Thoracic intervertebral disc calcification and herniation in adults: a report of two cases

Endoscopic Versus Traditional Thoracic Discectomy: A Multicenter Retrospective Case Series and Meta-Analysis

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.

Calcified Thoracic Disc - A descriptive classification with clinical and management implications

Introduction and Objective

Thoracic disc calcification is a radiological finding which may be incidental or diagnosed in patients presenting with myelopathy due to spinal cord compression. We performed a study to analyze the imaging patterns of calcified thoracic discs (CTDs).

Patients and Methods

A retrospective review of the spinal and radiology database of a tertiary referral orthopedic hospital was conducted for the incidence of CTDs between 2007 and 2020. Patients' demographics and radiological findings were recorded. The relationship between disc size, morphology, spinal cord compression, and management was assessed.

Results

Fifty-one cases of CTDs were identified. The mean size of CTD was 806.2 mm3 (range: 144-2340). The most common level of disc calcification was T9-T10 (24%) in 12 patients. Thoracic disc calcifications in our series commonly involved disc "protrusion" in 67% (34 patients), followed by "mushroom" type in 31% (16 patients) and "extrusion" in 2% (1 patient). 37% (19 patients) had spinal cord compression with 12% (6 patients) undergoing surgical interventions. There was no statistically significant difference in the mean sizes of CTD between the groups with and without spinal cord compression (P = 0.566, independent sample t-test). Patients with "mushroom" type calcification were more likely to have surgical intervention (P = 0.01, Fisher's exact test).

Conclusion

Thoracic disc calcifications, while common, can still be underdiagnosed till late myelopathic deterioration. Care of the elderly physicians, spinal surgeons, and radiologists need to be aware of them to guide diagnosis and management. Our study demonstrates that disc morphology plays a vital role in myelopathic presentation and therefore determines the need for surgical intervention instead of the absolute size of disc calcification.

Clinical and radiographic features of adult calcified thoracic disc herniation: a retrospective analysis of 31 cases

PURPOSE

To analyze the clinical and radiographic characteristics of calcified thoracic disc herniation (CTDH) and explore the possible pathogeneses.

METHODS

This is a retrospective clinical review of prospectively collected imaging data based at a single institute from 2004 to 2021. Clinical and radiographic parameters of CTDH patients were retrospectively collected and analyzed.

RESULTS

All 31 patients included presented thoracic myelopathy with a 17.05-month preoperative disease duration. Three (9.7%) patients had a history of trauma, and the rest had insidious onset. The average spinal canal ventral-occupying ratio was 74.90 ± 15.16%. The most prominent radiographic feature was the calcification of the nucleus pulposus in the intervertebral disc and the calcified lesion contiguous with the disc space protruding into the spinal canal. Three main imaging forms of CTDH were found: calcium-ringed lesion (5), heterogeneous calcification lesion (19), and homogeneous calcification lesion (7). The radiographic manifestations, intraoperative findings, and postoperative pathologies of the three subtypes were different. The calcium-ringed lesion type was younger and had a shorter preoperative duration and significantly lower mJOA score. A special case was observed conservatively for five years, which suggested that a heterogeneous lesion could progress to a homogeneous lesion.

CONCLUSIONS

Adult CTDH is a special thoracic disc disease with insidious onset, a long course, and a high spinal canal-occupying ratio. Calcium deposits in the spinal canal originate from the nucleus pulposus. The intraoperative findings and postoperative pathology of subtypes are different, which might indicate different pathological mechanisms.

Radiographic and clinical features of thoracic disk disease associated with myelopathy: a retrospective analysis of 257 cases

PURPOSE

To analyze the clinical and radiographic characteristics of thoracic disk disease associated with myelopathy (TDM).

METHODS

This is a retrospective clinical review of prospectively collected imaging data based at a single institute. Based on preoperative CT and MRI, we classified TDM as thoracic disk herniation (TDH), THD with ossification (THDO), TDH with posterior bony avulsions of the vertebrae (TDH with PBA), TDH with posterior vertebral osteophytes (TDH with PVO), giant thoracic osteophyte and calcific discitis with herniation (CDH). Patient characteristics and radiographic data were compared between different types of TDM.

RESULTS

Among the 257 patients included, 12.06% of patients presented with symptoms after traumatic events. The most frequent complaint at onset and preoperative was back pain (29.2%) and subjective lower limb weakness (75.5%), respectively. All TDH with PBA is distributed at the lower thoracic segments, while CDH predominantly in the middle and lower thoracic segments. TDH with PBA was more frequent in men than TDH and CDH. Compared with TDH, TDHO, and TDH with PVO, TDH with PBA was younger in surgery age, and TDH and CDH had lower preoperative JOA scores than TDH with PBA. CDH had a larger ventral occupying ratio than TDH, TDHO, and TDH with PBA.

CONCLUSIONS

The onset of TDM was generally insidious but may be triggered acutely by apparently trivial events. With a low prevalence, TDM varied clinical symptoms. Different types of TDM had various clinical features, which might indicate different pathological mechanisms.

Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases

PURPOSE

The authors illustrate their results in the surgical treatment of symptomatic thoracic disc herniations (TDHs) by comparing the traditional open to the less invasive retropleural lateral approaches.

METHODS

Retrospective review of 94 consecutive cases treated at a single Institution between 1988 and 2014. Fifty-two patients were males, 42 females, mean age was 53.9 years. Mean follow-up was 46.9 months (12-79 months). 33 patients were diagnosed with a giant thoracic disc herniation (GTDH). Upon admission, the most common symptoms were: motor impairment (91.4%, n = 86), neuropathic radicular pain with VAS > 4 (50%), bladder and bowel dysfunction (57.4% and 41.4% respectively) and sensory disturbances (29.7%). The surgical approach was based upon level, laterality and presence or absence of calcified lesions.

RESULTS

Decompression was performed in 7 cases via a thoraco-laparo-phrenotomy and in 87 cases via an antero-lateral thoracotomy. Out of the latter cases, 49 (56%) were trans-thoracic trans-pleural approaches (TTA) and 38 (44%) were less invasive retropleural approaches (MIRA). At follow-up, there were 59.5% neurologically intact patients according to the McCormick Scale, while 64.8% and 67% had no bladder or bowel dysfunction respectively. Complications occurred in 24 patients (25.5%). Pulmonary complications were the commonest (12.7%) with pleural effusion being significantly more common in patients treated with TTA compared to MIRA (20% vs 5.2%: X² 4.13 P:0.042). Severe post-operative neuralgia (VAS 7-10) was also significantly more frequent in the TTA group (22.4% vs 2.6% X² 7.07 p 0.0078).

CONCLUSIONS

MIRA is a safe and effective technique to obtain adequate TDH decompression and is associated with lower morbidity compared to TTA.

Acute Calcific Discitis or Symptomatic Calcified Schmorl's Node of the Upper Thoracic Spine in an Adult: A Case Report and Literature Review

We describe a patient with acute calcific discitis following symptomatic Schmorl's node (SN) of upper thoracic spine. A 28-year-old female suffered from sudden severe pain in mid-thoracic, left scapular area, radiating to her chest. Plain radiography of the thoracic spine showed calcification in T3–4 intervertebral disc space. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the spine demonstrated calcification of the T3–T4 nucleus pulposus, migrating into the inferior of T3 vertebral body with reactive bone marrow edema. By conservative treatment with multidrug therapy, the pain subsided and disappeared in 3 months. Follow-up CT scan and MRI of the thoracic spine confirmed complete resolution of calcified SN and reactive bone marrow edema.

The incidence and most common levels of thoracic degenerative disc pathologies

Objectives

In this study, we aimed to describe and characterize the incidence of thoracic degenerative disc pathologies, bulging/herniation, and the most common affected levels.

Patients and methods

Between January 2008 and May 2012, a total of 195 patients (109 females, 86 males; mean age 43.5 years; range, 15 to 74 years) who were admitted with the complaint of dorsalgia and underwent magnetic resonance imaging (MRI) of the thoracic vertebral column were included in the study. Data including MRI findings, endplate and disc degeneration, disc height loss, bulging, and disc herniation were retrospectively analyzed.

Results

Of 3,348 patients, 195 patients had disc bulging/herniation. When 12 levels in 195 cases were taken into consideration, disc pathologies were found in 412 (18%) levels among the total of 2,340 intervertebral disc levels. Bulging was present in 11% (244/2,340) of the levels. Disc herniation was present in 7% (168/2,340) of the levels. The most commonly affected site was T7-8, followed by T8-9 and T11-12.

Conclusion

Thoracic disc pathologies are still a significant diagnostic challenge. Our study results show that the incidence of these pathologies is higher than expected.

Clinical efficacy of lumbar interbody fusion using a channel system combined with ozone therapy for the treatment of central-type L3-L4 lumbar disc herniation

The clinical efficacy of minimally invasive lumbar interbody fusion via the intervertebral foramen combined with ozone (O₃) therapy for the treatment of L3-L4 central-type lumbar disc herniation was explored. We recruited patients with sciatica who attended our hospital between July 2013 and October 2015 and underwent lumbar X-ray (anteroposterior and lateral view), lumbar flexion-extension radiographs, computed tomography, and magnetic resonance imaging after admission. Seventy-four patients with central-type lumbar disc herniation but no other complications were randomly selected and divided into the observation and control groups. The observation group comprised 37 patients treated with lumbar fusion using a channel system combined with O₃ therapy, whereas the control group comprised 37 patients treated with lumbar fusion alone. The effects of the two therapies were evaluated using visual analog scale, Japanese Orthopaedic Association, and MacNab scores. There was no significant difference in scores between the two groups before surgery (P>0.05). The scores of the observation group after treatment were significantly lower than those before surgery and those of the control group (P<0.05). One patient in the observation group experienced no obvious improvement in symptoms after surgery, and two patients in the control group experienced postoperative recurrence; these three patients subsequently underwent laminectomy combined with planted bone fusion and internal fixation. There was no significant difference in total efficacy rates between the two groups (P>0.05). Lumbar fusion using a channel system combined with O₃ therapy for the treatment of L3-L4 central-type lumbar disc herniation is safe and effective. It has the advantages of reduced trauma, fewer complications, and rapid pain relief, and it promotes the recovery of lumbar function. Strict mastery of the surgical indications is key to the success of the procedure; however, it is worth expanding its use in the clinical setting.

Minimally Invasive Direct Thoracic Interbody Fusion (MIS-DTIF): Technical Notes of a Single Surgeon Study

Background

Minimally invasive direct thoracic interbody fusion (MIS-DTIF) is a new single surgeon procedure for fusion of the thoracic vertebrae below the scapula (T6/7) to the thoracolumbar junction. In this proof of concept study, we describe the surgical technique for MIS-DTIF and report our experience and the perioperative outcomes of the first four patients who underwent this procedure.

Study design/setting

In this study we attempt to establish the safety and efficacy of MIS-DTIF. We have performed MIS-DTIF on six spinal levels in four patients with degenerative disk disease or disk herniation. We recorded surgery time, blood loss, fluoroscopy time, complications, and patient-reported pain.

Methods

Throughout the MIS-DTIF procedure, the surgeon is aided by biplanar fluoroscopic imaging and electrophysiological monitoring. The surgeon approaches the spine with a series of gentle tissue dilations and inserts a working tube that establishes a direct connection from the outside of the skin to the disk space. Through this working tube, the surgeon performs a discectomy and inserts an interbody graft or cage. The procedure is completed with minimally invasive (MI) posterior pedicle screw fixation.

Results

For the single level patients the mean blood loss was 90 ml, surgery time 43 minutes, fluoroscopy time 293 seconds, and hospital stay two days. For the two-level surgeries, the mean blood loss was 27 ml, surgery time 61 minutes, fluoroscopy time 321 seconds, and hospital stay three days. We did not encounter any clinically significant complications. Thirty days post-surgery, the patients reported a statistically significant reduction of 5.3 points on a 10-point sliding pain scale.

Conclusions

MIS-DTIF with pedicle screw fixation is a safe and clinically effective procedure for fusions of the thoracic spine. The procedure is technically straightforward and overcomes many of the limitations of the current minimally invasive (MI) approaches to the thoracic spine. MIS-DTIF has the potential to improve patient outcomes and reduce costs relative to the current standard of care. We are currently expanding this study to a larger cohort and recording long term outcomes and costs.