Calcified giant thoracic disc herniations: considerations and treatment strategies

Abstract

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.

Surgery of Thoracic Disc Herniation: A Systematic Review of English-Language Literature

“…Выбор оптимальной методики оперативного лечения представляет собой непростую задачу для хирурга. Требования к хирургическому доступу определены и четко сформулированы: доступ должен обеспечить удаление грыжи и, что чрезвычайно важно, минимизировать контакт со спинным мозгом [6][7][8][9]. Целью оперативных вмешательств в иссле-дованиях являлась декомпрессия спинного мозга, а при изолированной радикулопатии -скомпрометированного спинно-мозгового корешка.…”

“…В настоящее время разработано множество методик хирургического лечения грыж межпозвонковых грудных дисков, используются малоинвазивные микрохирургические и эндоскопические технологии. Авторы включенных в обзор публикаций для удаления грыж применяли торакотомию [6,[10][11][12], мини-торакотомию [9,13,14], ретроплевральный трансторакальный [15], перкутанный торакоскопический доступ [4,5,16], а также различные виды задних хирургических доступов [7-9, 12, 17-26]. Торакотомия обеспечивала хороший обзор и контроль зоны хирургических манипуляций, широкий доступ к межпозвонковому диску, передним отде- лам дурального мешка без его тракции, снижая тем самым возможность конфликта со спинным мозгом [10,11].…”

Circumferential Decompression via a ModifiedCostotransversectomy Approach for the Treatment of Single Level Hard Herniated Disc between T10–L1

“…Pathologic examination may show either lamellar bone organized in trabeculae containing predominantly fatty marrow or the presence of calcium deposits . These lesions may be adherent to and even erode through the dural sac over time . For this reason, thoracic myelopathy caused by HTHD is often progressive and responds poorly to conservative treatment …”

“…evaluated the results of surgery via a modified costotransversectomy approach and concluded that the current costotransversectomy approach minimizes or avoids most of these possibilities while providing adequate visualization of the pathology and neural structures . The anterior approach carries potential morbidity associated with thoracotomy, such as pneumothorax, pleural effusion, chylothorax, atelectasis, and prolonged mechanical ventilation; however, it does provide direct visualization . Arts et al recently compared the outcomes of patients with symptomatic thoracic disc herniations treated via an anterolateral mini‐transthoracic approach (TTA) versus posterior transpedicular discectomy .…”

“…Surgery was complicated by a dural tear, which is associated with a high risk of cerebrospinal fluid (CSF) fistula, in seven patients and four of these seven required surgical revision. Thoracoscopic discectomy is therefore indicated only for small lateral and soft disc herniations . Cho et al .…”