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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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Corazzelli G, Di Noto G, Ciardo A, Colangelo M, Corvino S, Leonetti S, D'Elia A, Ricciardi F, Bocchino A, Paolini S, Esposito V, Innocenzi G. Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better? Acta Neurochir (Wien) 2024; 166:267. [PMID: 38877339 DOI: 10.1007/s00701-024-06146-3] [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: 04/11/2024] [Accepted: 05/26/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes. BACKGROUND Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH. METHODS A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal. RESULTS This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01). CONCLUSIONS No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.
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Affiliation(s)
- Giuseppe Corazzelli
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy.
| | - Giulio Di Noto
- Division of Neurosurgery, Università Degli Studi Di Messina - Policlinico "G. Martino", Messina, Italy
| | - Antonio Ciardo
- Division of Neurosurgery, Department of Human Neuroscience, University of Rome "Sapienza", Rome, Italy
| | - Manuel Colangelo
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Sergio Corvino
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | | | | | | | - Andrea Bocchino
- Division of Neurosurgery, Department of Neurosciences, Reproductive and Odontostomatological Sciences, "Federico II" University, Naples, Italy
| | - Sergio Paolini
- Department of Neurosurgery, IRCCS Neuromed, Pozzilli, IS, Italy
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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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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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Lockey SD, Jauregui JJ, Cavanaugh DL, Koh EY, Shen FHT, Ludwig SC, Ratanpal AS, Chiu AK. Diagnosis and Management of Thoracic Myelopathy. J Am Acad Orthop Surg 2024:00124635-990000000-00975. [PMID: 38739870 DOI: 10.5435/jaaos-d-23-00984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Indexed: 05/16/2024] Open
Abstract
Thoracic myelopathy can be a challenging condition to diagnose and treat. Successful outcomes depend on early recondition of the pathology and appropriate surgical referral in cases of progressive neurologic deterioration. The thoracic cord is tethered in kyphosis by the dentate ligaments and contains a tenuous blood supply. These conditions make the thoracic cord particularly susceptible to external compression and ischemic damage. Careful preoperative planning with specific attention to the location and source of thoracic stenosis is critical to successful decompression and complication avoidance. The purpose of this discussion is to outline the common sources of thoracic myelopathy and current recommendations regarding diagnosis and management. The review concludes with an overview of the most up-to-date literature regarding clinical outcomes.
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Affiliation(s)
- Stephen D Lockey
- From the Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA (Lockey and Shen); Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD (Jauregui, Cavanaugh, Koh, Ludwig, Ratanpal, and Chiu)
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Eghbal K, Zafarshamspour S, Sookhaklari M, Saffarian A, Taheri R. Clinical Outcome of Pedicle-Sparing Transfacet Diskectomy and Fusion with Segmental Instrumentation for Thoracic Disc Herniation. J Neurol Surg A Cent Eur Neurosurg 2024; 85:240-245. [PMID: 36584877 DOI: 10.1055/a-2005-0620] [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: 01/01/2023]
Abstract
BACKGROUND Thoracic disk herniations (TDHs) are relatively rare compared with their cervical and lumbar counterparts. Posterior approaches allow for a simpler and less invasive surgery than anterior and lateral approaches. A pedicle-sparing transfacet approach was initially described in 1995, and modified in 2010. A few clinical series have reported the outcome of this procedure in patients with TDH. This study aimed to evaluate the outcomes and complications of pedicle-sparing transfacet diskectomy with interbody fusion and segmental instrumentation in patients with TDH. METHODS Twenty-one consecutive patients with symptomatic TDH referred to our tertiary care center were included in this retrospective study. All patients underwent a pedicle-sparing transfacet diskectomy with polyetheretherketone (PEEK) cage interbody fusion and short segmental instrumentation. Distribution of TDH, operative duration, blood loss, Visual Analog Scale (VAS) pain scores, Nurick grades, modified Japanese Orthopaedic Association (mJOA) scores, and fusion rate were assessed. RESULTS All patients had single-level herniations. The most common location was T12-L1 (38.1%), followed by T11-T12 (33.3%). All patients were successfully operated on with no cerebrospinal fluid (CSF) leaks or wrong-level surgery. The VAS scores significantly diminished from 4.9 (preoperatively) to 2 (18 months after surgery). The average mJOA score increased from 4.6 to 8.5, and the average Nurick grade decreased from 3.1 to 1.6. All patients reported significant improvement in quality of life relative to their preoperative status. CONCLUSION A modified pedicle-sparing transfacet diskectomy combined with PEEK cage interbody fusion and segmental instrumentation offers a safe and less invasive approach for the treatment of TDHs.
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Affiliation(s)
- Keyvan Eghbal
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Saber Zafarshamspour
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
- Department of Surgery, Rafsanjan University of Medical Sciences, Kerman, Iran
| | | | - Arash Saffarian
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Taheri
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
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Haleem S, Adlan A, Azzopardi C, Botchu R. Calcified Thoracic Disc - A descriptive classification with clinical and management implications. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2024; 15:236-240. [PMID: 38957761 PMCID: PMC11216641 DOI: 10.4103/jcvjs.jcvjs_167_23] [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: 11/29/2023] [Accepted: 04/01/2024] [Indexed: 07/04/2024] Open
Abstract
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.
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Affiliation(s)
- Shahnawaz Haleem
- Department of Spinal Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Amirul Adlan
- Department of Spinal Surgery, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Christine Azzopardi
- Department of Musculoskeletal Imaging, The Royal Orthopaedic Hospital, Birmingham, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Imaging, The Royal Orthopaedic Hospital, Birmingham, UK
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LeRoy TE, Ruiz-Cardozo MA, Molina CA. Transdural Ventral Sling Technique for Calcified Thoracic Disk Herniations. World Neurosurg 2024; 183:123-127. [PMID: 38104932 DOI: 10.1016/j.wneu.2023.12.074] [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: 09/17/2023] [Revised: 12/11/2023] [Accepted: 12/12/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Surgery for thoracic disc herniations remains an ongoing challenge, with numerous surgical approaches, all with their own inherent risks. Discectomy via a posterior laminectomy was historically the treatment of choice; however, it was deemed very high risk with elevated rates of neurologic injury. The posterior transdural approach is an alternative surgical option for soft and calcified thoracic disc herniations. METHODS A 56-year-old female with many years of numbness/tingling in her hands and difficulty with fine motor tasks presented with progressive weakness and loss of balance in her legs. Imaging revealed a prominent focal central calcified disc herniation at the T5-T6 level causing severe effacement and distortion of the spinal cord. A posterior transdural approach for direct visualization of a large calcified disc herniation was performed, removing the calcified disc without the need for extensive exposure or entry into the thoracic cavity. A ventral sling of the dura was created to allow rotation of the spinal cord while removing the disc. RESULTS Intraoperative ultrasound confirmed complete disc resection, restoring cerebral spinal fluid flow circumferentially without residual impingement or cerebrospinal fluid leaks. At six months postsurgery, the patient's gait imbalance had resolved, and she had full lower extremity strength (5/5). Radiographic evaluation indicated stable implants without subsidence, pullout, fracture, or alignment loss. CONCLUSIONS The transdural approach is less invasive in nature, minimizes surgical exposure, patient morbidity, and provides better intraoperative control of the spinal cord. This constitutes an effective alternative surgical approach to both soft and calcified central thoracic disc herniations.
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Affiliation(s)
- Taryn E LeRoy
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, Massachusetts, USA
| | - Miguel A Ruiz-Cardozo
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Camilo A Molina
- Department of Neurosurgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA.
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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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Gelinne A, Harbert A, Galgano M. Technical Nuances of the Posterior Transpedicular Thoracic Diskectomy: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01055. [PMID: 38329352 DOI: 10.1227/ons.0000000000001087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/22/2023] [Indexed: 02/09/2024] Open
Abstract
Thoracic disk herniations are relatively rare when compared with cervical and lumbar disk pathology accounting for less than 3% of spinal disk herniations.1 In addition to this, a larger proportion of thoracic disk herniations are calcified making them challenging to remove because of adherence to the dura and anatomy of the thoracic spinal canal.2,3 Owing to these unique features of thoracic disk herniations, typical posterior approaches are not always feasible to provide adequate decompression of the thecal sac.4 In this video, we present a 64-year-old male patient who presented with progressive paraplegia and a large ventral, eccentric, calcified thoracic disk herniation causing severe canal stenosis. Because of the size and location of the disk, a thoracic laminectomy with costotransversectomy and pediculectomies for resection of the disk was performed. Ventral decompression was achieved, and the patient made a full neurologic recovery. This video highlights the principles and technical nuances used during thoracic disk resection. The patient provided informed consent for surgery and video recording.
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Affiliation(s)
- Aaron Gelinne
- Department of Neurological Surgery, University of North Carolina, Chapel Hill, North Carolina, USA
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11
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Sasani M, Sasani H, Akgun MY, Hekimoglu M, Basak AT, Oktenoglu T, Ates O, Ozer AF. Posterior video-assisted trans pedicular surgery for calcified midline thoracic disc herniation. J Orthop Sci 2024:S0949-2658(24)00010-1. [PMID: 38331600 DOI: 10.1016/j.jos.2024.01.009] [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] [Received: 11/17/2023] [Revised: 01/12/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND In the treatment of patients with calcified midline thoracic disc herniation (CMTDH), the posterior video-assisted transpedicular surgery (VATPS) technique is employed. Both anterior and posterior surgical approaches for treating CMTDH carry a significant risk of surgical complications and potential morbidity. This technical note introduces a surgical procedure that avoids the drawbacks associated with these approaches. METHODS The VATPS technique presents a comprehensive approach for treating thoracic disc herniation, combining both microscopic and endoscopic stages. The microscopic phase entails a small thoracoscopic incision, muscle release, hemilaminotomy, facet joint resection, and vertebra removal, culminating in creating a corpectomy cavity for endoscope access. Careful separation of adhesions between the dura and ligaments marks this stage. Transitioning to the endoscopic phase, an endoscope is inserted into the cavity, allowing for precise visualization and separation of residual adhesions, removal of calcified disc fragments using specialized instruments, and ensuring complete discectomy. RESULTS Fourteen patients underwent VATPS for CMTDH. During the procedure, evoked responses were reduced in one patient. However, no postoperative neurological deficits were observed. We also noted significant improvements in the Oswestry Disability Index (ODI) and the Visual Analog Scale (VAS) scores when comparing the preoperative and postoperative assessments. CONCLUSION VATPS, a minimally invasive technique, offers excellent anterior visibility comparable to that of the anterolateral approach, all while avoiding the adverse effects associated with thoracotomies and the complications resulting from spinal cord encroachment often seen in the posterolateral approach. Moreover, it is a safer alternative to conventional endoscopic posterior thoracic surgery. The cavity formed within the vertebral corpus provides ample working space for the use of an endoscope.
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Affiliation(s)
- Mehdi Sasani
- Koc University School of Medicine, Neurosurgery Department, Turkey; American Hospital, Neurosurgery Department, Turkey
| | - Hadi Sasani
- Namik Kemal University, Faculty of Medicine, Radiology Department, Turkey
| | | | | | | | - Tunc Oktenoglu
- Koc University School of Medicine, Neurosurgery Department, Turkey; American Hospital, Neurosurgery Department, Turkey
| | - Ozkan Ates
- Koc University School of Medicine, Neurosurgery Department, Turkey
| | - Ali Fahir Ozer
- Koc University School of Medicine, Neurosurgery Department, Turkey; American Hospital, Neurosurgery Department, Turkey
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12
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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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13
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Kasliwal MK. Evolution and current status of surgical management of thoracic disc herniation - A review. Clin Neurol Neurosurg 2024; 236:108055. [PMID: 37992532 DOI: 10.1016/j.clineuro.2023.108055] [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: 10/20/2023] [Revised: 11/02/2023] [Accepted: 11/05/2023] [Indexed: 11/24/2023]
Abstract
Thoracic disc herniations (TDH) are uncommon compared to cervical and lumbar disc herniations. Surgical treatment of TDH can be challenging due to the anatomical constraints and the high risk of morbidity due to proximity to the thoracic spinal cord. Moreover, the selection of appropriate surgical approach depends on various factors such as the size and location of disc herniation within the spinal canal, spinal level, presence or absence of calcification, degree of spinal cord compression, and familiarity with various approaches by the treating surgeon. While there is agreement that posterolateral approaches can be used to treat posterolateral and central soft disc herniation, there is a lack of consensus on the best surgical approach for central calcified and giant calcified TDH where an anterior approach is perceived as the best option. There is increasing evidence that support the safety and efficacy of posterolateral approaches even for central calcified and giant calcified TDH. This review highlights the evolution of surgical management for TDH based on the past and current literature and the author's experience at his institution.
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Affiliation(s)
- Manish K Kasliwal
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA.
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14
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Cho SS, Farber SH, Zhou JJ, Alan N, O'Neill LK, Giraldo JP, Snyder LA, Turner JD, Uribe JS. Stable Regional and Global Alignment in Patients Treated With Minimally Invasive Lateral Retropleural Thoracic Diskectomy Without Fixation. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00978. [PMID: 38032217 DOI: 10.1227/ons.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Thoracic disk herniations are challenging to treat, and open transthoracic or minimally invasive thoracoscopic approaches are associated with significant morbidity, substantial costs, and steep learning curves. The minimally invasive lateral retropleural thoracic diskectomy (MIS-LRP-TD) approach is straightforward and is associated with lower perioperative morbidity. With MIS-LRP-TD, the overlying rib, ipsilateral pedicle, ligamentum flavum, posterior longitudinal ligament, and posterior third of the adjacent vertebral bodies are resected. Adjunct fixation is typically not performed, eliminating hardware-related complications and costs. This radiographic study investigates long-term global and thoracic spine alignment after MIS-LRP-TD without fixation. METHODS This study was a single-institution, retrospective evaluation of all patients who underwent MIS-LRP-TD without fixation between November 7, 2017 and July 19, 2022. Preoperative and the most recent postoperative radiographs were used to determine the C7 plumb line to central sacral vertical line, thoracic Cobb angle (TCA), segmental Cobb angle, C7 to sagittal vertical axis, thoracic kyphosis, and segmental kyphosis. RESULTS In total, 22 patients with 24 disk herniations underwent MIS-LRP-TD without fixation. The mean (SD) radiographic follow-up was 12.9 (11.2) months. Overall, no significant differences were seen in C7 plumb line to central sacral vertical line (P = .65), C7 to sagittal vertical axis (P = .99), thoracic kyphosis (P = .30), TCA (P = .28), segmental kyphosis (P = .27), or segmental Cobb angle (P = .56) at follow-up. One patient demonstrated a >5° change in TCA but remained asymptomatic. CONCLUSION Despite requiring extensive resection of the middle column and ipsilateral costovertebral joint at the index level, MIS-LRP-TD without adjunct fixation does not lead to significant global, regional, or segmental deformity. Thus, MIS-LRP-TD appears to be a safe, effective treatment approach for challenging thoracic disk herniations.
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Affiliation(s)
- Steve S Cho
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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15
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Komp M, Ruetten S. Full-endoscopic anterior excision of thoracic disc herniations, including giant and calcified discs with spinal cord compression: surgical technique and outcomes. 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 2023; 32:2685-2693. [PMID: 37300583 DOI: 10.1007/s00586-023-07807-0] [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: 01/05/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE Operations on thoracic herniated discs are comparatively rare and often demanding. An individual approach and mastery of different surgical techniques and surgical approaches are necessary. The main factors for the chosen surgical technique and approach are the anatomical localization, consistency of the pathology, the general condition of the patient and the experience of the surgeon. The purpose of this study was to evaluate the technical possibilities and outcomes of the full-endoscopic technique with interlaminar, extraforaminal and transthoracic retropleural approaches in patients with symptomatic herniated discs with anterior neural compression. METHODS In 49 patients with thoracic disc herniations, decompression was performed between 2016 and 2020, using a full-endoscopic interlaminar, extraforaminal or transthoracic retropleural approach. Clinical data and imaging were collected during follow-up of 18 months. RESULTS Sufficient decompression was achieved in all cases with the full-endoscopic surgical technique. Two patients experienced worsening of myelopathy, one of which was of transient duration, and one patient required reoperation for an epidural hematoma. No other complications were recorded. All other patients experienced a regression or improvement of symptoms. CONCLUSION The full-endoscopic technique with interlaminar, extraforaminal or transthoracic retropleural approach is a sufficient and minimally invasive method. All three full-endoscopic approaches of the thoracic spine are required to enable sufficient decompression of the anterior pathologies examined here.
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Affiliation(s)
- Martin Komp
- Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group - Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University of Bochum/Marien Hospital Witten, Hospitalstrasse 19, 44649, Herne, Germany.
| | - Sebastian Ruetten
- Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology of the St. Elisabeth Group - Catholic Hospitals Rhein-Ruhr, St. Anna Hospital Herne/Marien Hospital Herne University Hospital of the Ruhr University of Bochum/Marien Hospital Witten, Hospitalstrasse 19, 44649, Herne, Germany
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16
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Yuan L, Chen Z, Liu Z, Li W, Sun C, Liu X. Clinical and radiographic features of adult calcified thoracic disc herniation: a retrospective analysis of 31 cases. 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 2023; 32:2387-2395. [PMID: 37222802 DOI: 10.1007/s00586-023-07784-4] [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: 12/25/2022] [Revised: 04/18/2023] [Accepted: 05/14/2023] [Indexed: 05/25/2023]
Abstract
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.
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Affiliation(s)
- Lei Yuan
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Zhongqiang Chen
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China.
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China.
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China.
| | - Zhongjun Liu
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Weishi Li
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Chuiguo Sun
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
| | - Xiaoguang Liu
- Department of Orthopedics, Peking University Third Hospital, 49 North Garden Street, Hai Dian, Beijing, 100191, China
- Beijing Key Laboratory of Spinal Disease Research, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
- Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education, Peking University Third Hospital, 49 North Garden Road, Beijing, 100191, China
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17
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Issa M, Neumann JO, Al-Maisary S, Dyckhoff G, Kronlage M, Kiening KL, Ishak B, Unterberg AW, Scherer M. Anterior Access to the Cervicothoracic Junction via Partial Sternotomy: A Clinical Series Reporting on Technical Feasibility, Postoperative Morbidity, and Early Surgical Outcome. J Clin Med 2023; 12:4107. [PMID: 37373799 DOI: 10.3390/jcm12124107] [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: 03/01/2023] [Revised: 06/06/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Surgical access to the cervicothoracic junction (CTJ) is challenging. The aim of this study was to assess technical feasibility, early morbidity, and outcome in patients undergoing anterior access to the CTJ via partial sternotomy. Consecutive cases with CTJ pathology treated via anterior access and partial sternotomy at a single academic center from 2017 to 2022 were retrospectively reviewed. Clinical data, perioperative imaging, and outcome were assessed with regards to the aims of the study. A total of eight cases were analyzed: four (50%) bone metastases, one (12.5%) traumatic instable fracture (B3-AO-Fracture), one (12.5%) thoracic disc herniation with spinal cord compression, and two (25%) infectious pathologic fractures from tuberculosis and spondylodiscitis. The median age was 49.9 years (range: 22-74 y), with a 75% male preponderance. The median Spinal Instability Neoplastic Score (SINS) was 14.5 (IQR: 5; range: 9-16), indicating a high degree of instability in treated cases. Four cases (50%) underwent additional posterior instrumentation. All surgical procedures were performed uneventfully, with no intraoperative complications. The median length of hospital stay was 11.5 days (IQR: 9; range: 6-20), including a median of 1 day in an intensive care unit (ICU). Two cases developed postoperative dysphagia related to stretching and temporary dysfunction of the recurrent laryngeal nerve. Both cases completely recovered at 3 months follow-up. No in-hospital mortality was observed. The radiological outcome was unremarkable in all cases, with no case of implant failure. One case died due to the underlying disease during follow-up. The median follow-up was 2.6 months (IQR: 23.8; range: 1-45.7 months). Our series indicates that the anterior approach to the cervicothoracic junction and upper thoracic spine via partial sternotomy can be considered an effective option for treatment of anterior spinal pathologies, exhibiting a reasonable safety profile. Careful case selection is essential to adequately balance clinical benefits and surgical invasiveness for these procedures.
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Affiliation(s)
- Mohammed Issa
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Jan-Oliver Neumann
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Sameer Al-Maisary
- Department of Cardiac Surgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Gerhard Dyckhoff
- Department of Otorhinolaryngology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Moritz Kronlage
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Karl L Kiening
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Basem Ishak
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Moritz Scherer
- Department of Neurosurgery, Heidelberg University Hospital, 69120 Heidelberg, Germany
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18
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Full-endoscopic discectomy for thoracic disc herniations: a single-arm meta-analysis of safety and efficacy outcomes. 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 2023; 32:1254-1264. [PMID: 36867252 DOI: 10.1007/s00586-023-07595-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 03/04/2023]
Abstract
INTRODUCTION Surgical intervention is the treatment of choice in patients with thoracic disc herniation with refractory symptoms and progressive myelopathy. Due to high occurrence of complications from open surgery, minimally invasive approaches are desirable. Nowadays, endoscopic techniques have become increasingly popular and full-endoscopic surgery can be performed in the thoracic spine with low complication rates. METHODS Cochrane Central, PubMed, and Embase databases were systematically searched for studies that evaluated patients who underwent full-endoscopic spine thoracic surgery. The outcomes of interest were dural tear, myelopathy, epidural hematoma, recurrent disc herniation, and dysesthesia. In the absence of comparative studies, a single-arm meta-analysis was performed. RESULTS We included 13 studies with a total of 285 patients. Follow-up ranged from 6 to 89 months, age from 17 to 82 years, with 56.5% male. The procedure was performed under local anesthesia with sedation in 222 patients (77.9%). A transforaminal approach was used in 88.1% of the cases. There were no cases of infection or death reported. The data showed a pooled incidence of outcomes as follows, with their respective 95% confidence intervals (CI)-dural tear (1.3%; 95% CI 0-2.6%); dysesthesia (4.7%; 95% CI 2.0-7.3%); recurrent disc herniation (2.9%; 95% CI 0.6-5.2%); myelopathy (2.1%; 95% CI 0.4-3.8%); epidural hematoma (1.1%; 95% CI 0.2-2.5%); and reoperation (1.7%; 95% CI 0.1-3.4%). CONCLUSION Full-endoscopic discectomy has a low incidence of adverse outcomes in patients with thoracic disc herniations. Controlled studies, ideally randomized, are warranted to establish the comparative efficacy and safety of the endoscopic approach relative to open surgery.
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19
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El-Ghandour NMF. Commentary: Lateral Retropleural Thoracic Diskectomy for a Calcified Herniated Disk: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 24:e108-e109. [PMID: 36637313 DOI: 10.1227/ons.0000000000000484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/02/2022] [Indexed: 01/14/2023] Open
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20
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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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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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22
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Kohei T. Postoperative Rehabilitation for Thoracic Disc Herniation in a Professional Rugby Player: A Case Report. Cureus 2022; 14:e30423. [DOI: 10.7759/cureus.30423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 11/07/2022] Open
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Kilmister EJ, Guy N, Wickremesekera A, Koeck H. Image-guided transthoracic transpedicular microdiscectomy for a giant thoracic disc herniation: patient series. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 4:CASE2297. [PMID: 36593678 PMCID: PMC9514284 DOI: 10.3171/case2297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/08/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND This case series reports on five consecutive patients who underwent image-guided transpedicular transthoracic microdiscectomy. The authors retrospectively reviewed five patients who had undergone Stealth image-guided transpedicular transthoracic microdiscectomy between 2015 and 2021. OBSERVATIONS Image guidance with O-arm verified critical anatomical landmarks in the setting of large central calcified and/or soft tissue disc prolapse. This allowed limited rib head resection, pedicle removal, and corpectomy to give adequate access and not require interbody fusion. The authors performed a partial posterior corpectomy anterior to the affected disc prolapse and microsurgical delivery of the affected disc anteriorly into the corpectomy cave away from the thecal sac. Electronic and radiographic records were analyzed at their initial presentation and at follow-up. The median patient age was 51 years (range, 44-56 years), with 80% of the patients being males. Four of five patients had significant improvement of their presenting clinical symptoms. One patient had a complicated postoperative recovery with a pneumothorax and subsequent bilateral pneumonia requiring intensive care. Another patient developed delayed postoperative worsening of paraparesis. LESSONS The use of Stealth image guidance with O-arm for transthoracic microdiscectomy for complex calcified thoracic disc herniation is an effective operative technical adjunct to verify anatomical landmarks and limit the microsurgical procedure.
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Sommer F, McGrath L, Kirnaz S, Goldberg J, Medary B, Schmidt FA, Shtayer L, Gadjradj PS, Härtl R. Lumbar Giant Disk Herniations Treated With a Unilateral Approach for Bilateral Decompression. Oper Neurosurg (Hagerstown) 2022; 23:60-66. [PMID: 35726929 DOI: 10.1227/ons.0000000000000198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/17/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Disk herniations that obstruct the spinal canal by more than 50% are named "giant disk herniations" (GDHs). GDHs are challenging to treat from a surgical perspective because of their size and the risk of iatrogenic manipulation during resection resulting in additional neurological compromise. As a result, the appropriateness of minimally invasive tubular approaches for the treatment of lumbar GDHs remains controversial. OBJECTIVE To report our experience in treating lumbar GDHs using tubular minimally invasive surgery. METHODS A total number of 228 disk herniations were evaluated for the criteria of GDH. In addition, the presence of neurological deficits such as cauda equina syndrome, pain as measured by a visual analog scale, operating time, complications, estimated intraoperative blood loss, and number of surgical revisions were assessed. The standard tubular diskectomy technique was modified to include unilateral laminectomy for bilateral decompression before the diskectomy to create a sufficient working space for removal of the disk fragments. RESULTS Twenty-three (10%) patients met the criteria for GDH. Clinically significant motor weakness was present in 21 patients (91.3%) before surgery, and 3 patients (13%) presented with cauda equina syndrome. The average mean visual analog scale (±SD) for the preoperative pain score was 8.3 and decreased to 2.4 at follow-up after surgery. All cases of cauda equina syndrome resolved postoperatively. CONCLUSION Unilateral tubular minimally invasive surgery diskectomy seems to be a safe and effective treatment alternative for lumbar GDHs, combined with the "over-the-top" decompression, which provides bilateral decompression and working space.
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Affiliation(s)
- Fabian Sommer
- Department of Neurological Surgery, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
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25
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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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Surgical management of giant calcified thoracic disc herniation and the role of neuromonitoring. The outcome of large mono centric series. J Clin Neurosci 2022; 100:37-45. [PMID: 35390556 DOI: 10.1016/j.jocn.2022.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/21/2022]
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Saway BF, Alshareef M, Lajthia O, Cunningham C, Shope C, Martinez JL, Kalhorn SP. Ultrasonic spine surgery for every thoracic disc herniation: a 43-patient case series and technical note demonstrating safety and efficacy using a partial transpedicular thoracic discectomy with ultrasonic aspiration and ultrasound guidance. J Neurosurg Spine 2022; 36:800-808. [PMID: 34798611 DOI: 10.3171/2021.8.spine21819] [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: 06/16/2021] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Thoracic disc herniations (TDHs) are a challenging pathology. A variety of surgical techniques have been used to achieve spinal cord decompression. This series elucidates the versatility, efficacy, and safety of the partial transpedicular approach with the use of intraoperative ultrasound and ultrasonic aspiration for resection of TDHs of various sizes, locations, and consistencies. This technique can be deployed to safely remove all TDHs. METHODS A retrospective review was performed of patients who underwent a thoracic discectomy via the partial transpedicular approach between January 2014 and December 2020 by a single surgeon. Variables reviewed included demographics, perioperative imaging, and functional outcome scores. RESULTS A total of 43 patients (53.5% female) underwent 54 discectomies. The most common presenting symptoms were myelopathy (86%), motor weakness (72%), and sensory deficit (65%) with a symptom duration of 10.4 ± 11.6 months. A total of 21 (38.9%) discs were fully calcified on imaging and 15 (27.8%) were partially calcified. A total of 36 (66.7%) were giant TDHs (> 40% canal compromise). The average operative time was 197.2 ± 77.1 minutes with an average blood loss of 238.8 ± 250 ml. Six patients required ICU stays. Hospital length of stay was 4.40 ± 3.4 days. Of patients with follow-up MRI, 38 of 40 (95%) disc levels demonstrated < 20% residual disc. Postoperative Frankel scores (> 3 months) were maintained or improved for all patients, with 28 (65.1%) patients having an increase of 1 grade or more on their Frankel score. Six (14%) patients required repeat surgery, 2 of which were due to reherniation, 2 were from adjacent-level herniation, and 2 others were from wound problems. Patients with calcified TDHs had similar improvement in Frankel grade compared to patients without calcified TDH. Additionally, improvement in intraoperative neuromonitoring was associated with a greater improvement in Frankel grade. CONCLUSIONS The authors demonstrate a minimally disruptive, posterior approach that uses intraoperative ultrasound and ultrasonic aspiration with excellent outcomes and a complication profile similar to or better than other reported case series. This posterior approach is a valuable complement to the spine surgeon's arsenal for the confident tackling of all TDHs.
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Affiliation(s)
- Brian F Saway
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mohammed Alshareef
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Orgest Lajthia
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Coby Cunningham
- 2College of Medicine, Drexel University, Philadelphia, Pennsylvania; and
| | - Chelsea Shope
- 3College of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jaime L Martinez
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Stephen P Kalhorn
- 1Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
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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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Cornips EMJ, Beuls EAM. Thoracoscopic Microdiscectomy with Preservation of Rib and Costovertebral Joint. Adv Tech Stand Neurosurg 2022; 45:359-378. [PMID: 35976457 DOI: 10.1007/978-3-030-99166-1_12] [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] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Thoracic disc herniations (TDH) may cause major morbidity. While thoracoscopic microdiscectomy (TMD) is an excellent technique, postoperative band-like pain is an important drawback. MATERIAL AND METHODS We performed 181 consecutive TMDs (including 39 high-risk cases) with preservation of rib and costovertebral joint (CVJ). We shave a few mm of the rib, drill straight to target, and avoid opening the canal before the TDH is completely free and (in case of giant TDHs) internally debulked, creating initial decompression and limiting epidural venous oozing. Subsequently, we gently mobilize and remove the residual TDH while avoiding leverage. RESULTS Skin-to-skin time was <90' in 64, 90-120' in 48, >120' in 20, unknown in 10, and 162' mean in 39 high-risk procedures. Blood loss was <100 mL in 76, <250 mL in 48, and 537 mL mean in 39 high-risk procedures. The technique was successfully applied in all (including nine dural repairs) without a single conversion. We observed an increased neurological deficit in two (1.1%) and inadequate decompression in merely one (wrong level). Complications (mainly pulmonary) were few and managed conservatively, except for a segmental artery pseudoaneurysm treated endovascularly. We observed a substantial decrease in acute and chronic postoperative pain. DISCUSSION The technique is fast, straightforward, minimizes bone resection and blood loss, improves orientation, safely and effectively deals with any TDH, and prevents postoperative band-like pain as the CVJ is preserved. CONCLUSION We hope this technique will find broader acceptance among a new generation of spine surgeons to benefit patients suffering TDH-related myelopathy or merely intractable pain.
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Affiliation(s)
- E M J Cornips
- Department of Neurosurgery, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - E A M Beuls
- Centrum voor Gerechtelijke Geneeskunde, Antwerp University, Antwerp, Belgium
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30
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Lisitzky IY, Lychagin AV, Zarov AY, Korkunov AL, Cherepanov VG, Vyazankin IA. [Surgical treatment of herniated thoracic discs using transthoracic extrapleural approach]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:50-59. [PMID: 35942837 DOI: 10.17116/neiro20228604150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To analyze the results of herniated thoracic disc resection via transthoracic extrapleural approach. MATERIAL AND METHODS The study included 16 patients with 18 symptomatic herniated thoracic discs wo underwent transthoracic extrapleural surgery. In 11 cases, clinical pattern of disease was represented by myelopathy with radicular or axial pain syndrome. Five patients had radiculopathy alone. Median localization of hernias was observed in 8 (44.4%) cases, paramedian hernias - in 10 (55.6%) cases. There were 10 (55.6%) ossified hernias, 5 (27.7%) giant, 10 (55.5%) large and 3 (16.6%) medium hernias. RESULTS In most patients, VAS score of pain syndrome decreased by 2-6 points (mean 3.6). In 4 patients, this value remained the same. Among 11 patients with myelopathy, regression of conduction disorders in 1 year after surgery was achieved in 9 (82%) cases including complete recovery in 6 (55%) patients (Frankel E, Nurick - 0-I). In 2 patients, neurological status was equal to preoperative one. In all cases, the follow-up examination confirmed total removal of compressive substrate and found no signs of spine instability. Surgery time varied from 80 to 210 min (mean 161), blood loss - from 300 to 800 ml (mean 378 ml). Two patients had transient neurological deterioration. There was damage to dura mater in 4 cases. Intercostal neuralgia was observed in 3 patients. CONCLUSION While retaining the advantages of open thoracotomy, transthoracic extrapleural approach is less traumatic, allows complete spinal cord decompression, minimizes the risk of iatrogenic spinal cord injury and avoids certain postoperative complications.
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Affiliation(s)
- I Yu Lisitzky
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Lychagin
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A Yu Zarov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A L Korkunov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - V G Cherepanov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - I A Vyazankin
- Sechenov First Moscow State Medical University, Moscow, Russia
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T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach. World Neurosurg 2021; 158:e984-e995. [PMID: 34875390 DOI: 10.1016/j.wneu.2021.11.128] [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: 08/16/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To describe a cohort of T3-T4 thoracic disc herniations (TDHs), their clinical and radiologic characteristics, and unique thoracoscopic transaxillary approach (TAA). METHODS All patients operated on for a T3-T4 TDH with minimal follow-up of 1 year were selected. RESULTS Eight TAA procedures (6 males and 2 females) were included (1.4%). Six patients reported axial pain, irradiating in 2, 4 sensory changes, 1 objective and 1 merely subjective motor weakness. Only 1 TDH was calcified, none was giant, 2 were accompanied by myelomalacia, and 2 by a small segmental syrinx. A cardiothoracic surgeon helped with exposure through a curved axillary incision using anterior cervical and more recently double-ring wound retractors. All patients were operated on using a 10-mm 30° rigid (three-dimensional) high-definition scope. There were no major complications and a good outcome with symptomatic relief in 7 of 8 patients. CONCLUSIONS T3-T4 TDHs are infrequent but may be underdiagnosed because they tend to be small and their signs and symptoms may mimic a cervical problem involving the shoulders and even the arms. There may be a male predominance. The TAA is straightforward, safe, efficacious, and well tolerated despite the supposed vulnerability of the upper thoracic spinal cord. Dissection between large crowded subpleural veins characteristic for the upper thoracic spine and ensuring adequate dura decompression when the steep angle may partially obscure the tip of the instruments does require some extra time. Thorough knowledge of the unique anatomy of the upper thorax is mandatory and the assistance of a cardiothoracic surgeon is highly recommended.
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Alexander TD, Stefanelli A, Thalheimer S, Heller JE. Sleep apnea and unilateral upper and lower extremity allodynia as a result of a large thoracic disc herniation: a case report. SLEEP SCIENCE AND PRACTICE 2021. [DOI: 10.1186/s41606-021-00067-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clinically significant disc herniations in the thoracic spine are rare accounting for approximately 1% of all disc herniations. In patients with significant spinal cord compression, presenting symptoms typically include ambulatory dysfunction, lower extremity weakness, lower extremity sensory changes, as well as bowl, bladder, or sexual dysfunction. Thoracic disc herniations can also present with thoracic radiculopathy including midback pain and radiating pain wrapping around the chest or abdomen. The association between thoracic disc herniation with cord compression and sleep apnea is not well described.
Case presentation
The following is a case of a young male patient with high grade spinal cord compression at T7-8, as a result of a large thoracic disc herniation. The patient presented with complaints of upper and lower extremity unilateral allodynia and sleep apnea. Diagnosis was only made once the patient manifested more common symptoms of thoracic stenosis including left lower extremity weakness and sexual dysfunction. Following decompression and fusion the patient’s allodynia and sleep apnea quickly resolved.
Conclusions
Thoracic disc herniations can present atypically with sleep apnea. We recommend taking into consideration that sleep symptoms may resolve when planning treatment for thoracic disc herniation.
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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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Abstract
In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome. However, this review summarized the relative indications for surgery in each level. In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications. In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure. In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care.
Cite this article: EFORT Open Rev 2021;6:526-530. DOI: 10.1302/2058-5241.6.210020
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Affiliation(s)
- Wai Weng Yoon
- Spinal Surgery Unit, University Hospitals of Leicester NHS Trust, Leicester, UK.,Centre for Spinal Surgery, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Jonathan Koch
- Centre for Spinal Surgery, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
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Risk factors associated with post-operative neurological deterioration in patients with thoracic disc disorders with myelopathy. INTERNATIONAL ORTHOPAEDICS 2021; 45:1539-1547. [PMID: 33825002 DOI: 10.1007/s00264-021-04999-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Post-operative neurological deterioration (ND) is a severe complication. However, limited literature exists on the ND in thoracic disc disorders with myelopathy (TDM). This study describes the risk factors of neurological deterioration in TDM with instrumentation and fusion. METHODS A single-centre review of TDM with instrumentation and fusion during 2006-2019 was performed. Post-operative neurological deterioration was defined as the deterioration of pre-existing neurological function or the appearance of new neurological symptoms. Patients were then grouped into two groups depending on neurological deterioration (ND group) or not (non-ND group). Demographics, radiographic parameters, and surgical characteristics were compared between the two groups. RESULTS A total of 257 cases were included, and neurological deterioration occurred in 16 (6.23%) cases. Multivariate analysis revealed spinal canal occupancy ratio > 75%, U-shaped compressed spinal cord in axial MRI, calcified herniated disc, anterior approach, and intra-operative blood loss > 1500 mL were associated with ND. Ten patients (62.5%) had complete neurological recovery within six months, and four patients (25%) had progressive neurological function improvement and equal or better than pre-operation within nine months. CONCLUSIONS The rate of neurological deterioration is 6.23%, and a higher spinal canal occupancy ratio, U-shaped compressed spinal cord, calcified herniated disc, anterior approach, and massive intra-operative blood loss were associated with neurological deterioration. Long-term outcomes of neurological deterioration are favourable, and 62.5% of patients experienced complete neurological recovery within six months. Patients with TMD who undergo surgery should be properly informed of the potential risks of neurological deterioration, despite its usually transient nature in most patients.
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Abstract
In the last five years, surgeons have applied endoscopic transforaminal surgical techniques mastered in the lumbar spine to the treatment of thoracic pathology. The aim of this systematic review was to collate the available literature to determine the place and efficacy of full endoscopic approaches used in the treatment of thoracic disc prolapse and stenosis. An electronic literature search of PubMed, Embase, the Cochrane database and Google Scholar was performed as suggested by the Preferred Reporting Items for Systematic Review and Meta-analysis statements. Included were any full-text articles referring to full endoscopic thoracic surgical procedures in any language. We identified 17 patient series, one cohort study and 13 case reports with single or of up to three patients. Although the majority included disc pathology, 11 papers related cord compression in a proportion of cases to ossification of the ligamentum flavum or posterior longitudinal ligament. Two studies described the treatment of discitis and one reported the use of endoscopy for tumour resection. Where reported, excellent or good outcomes were achieved for full endoscopic procedures in a mean of 81% of patients (range 46–100%) with a complication rate of 8% (range 0–15%), comparing favourably with rates reported after open discectomy (anterior, posterolateral and thoracoscopic) or by endoscopic tubular assisted approaches. Twenty-one of the 31 author groups reported use of local anaesthesia plus sedation rather than general anaesthesia, providing ‘self-neuromonitoring’ by allowing patients to respond to cord and/or nerve stimuli.
Cite this article: EFORT Open Rev 2021;6:50-60. DOI: 10.1302/2058-5241.6.200080
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Affiliation(s)
| | - Ralf Wagner
- Ligamenta Spine Centre, Frankfurt am Main, Germany
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Radiographic and clinical features of thoracic disk disease associated with myelopathy: a retrospective analysis of 257 cases. 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 2021; 30:2211-2220. [PMID: 33389202 DOI: 10.1007/s00586-020-06688-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/11/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
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.
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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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Krishnan A, Degulmadi D, Mayi S, Kulkarni M, Reddy C, Singh M, Rai RR, Dave BR. Transforaminal Thoracic Interbody Fusion for Thoracic Disc Prolapse: Surgicoradiological Analysis of 18 Cases. Global Spine J 2020; 10:706-714. [PMID: 32707016 PMCID: PMC7383794 DOI: 10.1177/2192568219870459] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
STUDY DESIGN Retrospective observational study. OBJECTIVES Thoracic disc prolapse (TDP) surgeries have reported complications ranging from paraplegia to approach related complications. This study is to present a series of TDP patients surgically treated with transforaminal thoracic interbody fusion (TTIF). Emphasis on surgical technique and strategies to avoid complications are analyzed. METHODS Eighteen patients with TDP were included. Imagings were analyzed for end-plate changes and calcification. Type of disc prolapse (central/para-central) and percentage of canal occupancy were noted. Objective outcome was quantified with Visual Analogue Scale (VAS), modified Nurick's grade, and ASIA (American Spinal Injury Association) score. All complications were noted. RESULTS Eighteen patients (average age 43.65 years) having total 22 levels operated, that included double level (n = 2) and missed level (n = 2) are reported. All patients had myelopathy. Calcification of disc (n = 13), central disc prolapses (n = 9), para-central (n = 11) and more than 50% canal occupancy (n = 8) were noted. VAS back pain, modified Nurick's grade and ASIA grade improved significantly in all patients. One patient had postoperative transient deficit. The functional score achieved its maximum at 1 year follow-up and remained static at final follow-up of 65.05 months. Union was achieved in all patients. CONCLUSIONS The most important factor for outcome in TDP is the technical aspect of avoiding cord manhandling and avoiding wrong level surgeries. TTIF is not devoid of complications but can give good results to posterior approach trained surgeons.
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Affiliation(s)
- Ajay Krishnan
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
- BIMS Hospital, Bhavnagar, Gujarat, India
- Ajay Krishnan, C302, Orange Avenue, Maple County 1, Thaltej, Ahmedabad, Gujarat 380059, India.
| | | | - Shivanand Mayi
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Mahesh Kulkarni
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Chaitanya Reddy
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Mreetunjay Singh
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Ravi Ranjan Rai
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
| | - Bharat R. Dave
- Stavya Spine Hospital & Research Institute, Ahmedabad, Gujarat, India
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Butenschoen VM, Hoenikl L, Deschauer M, Meyer B, Gempt J. Bilateral thoracic disc herniation with abdominal wall paresis: a case report. Acta Neurochir (Wien) 2020; 162:2055-2059. [PMID: 32500255 PMCID: PMC8203549 DOI: 10.1007/s00701-020-04431-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 05/26/2020] [Indexed: 11/16/2022]
Abstract
We present a rare case of a patient initially presenting with unilateral abdominal wall bulging and radicular pain caused by a lateral disc herniation at Th11/12, later suffering from a hernia recurrence with bilateral disc prolapse and motor deficits. The patient underwent sequesterectomy via a right hemilaminectomy at Th11, and after 8 weeks, a bilateral sequesterectomy with semirigid fusion Th11/12 was performed. Unilateral motor deficits at the thoracic level have been discussed in case reports; a bilateral disc protrusion with abdominal wall bulging occurring as a recurrent disc herniation has never been described before.
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Affiliation(s)
- Vicki Marie Butenschoen
- School of Medicine, Klinikum rechts der Isar, Neurosurgical Department, Technical University of Munich, Munich, Germany
| | - Lisa Hoenikl
- School of Medicine, Klinikum rechts der Isar, Neurosurgical Department, Technical University of Munich, Munich, Germany
| | - Marcus Deschauer
- School of Medicine, Klinikum rechts der Isar, Neurological Department, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- School of Medicine, Klinikum rechts der Isar, Neurosurgical Department, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- School of Medicine, Klinikum rechts der Isar, Neurosurgical Department, Technical University of Munich, Munich, Germany
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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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Soda C, Faccioli F, Marchesini N, Ricci UM, Brollo M, Annicchiarico L, Benato C, Tomasi I, Pinna GP, Teli M. Trans-thoracic versus retropleural approach for symptomatic thoracic disc herniations: comparative analysis of 94 consecutive cases. Br J Neurosurg 2020; 35:195-202. [PMID: 32558605 DOI: 10.1080/02688697.2020.1779660] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Christian Soda
- Department of Neurosurgery, Verona Borgo Trento Hospital, Verona, Italy
| | - Franco Faccioli
- Department of Neurosurgery, Verona Borgo Trento Hospital, Verona, Italy
| | - Nicolò Marchesini
- Department of Neurosurgery, Verona Borgo Trento Hospital, University of Verona, Verona, Italy
| | - Umberto M Ricci
- Department of Neurosurgery, Verona Borgo Trento Hospital, Verona, Italy
| | - Marco Brollo
- Department of Neurosurgery, Mestre Hospital, Mestre, Italy
| | | | - Cristiano Benato
- Department of Thoracic Surgery, Borgo Trento Hospital, Verona, Italy
| | - Ivan Tomasi
- Department of Emergency General Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Marco Teli
- Department of Neurosurgery, Walton Centre NHS Foundation Trust, Liverpool, UK
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Efficacy Analysis of Percutaneous Endoscopic Lumbar Discectomy Combined with PEEK Rods for Giant Lumbar Disc Herniation: A Randomized Controlled Study. Pain Res Manag 2020; 2020:3401605. [PMID: 32215135 PMCID: PMC7085829 DOI: 10.1155/2020/3401605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 02/05/2020] [Indexed: 12/28/2022]
Abstract
Objective This study describes a randomized controlled trial that assesses percutaneous endoscopic lumbar discectomy (PELD) combined with a polyetheretherketone (PEEK) rod in patients with GLDH (herniation affecting 50% of the sagittal diameter of the spinal canal) and reports the 2-year follow-up outcome. Methods In all, 243 patients were randomly assigned to undergo PELD or PELD combined with a PEEK rod by generating random numbers with a random number generator. Clinical outcome data, including the numerical rating scale (NRS), were used to assess the patients' back and leg pain, while the Oswestry Disability Index (ODI) was used to quantify pain and disability. Imaging data included intervertebral disc height (IDH), range of motion (ROM), and modified Pfirrmann grades. Results At the final follow-up, the NRS for back and leg pain and the ODI scores were significantly decreased in both groups. The NRS for back pain and the ODI scores in the PELD + PEEK group (1.32 ± 0.70, 14.10 ± 4.74) were better than those in the PELD group (1.91 ± 0.69, 16.93 ± 4.33) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) (P < 0.05). The IDH of the PELD + PEEK group (10.54 ± 1.62) was significantly higher than that in the PELD group (9.98 ± 1.90) ( Conclusion For symptomatic patients with GLDH, both PELD and PELD combined with a PEEK rod showed good efficacy. However, the long-term effect of PELD combined with a PEEK rod is better than that of PELD alone. Moreover, PELD combined with a PEEK rod can effectively reduce the recurrence rate. Maximum benefit can be gained if we adhere to strict selection criteria for PELD combined with a PEEK rod.
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Revision surgery in 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 2019; 29:39-46. [PMID: 31734804 DOI: 10.1007/s00586-019-06212-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Surgical treatment failures or strategies for the reoperation of residual thoracic disc herniations are sparsely discussed. We investigated factors that led to incomplete disc removal and recommend reoperation strategies. METHODS As a referral centre for thoracic disc disease, we reviewed retrospectively the clinical records and imaging studies before and after the treatment of patients who were sent to us for revision surgery for thoracic disc herniation from 2013 to 2018. RESULTS A total of 456 patients were treated from 2013 to 2018 at our institution. Twenty-one patients had undergone previously thoracic discectomy at an outside facility and harboured residual, incompletely excised and symptomatic herniated thoracic discs. In 12 patients (57%), the initial symptoms that led to their primary operation were improved after the first surgery, but recurred after a mean of 2.8 years. In seven patients (33%) they remained stable, and in two cases they were worse. All patients were treated via all dorsal approaches. In all 21 cases, the initial excision was incomplete regarding medullar decompression. All of the discs were removed completely in a single revision procedure. After mean follow-up of 24 months (range 12-57 months), clinical neurological improvement was demonstrated in seven patients, while three patients suffered a worsening and 11 patients remained stable. CONCLUSION Our data suggest that pure dorsal decompression provides a short relief of the symptoms caused by spinal cord compression. Progressive myelopathy (probably due to mechanical and vascular deficits) and scar formation may cause worsening of symptoms. These slides can be retrieved under Electronic Supplementary Material.
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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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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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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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Oltulu I, Cil H, Ulu MO, Deviren V. Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach. Neurosurg Rev 2019; 42:885-894. [PMID: 30617649 DOI: 10.1007/s10143-018-01064-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 11/03/2018] [Accepted: 12/03/2018] [Indexed: 10/27/2022]
Abstract
Although symptomatic thoracic disk herniation (TDH) is relatively rare, its treatment is quite difficult. Our aim is to present the outcomes and complications in patients with thoracic disk herniation treated with minimally invasive lateral transthoracic approach (LTTA). Fifty-nine consecutive patients with 69 symptomatic disk herniations that underwent minimally invasive LTTA to treat TDH between 2007 and 2016 were enrolled. Medical records were reviewed retrospectively. The numbers of TDH were as follows: 41 central, 10 paracentral, and 18 both central and paracentral. The number of calcified disk herniations was found to be 32. No patient developed neurological deficit. Postoperative neurological improvement occurred in 39 (90.7%) of 43 patients with myelopathy. Preoperative VAS scores, ODI scores, and SF-36 scores improved at the follow-up, respectively. Mean blood loss, hospitalization period, and follow-up period were found to be 391.2 mL, 4.7 days, and 60 months; respectively. The following complications were observed: dural tear (five patients), intercostal neuralgia (three patients), rib fracture (one patient), pleural effusion requiring chest tube (two patients), hydropneumothorax requiring chest tube (one patient), small pneumothorax (one patient), atelectasis (one patient), pulmonary embolism (one patient), and pneumonia (one patient). Minimally invasive LTTA not only minimizes the manipulation of the thecal sac decreasing the risk for neurological injury compared to traditional posterior methods but also significantly decreases the pulmonary complications associated with traditional open procedures. Based on the authors' experience, anterior approach should be preferred especially in calcified central disk herniations regardless of surgeon's experience.
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Affiliation(s)
- Ismail Oltulu
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Avenue, MU 320W, San Francisco, CA, 94143-0728, USA
| | - Hemra Cil
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Avenue, MU 320W, San Francisco, CA, 94143-0728, USA
| | - Mustafa Onur Ulu
- Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California, 500 Parnassus Avenue, MU 320W, San Francisco, CA, 94143-0728, USA.
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Andrade P, Cornips EMJ, Sommer C, Daemen MA, Visser-Vandewalle V, Hoogland G. Elevated inflammatory cytokine expression in CSF from patients with symptomatic thoracic disc herniation correlates with increased pain scores. Spine J 2018; 18:2316-2322. [PMID: 30077044 DOI: 10.1016/j.spinee.2018.07.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND The pathophysiology of pain in patients with symptomatic thoracic disc herniation (TDH) remains poorly understood. Mere mechanical compression of the spinal cord and/or the exiting nerve root by a prolapsed disc cannot explain the pathogenesis of pain in all cases. Previous studies report a direct correlation between the levels of proinflammatory cytokines in disc biopsies and the severity of leg pain in patients with lumbar disc herniation. A similar correlation in patients with TDH has not been investigated. PURPOSE To correlate the cerebrospinal fluid (CSF) expression of cytokines and pain-related amino acids with preoperative pain scores in patients with symptomatic TDH. STUDY DESIGN A prospective human study of CSF samples and clinical outcome scores. METHODS Using enzyme-linked immunosorbent assay (ELISA) and high-performance liquid chromatography (HPLC), we determined inflammatory cytokine levels (TNF-α, IL-1β, and IL-10) and amino acid levels (glutamate, aspartate, gamma-aminobutyric acid, glycine, and arginine) in CSF samples from 10 patients with TDH and 10 control subjects who did not suffer an inflammatory disease nor pain related to spinal cord compression and subsequently correlated these levels with preoperative pain scores. Differences between both groups were evaluated by a Mann-Whitney U test. In order to estimate the correlation between cytokine or amino acid expression and pain scores, data were analyzed using a linear regression analysis. RESULTS No inflammatory cytokines were found in CSF samples from control subjects, whereas TNF-α, IL-1β, and IL-10 were detectable by ELISA in all CSF samples from patients with TDH. TNF-α and IL-10 but not IL-1β levels moderately correlated with preoperative pain scores. Elevated TNF-αlevels positively correlated with high pain scores; elevated IL-10 levels negatively correlated with high pain scores. Amino acids were detectable in all samples from both groups. There were no significant differences between the groups in any of the amino acids measured with HPLC. CONCLUSION Increased proinflammatory cytokine expression is associated with elevated pain scores in patients with symptomatic TDH. On the other hand, there is no conclusive correlation between the intensity of pain and the local or systemic presence of amino acids associated with pain transmission.
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Affiliation(s)
- Pablo Andrade
- Department of General Neurosurgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany; School for Mental Health and Neuroscience, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, Netherlands.
| | - Erwin M J Cornips
- Department of Neurosurgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, Netherlands
| | - Claudia Sommer
- Department of Neurology, University of Würzburg, Josef-Schneider-StraÔe 11, 97080, Würzburg, Germany
| | - Marc A Daemen
- Department of Neurosurgery, NedSpine, Pascalstraat 21, 6716 AZ, Ede, Netherlands
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Govert Hoogland
- School for Mental Health and Neuroscience, Maastricht University, Universiteitssingel 40, 6229 ER, Maastricht, Netherlands; Department of Neurosurgery, Maastricht University Medical Center, P. Debyelaan 25, 6229 HX, Maastricht, Netherlands
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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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