Introduction Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD. Methods This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients' notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications. Results During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31-83 years). The average canal encroachment was 62 % (range 40-90 %); mean follow-up 37 months (12-98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212-601 min) and estimated blood loss 1,230 ml (range 350-3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62 %), 2 improved by 2 grades (15 %) and 3 did not change their grade (23 %). The complication rate was 4/13 (31 %; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence). Discussion Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23 %) or improved by at least 1 grade (77 %) neurologically, without radiographic failure at final follow-up.
Injury to the hypoglossal nerve is a recognised complication after soft tissue surgery in the upper part of the anterior aspect of the neck, e.g. branchial cyst or carotid body tumour excision. However, this complication has been rarely reported following surgery of the upper cervical spine. We report the case of a 35-year-old woman with tuberculosis of C2-3. She underwent corpectomy and fusion from C2 to C5 using iliac crest bone graft, through a left anterior oblique incision. She developed hypoglossal nerve palsy in the immediate postoperative period, with dysphagia and dysarthria. It was thought to be due to traction neurapraxia with possible spontaneous recovery. At 18 months' follow-up, she had a solid fusion and tuberculosis was controlled. The hypoglossal palsy persisted, although with minimal functional disability. The only other reported case of hypoglossal lesion after anterior cervical spine surgery in the literature also failed to recover. It is concluded that hypoglossal nerve palsy following anterior cervical spine surgery is unlikely to recover spontaneously and it should be carefully identified.
This innovative new technique provides for a safe, controlled reduction for cervical osteotomy for fixed cervicothoracic kyphosis in AS. The technique reliably renders rigid immobilization that obviates the risk of intra- and postoperative junctional subluxation, eliminates the need for postoperative halo-vest immobilization, and achieves satisfactory fusion.
The two patients with observable deficit had their instrumentation left in situ after discussion with them and/or parents. Spinal cord monitoring in this population is possible but potentially unreliable. Surgeons will need to carefully consider the use of monitoring in their management of this challenging population.
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