Surgical treatment of thoracic disc herniation: an overview
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Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord.
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.
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.
KeywordsThoracic disc herniation Surgical treatment Complications Minimally invasive surgery Thoracic spine approach
Compliance with ethical standards
Conflict of interest
C. Bouthors and A. Benzakour declare that they have no conflict of interest. Ch. Court has received financial supports from Medtronic® and Safe Orthopedics® for educational programs and has investment interest in NeuroFrance® and SpineGuard®.
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