Thoracic Disc Herniation: Case Series and Protocol for Surgical Approaches

Abstract

Objective To describe the surgical results of a prospective series of five patients operated according to an approach indication protocol. Methods: Patients were classified according to surgical risk: Group A (high risk) or B (low risk) and subsequently into subgroups according to characteristics of the herniation and ultimately the surgical approach was defined: A.1) calcified central herniations - thoracoscopy; A.2) soft lateral herniations - posterolateral approach; A.3) centrolateral herniations - partial calcification in lateral position - posterolateral approach; higher density central calcification - thoracoscopy; B.1) central or centrolateral calcified herniations - thoracotomy or thoracoscopy; B.2) soft lateral herniations - posterolateral approach. Results: The duration of symptoms ranged from 2 months to 3 years; the age bracket was from 37 to 58 years; sex distribution was 3 female and 2 male patients and the length of hospital stay ranged from 2 to 20 days. The most affected level was T11/12. A patient classified as Group A.3 underwent posterolateral approach. The remaining patients were Group B.1, 3 submitted to thoracotomy and 1 to thoracoscopy. The herniation removal was completed in 5 cases; 3 patients improved and 2 remained stable. The morbidity and the recovery time were higher in patients who underwent anterolateral approaches. Conclusions: Classify patients according to surgical risk and the anatomical characteristics of disc herniation allows for complete decompression, minimizing morbidity and mortality.

Anterior Versus Posterior Decompression for Degenerative Thoracic Spine Diseases: A Comparison of Complications

“…Anterior transthoracic approaches, including the trans-sternal, trans-pleural, and retro-pleural techniques 23 provide enhanced disc visualization, lower the risk of iatrogenic spinal cord injury, and preserve the integrity of posterior elements. 5,12,18,25 However, our study showed that patients undergoing anterior surgery are at significant risk of cardiovascular, gastrointestinal, respiratory, and device-/implant-/graft-related complications, as well as deep vein thrombosis/pulmonary embolism and organ failure. In a similar study focused on thoracic disc herniation, Yoshihara et al 24 compared the complications of anterior and nonanterior decompression using discharge data from the Nationwide Inpatient Sample (NIS) database.…”

“…18,23,24 This approach is considered advantageous in terms of neurological outcomes, safety, and length of hospital stay. 5,25 However, it can require extensive paravertebral muscle dissection and substantial bone resection, leading to increased postoperative morbidity. 12,25 Moreover, the posterior approach does not provide sufficient access for ventral dural decompression in central disc herniations.…”

“…Thoracic disc herniation commonly presents with radiculopathy and nonspecific pain, which are due to neural compression and increase in inflammatory cytokines. 5,6 However, atypical manifestations such as chronic abdominal pain, gastrointestinal symptoms, and cardiopulmonary presentations are not uncommon. [7][8][9][10] These unusual presentations often overlap with other thoraco-abdominal pathologies and hinder a timely diagnosis.…”

“…[7][8][9][10] Historically, direct posterior decompression with laminectomy was used for surgical treatment of thoracic disc herniation. 5 This technique was associated with increased risks of iatrogenic spinal cord injury due to limitation of the space available for thoracic cord. 5,[11][12][13] Therefore, this approach was abandoned in favor of other methods.…”

“…5 This technique was associated with increased risks of iatrogenic spinal cord injury due to limitation of the space available for thoracic cord. 5,[11][12][13] Therefore, this approach was abandoned in favor of other methods. Current techniques for surgical decompression of thoracic spine are broadly categorized to posterior and anterior approaches, the former being the most common approach and the latter gaining increasing interest due to its advantage in disc visualization.…”