine Surgery, Qilu Hospital of Shandong University, Shandong University, Jinan, 250012, China
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12
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Cummins D, Callahan M, Clark AJ, Theologis AA. Lower Neurological Risk with Anterior Operations Compared to Posterior Operations for Thoracic Disc Herniations: Analysis of 697 Patients. Spine (Phila Pa 1976) 2022; 47:E94-E100. [PMID: 34381003 DOI: 10.1097/brs.0000000000004196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined. METHODS Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge. RESULTS Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01). CONCLUSION Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4.
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Affiliation(s)
- Daniel Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
| | - Matthew Callahan
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
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13
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Shedid D, Wang Z, Najjar A, Yuh SJ, Boubez G, Sebaaly A. Posterior Minimally Invasive Transpedicular Approach for Giant Calcified Thoracic Disc Herniation. Global Spine J 2021; 11:918-924. [PMID: 32677524 PMCID: PMC8258812 DOI: 10.1177/2192568220933275] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Retrospective case series. OBJECTIVE Posterior surgery for thoracic disc herniation was associated with increased morbidity and mortality and new minimally invasive approaches have been recommended for soft disc herniation but not for calcified central disc. The objective of this study is to describe a posterolateral microscopic transpedicular approach for central thoracic disc herniation. METHODS This is a single center retrospective review of all the cases of giant thoracic calcified disc herniation as defined by Hott et al. Presence of myelopathy, percentage of canal compromise, T2 hypersignal, ASIA score, and ambulatory status were recorded. This posterolateral technique using a tubular retractor was thoroughly described. RESULTS Eight patients were operated upon with a mean follow-up of 16 months. Mean canal compromise was 61%. Mean operative time was 228 minutes and mean operative bleeding was 250 mL. There were no cases of dural tear or neurologic degradation. CONCLUSION This is the first report of posterior minimally invasive transpedicular approach for giant calcified disc herniation. There were neither cases of neurological deterioration nor increased rate of dural tears. This technique is thus safe and could be recommended for treatment of this rare disease.
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Affiliation(s)
- Daniel Shedid
- Centre Hopitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
| | - Zhi Wang
- Centre Hopitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
| | - Ahmad Najjar
- Centre Hopitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
| | - Sung-Joo Yuh
- Centre Hopitalier de l’Université de Montréal (CHUM), Montréal, Quebec, Canada
| | | | - Amer Sebaaly
- Hotel Dieu de France Hospital, Beirut, Lebanon,Saint Joseph University, Beirut, Lebanon,Amer Sebaaly, Department of Orthopedic surgery, Spine Unit, Hotel Dieu de France Hospital, Alfred Naccache Street, Beirut, Lebanon.
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14
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Rusconi A, Roccucci P, Peron S, Stefini R. Spinal navigation applied to the anterior approach for the resection of thoracic disc herniation: patient series. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE21262. [PMID: 35854903 PMCID: PMC9245749 DOI: 10.3171/case21262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/18/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thoracic disc herniation (TDH) represents a challenge for spine surgeons. The goal of this study is to report the surgical technique and clinical results concerning the application of navigation to anterior transthoracic approaches. OBSERVATIONS Between 2017 and 2019, 8 patients with TDH were operated in the lateral decubitus by means of mini-open thoracotomy. An adapted patient referent frame was secured to the iliac wing. The high-speed drill was also navigated. Intraoperative three-dimensional scans were used for level identification, optimized drilling trajectory, and assessment of complete resection. At 12 months follow up, all patients were ambulatory. Seven out of 8 patients (87%) experienced a postoperative neurological improvement. We observed 2 postoperative complications: 1 case of pleural effusion and 1 case of abdominal wall weakness. LESSONS In order to increase the safety of anterior transthoracic discectomy, the authors applied the concepts of spinal navigation to the thoracotomy setting. The advantages of this technique include decrease in wrong-level procedure, continuous matching of intraoperative and navigation anatomical findings, better exposure of the TDH, optimized vertebral body drilling, and minimized risk of neurological damage. In conclusion, the authors consider spinal navigation as an important resource for the surgical treatment of patients with TDH.
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Affiliation(s)
- Angelo Rusconi
- Department of Neurosurgery, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Legnano Civil Hospital, Milan, Italy
| | - Paolo Roccucci
- Department of Neurosurgery, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Legnano Civil Hospital, Milan, Italy
| | - Stefano Peron
- Department of Neurosurgery, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Legnano Civil Hospital, Milan, Italy
| | - Roberto Stefini
- Department of Neurosurgery, Azienda Socio-Sanitaria Territoriale Ovest Milanese, Legnano Civil Hospital, Milan, Italy
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15
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Shin SH, Bae JS, Lee SH, Keum HJ, Jang WS. In Reply to the Letter to the Editor Regarding "Transforaminal Endoscopic Discectomy for Hard or Calcified Lumbar Disc Herniation: A New Surgical Technique And Clinical Outcomes". World Neurosurg 2020; 144:318-319. [PMID: 33227861 DOI: 10.1016/j.wneu.2020.08.223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Sang-Ha Shin
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea.
| | - Jun-Seok Bae
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Han-Joong Keum
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Won-Seok Jang
- Department of Anesthesiology, Wooridul Spine Hospital, Seoul, Korea
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"IV+V+VI" Circumferential Decompression Technique for Thoracic Myelopathy Caused by the Ossification of Posterior Longitudinal Ligament or Hard Disc Herniation. Spine (Phila Pa 1976) 2020; 45:1605-1612. [PMID: 32756269 DOI: 10.1097/brs.0000000000003617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE The aim of this study was to describe a novel posterior approach, circumspinal decompression technique "IV+V+VI" for ossification of the posterior longitudinal ligament (OPLL) or hard disc herniation (HDH) in thoracic spine and assess its safety and efficacy. SUMMARY OF BACKGROUND DATA Thoracic myelopathy caused by OPLL or HDH is a rare but intractable disorder that can only be effectively treated with surgery. Nevertheless, few studies have reported on a detailed resection of OPLL or HDH using a single posterior approach and no consistent procedures have been established. METHODS Fifteen consecutive patients with single-level OPLL or HDH who were treated with this novel technique at our center between January 2016 and June 2017 were recruited. The perioperative complications, operation time, blood loss, pre- and postoperative neurological statuses were recorded and analyzed. Neurological status was evaluated with a modified Japanese Orthopaedic Association (JOA) scale and the neurological recovery rate was calculated using the Hirabayashi's Method. RESULTS All the included patients underwent one-stage posterior circumferential decompression. The average age at surgery was 43.3 ± 12.8 years. Eight cases were diagnosed with HDH, four with OPLL, and three with OPLL+OLF (ossification of the ligamentum flavum). The mean operation time was 109.9 ± 25.3 minutes with an average blood loss of 433.3 ± 221.8 mL. The mean follow-up period was 33.1 ± 7.5 months. Five patients experienced a dural tear, whereas another case experienced a transient numbness in the right lower limb. All these patients were treated conservatively and their neurological function recovered well at the final follow-up. The average JOA score increased from 5.8 ± 1.9 before surgery to 10.2 ± 1.0 postoperatively, and the average recovery rate was 87.2%. CONCLUSION The "IV+V+VI" technique is a safe and effective method for thoracic OPLL and HDH resection. It can be used as a standard surgical procedure for thoracic spinal circumferential decompression. LEVEL OF EVIDENCE 4.
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17
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Posterior transdural resection of giant calcified thoracic disc herniation in a case series of 12 patients. Neurosurg Rev 2020; 44:2277-2282. [PMID: 33067681 PMCID: PMC8338809 DOI: 10.1007/s10143-020-01413-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/17/2020] [Accepted: 10/05/2020] [Indexed: 11/01/2022]
Abstract
Calcified thoracic disc herniations present a rare and challenging entity. Due to the close proximity to the spinal cord and relative narrowing of the spinal canal, the optimal approach remains a matter of debate. While the transthoracic approach is usually preferred, we adapted a new technique described in 2012: the transdural posterior approach. Our aim was to evaluate its benefits in patients with giant thoracic disc protrusions. We retrospectively reviewed all patients treated in our neurosurgical department from July 2012 to March 2020. Demographics, pre- and postoperative clinical status, and operative technique and complications were extracted and analyzed. In total, 12 patients underwent a posterior transdural resection of giant calcified thoracic hard discs between 2012 and 2020. All patients underwent a posterior decompression (laminectomy, hemilaminectomy, or laminoplasty). The median duration of surgery was 152 min. Transient postoperative neurological deterioration occurred in 4 patients, with complete recovery until time of discharge. No patient underwent a surgical revision. The transdural resection of giant calcified thoracic hard discs through a posterior approach provides an excellent decompression with sufficient visualization of the spinal cord and a satisfying postoperative outcome.
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18
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Beh SRW, Chandy S, Nazir F, Farooq U, Jamjoom AAB, Buchan K, Kamel M. Repair of durotomy using a pedicled thymopericardial fat pad following excision of thoracic intervertebral disc prolapse: A case report. Clin Neurol Neurosurg 2020; 198:106114. [PMID: 32763667 DOI: 10.1016/j.clineuro.2020.106114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Sean Rong-Wen Beh
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom.
| | - Shekinah Chandy
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
| | - Faiza Nazir
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
| | - Umar Farooq
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
| | - Aimun A B Jamjoom
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
| | - Keith Buchan
- Department of Cardiothoracic Surgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
| | - Mahmoud Kamel
- Department of Neurosurgery, Aberdeen Royal Infirmary, Scotland, United Kingdom
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19
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Shin SH, Bae JS, Lee SH, Keum HJ, Jang WS. Transforaminal Endoscopic Discectomy for Hard or Calcified Lumbar Disc Herniation: A New Surgical Technique and Clinical Outcomes. World Neurosurg 2020; 143:e224-e231. [PMID: 32712402 DOI: 10.1016/j.wneu.2020.07.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/14/2020] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Hard or calcified discs are often adherent to surrounding nerve tissue. The whole herniated disc is difficult to remove by pulling part of the hernia mass, which makes obtaining good results through endoscopic treatment difficult. The purpose of this study was to describe the details of the transforaminal endoscopic lumbar discectomy technique for a hard or calcified disc and report the clinical results. METHODS From October 2016 to June 2019, 43 consecutive cases diagnosed as hard or calcified lumbar disc herniation at our institution and treated with transforaminal endoscopic discectomy were evaluated. Endoscopic decompression was performed in patients with hard or calcified lumbar disc herniation. RESULTS The preoperative visual analog scale score for leg pain (mean ± standard deviation) was 7.09 ± 1.74. The score improved to 2.55 ± 1.35 at 1 week postoperatively, 1.88 ± 1.29 at 4 weeks postoperatively, and 1.58 ± 1.0 at 26 weeks postoperatively (P < 0.01 for all). The preoperative Oswestry Disability Index (mean ± standard deviation) was 55.4 ± 23.04, which improved to 30.89 ± 13.64 at 1 week postoperatively, 23.08 ± 11.64 at 4 weeks postoperatively, and 16.42 ± 9.76 at 26 weeks postoperatively (P < 0.01 for all). Two patients developed a dural laceration. Both patients were discharged after several hours of observation. None of the patients had postoperative infection, epidural hematoma, or delayed neurological deterioration. CONCLUSIONS Transforaminal endoscopic discectomy could be an effective treatment method for a selected group of patients with hard or calcified lumbar disc herniation.
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Affiliation(s)
- Sang-Ha Shin
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea.
| | - Jun-Seok Bae
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Sang-Ho Lee
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Han-Joong Keum
- Department of Neurosurgery, Wooridul Spine Hospital, Seoul, Korea
| | - Won-Seok Jang
- Department of Anesthesiology, Wooridul Spine Hospital, Seoul, Korea
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20
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Brotis AG, Tasiou A, Paterakis K, Tzerefos C, Fountas KN. Complications Associated with Surgery for Thoracic Disc Herniation: A Systematic Review and Network Meta-Analysis. World Neurosurg 2019; 132:334-342. [PMID: 31493617 DOI: 10.1016/j.wneu.2019.08.202] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 08/23/2019] [Accepted: 08/24/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND A systematic review and network meta-analysis (Prospero ID CRD42018106936) were performed. OBJECTIVE The selection of the appropriate surgical approach for the management of thoracic disc herniation (TDH) is often challenging because of the frequency and variability of the associated complications. We evaluated the safety of the surgical approaches for TDH by estimating the mortality (Q1) and morbidity (Q2), and frequency of the most common complications (Q3). METHODS We searched the medical literature for randomized controlled trials and observational studies reporting on the management of TDH. Postoperative complications were the outcome of interest. The absolute and relative risk estimates, along with the rank probability scores, were estimated for each approach, through a network meta-analysis. The results were read in the light of the quality of the available evidence. RESULTS Fifteen studies with a total of 1036 patients fulfilled our eligibility criteria. Three deaths were reported. The overall morbidity was as high as 29%, largely attributed to medical (21%; 95% confidence interval [CI], 10%-38%), surgical site (11%; 95% CI, 5%-22%), cerebrospinal fluid-related (8%; 95% CI, 3%-8%), and neurologic complications (5%; 95% CI, 1%-24%). The anterior and lateral approaches were associated with a higher risk for medical and surgical complications compared with the posterolateral approach. CONCLUSIONS Surgery for TDH is associated with minimal mortality but significant morbidity, with large variations among the available approaches. An understanding of the perioperative complications rates is important to develop complication avoidance strategies and to aid accurate patient-to-doctor communication.
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Affiliation(s)
- Alexandros G Brotis
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece.
| | - Anastasia Tasiou
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece
| | - Kostantinos Paterakis
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece; Medical School, University of Thessaly, Thessaly, Greece
| | - Christos Tzerefos
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece
| | - Kostas N Fountas
- Department of Neurosurgery, University Hospital of Larissa, Larissa, Thessaly, Greece; Medical School, University of Thessaly, Thessaly, Greece
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21
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Sharma SB, Kim JS. A Review of Minimally Invasive Surgical Techniques for the Management of Thoracic Disc Herniations. Neurospine 2019; 16:24-33. [PMID: 30943704 PMCID: PMC6449820 DOI: 10.14245/ns.1938014.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 03/14/2019] [Accepted: 03/15/2019] [Indexed: 11/19/2022] Open
Abstract
Thoracic disc herniation (TDH) is a rare, but technically challenging, disorder. Apart from their unfamiliarity with this condition, surgeons are often posed with challenges regarding the diverse methods available to address TDH, the neurological disturbances accompanying the disorder, the prospect of iatrogenic cord damage during surgical procedures, and the complications associated with various surgical approaches. In today's era, when minimally invasive surgery has been incorporated into almost every aspect of managing spine disorders, it is necessary for surgeons to be aware of the various minimally invasive techniques available for the management of these rare and difficult conditions. In this review article, we provide a synopsis of the epidemiology, clinical features, and technical aspects of TDH, starting from level identification to intraoperative neuromonitoring and including important steps and guidance for all the minimally invasive approaches to TDH. We conclude the review by providing insights into the clinical decision-making process and outline the specific aspects of "giant" thoracic discs and indications for fusion in certain conditions. Outcomes of minimally invasive surgery for these conditions are generally favorable. The location of herniation is an important factor for surgical planning.
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Affiliation(s)
- Sagar B. Sharma
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
| | - Jin-Sung Kim
- Department of Neurosurgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea
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22
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Desai B, Kolcun JPG, Shaffrey ME. Giant Thoracic Calcified Disk: Conservative Management with 3-Year Follow-Up. World Neurosurg 2019; 125:1-2. [PMID: 30703602 DOI: 10.1016/j.wneu.2019.01.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 01/04/2019] [Accepted: 01/08/2019] [Indexed: 11/28/2022]
Abstract
Calcified disk herniation of the thoracic spine is by no means a rare clinical entity in neurosurgery. We present a 63-year-old woman with a long-standing giant calcified disk in the thoracic spine. Initial imaging studies indicated a differential diagnosis of calcified disk versus meningioma. Given her benign neurologic examination and the presumed morbidity of attempting to resect the lesion, we elected to follow her closely with serial imaging. Over 3 years of consistent follow-up, the lesion has not grown and she has remained free of neurologic changes.
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Affiliation(s)
- Bhargav Desai
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - John Paul G Kolcun
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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23
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Thoracic disc herniation, avoidance, and management of the surgical complications. INTERNATIONAL ORTHOPAEDICS 2019; 43:817-823. [DOI: 10.1007/s00264-018-04282-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/26/2018] [Indexed: 02/06/2023]
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Bouthors C, Benzakour A, Court C. Surgical treatment of thoracic disc herniation: an overview. INTERNATIONAL ORTHOPAEDICS 2018; 43:807-816. [PMID: 30406842 DOI: 10.1007/s00264-018-4224-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 10/29/2018] [Indexed: 10/27/2022]
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. Non-anterior 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.
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Affiliation(s)
- Charlie Bouthors
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France.
| | - Ahmed Benzakour
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Charles Court
- Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de Paris, Paris-Sud University ORSAY, 78 Rue du Général Leclerc, 94275, Le Kremlin-Bicêtre, France
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Brauge D, Horodyckid C, Arrighi M, Reina V, Eap C, Mireau E, Bertrand B, Aldéa S, Gaillard S. Management of Giant Thoracic Disc Herniation by Thoracoscopic Approach: Experience of 53 Cases. Oper Neurosurg (Hagerstown) 2018; 16:658-666. [DOI: 10.1093/ons/opy250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 08/05/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Giant thoracic disc herniation (gTDH) is a rare condition. It is defined by a herniation that occupies at least 40% of the thoracic spinal canal and is usually calcified. Several surgical techniques have been described to date but this surgery remains a technically difficult procedure.
OBJECTIVE
To report the long-term outcome of 53 patients with myelopathy due to gTDH who were operated on by a thoracoscopic approach. The technical details of the preoperative assessment and the surgical procedure are presented.
METHOD
We present a retrospective study of a database of 53 patients operated for symptomatic gTDH by a thoracoscopic approach. The following clinical parameters were assessed initially and used during follow-up: Frankel grade and JOA score adapted to the thoracic spine (mJOA), pain in the lower limbs and limitation of the walking perimeter to less than 500 meters. The quality of spinal cord decompression was assessed postoperatively by magnet resonance imaging (MRI).
RESULTS
The mean follow-up was 78.1 mo (SD 49.4). At the last follow-up visit, clinical examination showed a mean improvement of 0.91 Frankel grade (P < 0.001) and 2.56 mJOA score respectively (P < 0.001). Lower limb pain and walking perimeter were also improved. Postoperative MRI revealed that the resection was complete in 35 cases, subtotal in 13 cases, and incomplete in 5 cases.
CONCLUSION
gTDH is a condition that often evolves favorably after surgery. The thoracoscopic approach is a feasible alternative technique.
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Affiliation(s)
- David Brauge
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
- Institut de Biomécanique Humaine Georges Charpak, Arts et Métiers Paris Tech, Paris, France
| | | | - Marta Arrighi
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
| | - Vincent Reina
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
| | - Christophe Eap
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
| | - Etienne Mireau
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
| | | | - Sorin Aldéa
- Service de Neurochirurgie, Hôpital Foch, Suresnes, France
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Surgery for Giant Calcified Herniated Thoracic Discs: A Systematic Review. World Neurosurg 2018; 118:109-117. [DOI: 10.1016/j.wneu.2018.06.232] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/25/2018] [Accepted: 06/27/2018] [Indexed: 11/21/2022]
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Court C, Mansour E, Bouthors C. Thoracic disc herniation: Surgical treatment. Orthop Traumatol Surg Res 2018; 104:S31-S40. [PMID: 29225115 DOI: 10.1016/j.otsr.2017.04.022] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/20/2017] [Accepted: 04/21/2017] [Indexed: 02/02/2023]
Abstract
Thoracic disc herniation is rare and mainly occurs between T8 and L1. The herniation is calcified in 40% of cases and is labeled as giant when it occupies more than 40% of the spinal canal. A surgical procedure is indicated when the patient has severe back pain, stubborn intercostal neuralgia or neurological deficits. Selection of the surgical approach is essential. Mid-line calcified hernias are approached from a transthoracic incision, while lateralized soft hernias can be approached from a posterolateral incision. The complication rate for transthoracic approaches is higher than that of posterolateral approaches; however, the former are performed in more complex herniation cases. The thoracoscopic approach is less invasive but has a lengthy learning curve. Retropleural mini-thoracotomy is a potential compromise solution. Fusion is recommended in cases of multilevel herniation, herniation in the context of Scheuermann's disease, when more than 50% bone is resected from the vertebral body, in patients with preoperative back pain or herniation at the thoracolumbar junction. Along with complications specific to the surgical approach, the surgical risks are neurological worsening, dural breach and subarachnoid-pleural fistulas. Giant calcified herniated discs are the largest contributor to myelopathy, intradural extension and postoperative complications. Some of the technical means that can be used to prevent complications are explored, along with how to address these complications.
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Affiliation(s)
- C Court
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France.
| | - E Mansour
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - C Bouthors
- Centre hospitalier universitaire de Bicêtre, Assistance publique-Hôpitaux de Paris, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
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Walker CT, Kalani MYS, Oppenlander ME, Godzik J, Martirosyan NL, Standerfer RJ, Theodore N. Circumferential dural resection technique and reconstruction for the removal of giant calcified transdural herniated thoracic discs. J Neurosurg Spine 2018; 28:167-172. [DOI: 10.3171/2017.5.spine161285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe 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.METHODSThe 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.RESULTSDuring 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.CONCLUSIONSThis 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.
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Affiliation(s)
| | | | | | | | | | - Robert J. Standerfer
- 2Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona
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Anterior Transthoracic Surgery with Motor Evoked Potential Monitoring for High-Risk Thoracic Disc Herniations: Technique and Results. World Neurosurg 2017; 105:441-455. [DOI: 10.1016/j.wneu.2017.05.173] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 11/23/2022]
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Giant thoracic discs: treatment, outcome, and follow-up of 33 patients in a single centre. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 27:1555-1566. [DOI: 10.1007/s00586-017-5192-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 06/03/2017] [Accepted: 06/11/2017] [Indexed: 10/19/2022]
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Pei B, Sun C, Xue R, Xue Y, Zhao Y, Zong YQ, Lin W, Wang P. Circumferential Decompression via a ModifiedCostotransversectomy Approach for the Treatment of Single Level Hard Herniated Disc between T10 -L1. Orthop Surg 2017; 8:34-43. [PMID: 27028379 DOI: 10.1111/os.12223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe a novel surgical strategy for circumferentially decompressing the T10 -L1 spinal canal when impinged upon by single level hard thoracic herniated disc (HTHD) via a modified costotransversectomy approach. METHODS This is a retrospective review of 26 patients (17 men, 9 women; mean age at surgery 48.5 years, range 20-77 years) who had undergone single level HTHD between T10 -L1 by circumferential decompression via a modified costotransversectomy approach. The characteristics of the approach are using a posterior midline covered incision, which keeps the paraspinal muscle intact and ensures direct visualization of circumferential spinal cord decompression of single level HTHD between T10 -L1 . RESULTS The average operative time was 208 ± 36 min (range, 154-300 min), mean blood loss 789 ± 361 mL (range, 300-2000 mL), mean preoperative and postoperative mJOA scores 5.2 ± 1.5 and 9.0 ± 1.3, respectively (t = 19.7, P < 0.05). The rate of recovery of neurological function ranged from 33.3% to 100%. The ASIA grade improved in 24 patients (92.3%) and stabilized (no grade change) in two (7.7%). MRI indicated that the cross-sectional area of the dural sac at the level of maximum compression increased from 45.0 ± 5.8 mm(2) preoperatively to 113.5 ± 6.1 mm(2) postoperatively (t = 68.2, P < 0.05). Anterior tibialis muscle strength of the 15 patients with foot drop had a mean recovery rate of 95% at final follow-up. One patient who resumed work early after the surgery showed a significantly augmented Cobb angle. One patient had transient postoperative cerebrospinal fluid leakage. No patients showed neurological deterioration. CONCLUSIONS This procedure achieves sufficient direct visualization for circumferential decompression of the spinal cord via a posterior midline covered costotransversectomy approach with friendly bleeding control and without muscle sacrifice. It is a reasonable alternative treatment option for thoracic myelopathy caused by single level HTHD between T10 -L1 .
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Affiliation(s)
- Bo Pei
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Chao Sun
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ruoyan Xue
- School of Medical Imaging, Tianjin Medical University, Tianjin, China
| | - Yuan Xue
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying Zhao
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Ya-qi Zong
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Wei Lin
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Pei Wang
- Department of Orthopaedic Surgery, Tianjin Medical University General Hospital, Tianjin, China
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Wong YW, Cheung JPY, Luk KDK, Cheung KMC. A rare postoperative complication of anterior lower thoracic instrumentation: diaphragmatic laceration with hemothorax. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:146-150. [PMID: 28035466 DOI: 10.1007/s00586-016-4932-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 12/20/2016] [Accepted: 12/22/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE To highlight the importance of preventing visceral injury due to prominent anterior implants at the spinal column. METHODS A 52-year-old man with cord compression was treated with a T9/10 discectomy and instrumented fusion via a right thoracotomy and trans-pleural approach. Postoperatively, he had improved lower limb numbness. However, after a bout of coughing, there was sudden increase in chest drain output, hemodynamic instability and massive fluid collection in the right chest cavity. RESULTS Emergency re-exploration of the thoracotomy was performed and a 6 cm laceration of the right postero-medial diaphragm was identified as the bleeding source and was found to be in close proximity with the locking nut of the anterior implants. The laceration was repaired and a soft synthetic patch was used to cover the implants. Postoperatively, the hemothorax resolved and the patient recovered from the neurological deficit. CONCLUSIONS Prevention of diaphragmatic injury can be performed using lower profile and less sharp-edged implants. Implant coverage with a soft synthetic material is necessary if unable to perform direct repair of the parietal pleura over the implants.
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Affiliation(s)
- Yat Wa Wong
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, SAR, China
| | - Jason Pui Yin Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, SAR, China.
| | - Keith Dip Kei Luk
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, SAR, China
| | - Kenneth Man Chee Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, The University of Hong Kong, Pokfulam Road, Hong Kong, SAR, China
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Mehdian H, Nasto LA. Surgical management of thoracic disc herniation. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25:483-485. [DOI: 10.1007/s00586-016-4762-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Diehn FE, Maus TP, Morris JM, Carr CM, Kotsenas AL, Luetmer PH, Lehman VT, Thielen KR, Nassr A, Wald JT. Uncommon Manifestations of Intervertebral Disk Pathologic Conditions. Radiographics 2016; 36:801-23. [PMID: 27082664 DOI: 10.1148/rg.2016150223] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Beyond the familiar disk herniations with typical clinical features, intervertebral disk pathologic conditions can have a wide spectrum of imaging and clinical manifestations. The goal of this review is to illustrate and discuss unusual manifestations of intervertebral disk pathologic conditions that radiologists may encounter, including disk herniations in unusual locations, those with atypical imaging features, and those with uncommon pathophysiologic findings. Examples of atypical disk herniations presented include dorsal epidural, intradural, symptomatic thoracic (including giant calcified), extreme lateral (retroperitoneal), fluorine 18 fluorodeoxyglucose-avid, acute intravertebral (Schmorl node), and massive lumbar disk herniations. Examples of atypical pathophysiologic conditions covered are discal cysts, fibrocartilaginous emboli to the spinal cord, tiny calcified disks or disk-level spiculated osteophytes causing spinal cerebrospinal fluid (CSF) leak and intracranial hypotension, and pediatric acute calcific discitis. This broad gamut of disease includes a variety of sizes of disk pathologic conditions, from the tiny (eg, the minuscule calcified disks causing high-flow CSF leaks) to the extremely large (eg, giant calcified thoracic intradural disk herniations causing myelopathy). A spectrum of clinical acuity is represented, from hyperacute fibrocartilaginous emboli causing spinal cord infarct, to acute Schmorl nodes, to chronic intradural herniations. The entities included are characterized by a range of clinical courses, from the typically devastating cord infarct caused by fibrocartilaginous emboli, to the usually spontaneously resolving pediatric acute calcific discitis. Several conditions have important differential diagnostic considerations, and others have relatively diagnostic imaging findings. The pathophysiologic findings are well understood for some of these entities and poorly defined for others. Radiologists' knowledge of this broad scope of unusual disk disease is critical for accurate radiologic diagnoses. Online supplemental material is available for this article. (©)RSNA, 2016.
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Affiliation(s)
- Felix E Diehn
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Timothy P Maus
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Jonathan M Morris
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Carrie M Carr
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Amy L Kotsenas
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Patrick H Luetmer
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Vance T Lehman
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Kent R Thielen
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - Ahmad Nassr
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
| | - John T Wald
- From the Departments of Radiology (F.E.D., T.P.M., J.M.M., C.M.C., A.L.K., P.H.L., V.T.L., K.R.T., J.T.W.) and Orthopedic Surgery (A.N.), Mayo Clinic, 200 First St SW, Rochester, MN 55905
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Xu N, Wei F, Liu X, Jiang L, Liu Z. Calcific discitis with giant thoracic disc herniations in adults. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 25 Suppl 1:204-8. [PMID: 26821144 DOI: 10.1007/s00586-016-4402-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 01/11/2016] [Accepted: 01/15/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Calcific discitis is a self-limiting process most commonly seen in the cervical spine of children. Rare literature exists regarding the natural history and management of this condition in adults, especially when it presents as a giant thoracic disc herniation into the spinal canal. Giant herniations in the thoracic spine are typically surgically removed to reduce the chance of permanent neurologic deficit from spinal cord compression. However, when associated with calcific discitis, they may undergo spontaneous regression with the need for surgery obviated. METHODS Medical records and radiographic studies of two adult patients with calcific discitis and myelopathy due to spinal cord compression by giant thoracic disc herniations were retrospectively reviewed. Search of the literature on calcific discitis in adults and spontaneous regression of calcified thoracic disc herniations was separately performed. RESULTS Both patients were young male adults presenting with back pain and early signs of myelopathy. With restriction of activities and oral NSAIDs, their symptoms were relieved within 3 months. Four adult cases of calcific discitis (characteristic central calcification confined within the nucleus pulposus) and three instances of spontaneous regression of small- to medium-sized thoracic calcified disc herniations were identified from the literature. CONCLUSIONS The demonstration of spontaneous resorption of giant calcified thoracic disc herniations in two adult patients with calcific discitis supplements the existing literature and provides the first evidence that giant calcified thoracic disc herniations may still undergo spontaneous remission and a "wait and watch" strategy may be justified at least in the initial management of these patients, even with the presence of mild myelopathy.
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Affiliation(s)
- Nanfang Xu
- Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, 100191, China
| | - Feng Wei
- Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, 100191, China
| | - Xiaoguang Liu
- Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, 100191, China
| | - Liang Jiang
- Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, 100191, China
| | - Zhongjun Liu
- Department of Orthopaedics, Peking University Third Hospital, 49 Huayuan North Road, Beijing, 100191, China.
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Schlag HR, Muquit S, Hristov TB, Morassi G, Boszczyk BM, Shafafy M. Subarachnoidal pleural fistula after resection of intradural thoracic disc herniation and multimodal treatment with noninvasive positive pressure ventilation (NPPV). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2015. [DOI: 10.1007/s00586-015-4137-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Woodbury A, McKenzie-Brown AM. Extradural thoracic spinal lesion presenting as low back and leg pain. PAIN MEDICINE 2014; 16:1030-2. [PMID: 25546132 DOI: 10.1111/pme.12671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Anna Woodbury
- Department of Anesthesiology and Pain Management, Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Anne Marie McKenzie-Brown
- Department of Anesthesiolgoy and Center for Pain Management, Emory University, Atlanta, Georgia, USA
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Zuckerman SL, Forbes JA, Mistry AM, Krishnamoorthi H, Weaver S, Mathews L, Cheng JS, McGirt MJ. Electrophysiologic deterioration in surgery for thoracic disc herniation: impact of mean arterial pressures on surgical outcome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:2279-90. [DOI: 10.1007/s00586-014-3390-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/05/2014] [Accepted: 05/18/2014] [Indexed: 11/30/2022]
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Reviewer's comment concerning "Calcified giant thoracic disc herniations--considerations and treatment strategies" (DOI 10.1007/s00586-014-3210-5 by N.A. Quraishi et al.). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23 Suppl 1:S84-5. [PMID: 24487559 DOI: 10.1007/s00586-014-3215-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/22/2014] [Indexed: 10/25/2022]
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