International Orthopaedics

, Volume 43, Issue 4, pp 807–816 | Cite as

Surgical treatment of thoracic disc herniation: an overview

  • Charlie BouthorsEmail author
  • Ahmed Benzakour
  • Charles Court



Surgical treatment of thoracic disc herniation (TDH) is technically demanding due to its proximity to the spinal cord.


Literature review.


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.


Thoracic 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®.


  1. 1.
    Le Huec J-C, Faundez A, Dominguez D et al (2015) Evidence showing the relationship between sagittal balance and clinical outcomes in surgical treatment of degenerative spinal diseases: a literature review. Int Orthop 39:87–95. CrossRefGoogle Scholar
  2. 2.
    Flouzat-Lachaniette C-H, Jullien N, Bouthors C et al (2018) A novel in vivo porcine model of intervertebral disc degeneration induced by cryoinjury. Int Orthop.
  3. 3.
    Quint U, Bordon G, Preissl I et al (2012) Thoracoscopic treatment for single level symptomatic thoracic disc herniation: a prospective followed cohort study in a group of 167 consecutive cases. Eur Spine J 21:637–645. CrossRefGoogle Scholar
  4. 4.
    Hott JS, Feiz-Erfan I, Kenny K, Dickman CA (2005) Surgical management of giant herniated thoracic discs: analysis of 20 cases. J Neurosurg Spine 3:191–197. CrossRefGoogle Scholar
  5. 5.
    Palazzo C, Sailhan F, Revel M (2014) Scheuermann’s disease: an update. Joint Bone Spine 81:209–214. CrossRefGoogle Scholar
  6. 6.
    Kim YJ, Bridwell KH, Lenke LG et al (2006) Sagittal thoracic decompensation following long adult lumbar spinal instrumentation and fusion to L5 or S1: causes, prevalence, and risk factor analysis. Spine 31:2359–2366. CrossRefGoogle Scholar
  7. 7.
    He B, Yan L, Xu Z et al (2014) Treatment strategies for the surgical complications of thoracic spinal stenosis: a retrospective analysis of two hundred and eighty three cases. Int Orthop 38:117–122. CrossRefGoogle Scholar
  8. 8.
    Morgan H, Abood C (1998) Disc herniation at T1-2. Report of four cases and literature review. J Neurosurg 88:148–150. CrossRefGoogle Scholar
  9. 9.
    Guest JD, Griesdale DE, Marotta T (2000) Thoracic disc herniation presenting with transient anterior spinal artery syndrome. A case report. Interv Neuroradiol 6:327–331. CrossRefGoogle Scholar
  10. 10.
    Rohde RS, Kang JD (2004) Thoracic disc herniation presenting with chronic nausea and abdominal pain. A case report. J Bone Joint Surg Am 86-A:379–381CrossRefGoogle Scholar
  11. 11.
    Baba H, Imura S (1993) An unusual ossified thoracic disc herniation. Int Orthop 17:290–292Google Scholar
  12. 12.
    Sari H, Misirlioglu TO, Palamar D (2016) Regression of a symptomatic thoracic disc herniation with a calcified intervertebral disc component. Acta Orthop Traumatol Turc 50:698–701. CrossRefGoogle Scholar
  13. 13.
    Gong M, Liu G, Guan Q et al (2018) Surgery for giant calcified herniated thoracic discs: a systematic review. World Neurosurg 118:109–117. CrossRefGoogle Scholar
  14. 14.
    N’da HA, Chenin L, Capel C et al (2016) Microsurgical anatomy of the Adamkiewicz artery-anterior spinal artery junction. Surg Radiol Anat 38:563–567. CrossRefGoogle Scholar
  15. 15.
    Stillerman CB, Chen TC, Couldwell WT et al (1998) Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 88:623–633. CrossRefGoogle Scholar
  16. 16.
    Takagi H, Ota H, Natsuaki Y et al (2015) Identifying the Adamkiewicz artery using 3-T time-resolved magnetic resonance angiography: its role in addition to multidetector computed tomography angiography. Jpn J Radiol 33:749–756. CrossRefGoogle Scholar
  17. 17.
    Onishi E, Yasuda T, Yamamoto H et al (2016) Outcomes of surgical treatment for thoracic myelopathy: a single-institutional study of 73 patients. Spine 41:E1356–E1363. CrossRefGoogle Scholar
  18. 18.
    Rosahl SK, Gharabaghi A, Liebig T et al (2002) Skin markers for surgical planning for intradural lesions of the thoracic spine. Technical note. Surg Neurol 58:346–348Google Scholar
  19. 19.
    Paolini S, Ciappetta P, Missori P et al (2005) Spinous process marking: a reliable method for preoperative surface localization of intradural lesions of the high thoracic spine. Br J Neurosurg 19:74–76. CrossRefGoogle Scholar
  20. 20.
    Hsu W, Sciubba DM, Sasson AD et al (2008) Intraoperative localization of thoracic spine level with preoperative percutaneous placement of intravertebral polymethylmethacrylate. J Spinal Disord Tech 21:72–75. CrossRefGoogle Scholar
  21. 21.
    Binning MJ, Schmidt MH (2010) Percutaneous placement of radiopaque markers at the pedicle of interest for preoperative localization of thoracic spine level. Spine 35:1821–1825. CrossRefGoogle Scholar
  22. 22.
    Sammon PM, Gibson R, Fouyas I, Hughes MA (2011) Intra-operative localisation of spinal level using pre-operative CT-guided placement of a flexible hook-wire marker. Br J Neurosurg 25:778–779. CrossRefGoogle Scholar
  23. 23.
    Thambiraj S, Quraishi NA (2012) Intra-operative localisation of thoracic spine level: a simple “‘K’-wire in pedicle” technique. Eur Spine J 21(Suppl 2):S221–S224. CrossRefGoogle Scholar
  24. 24.
    Baba H, Kawahara N, Tomita K, Imura S (1993) Spinal cord evoked potentials in cervical and thoracic myelopathy. Int Orthop 17:82–86Google Scholar
  25. 25.
    Uribe JS, Smith WD, Pimenta L et al (2012) Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine 16:264–279. CrossRefGoogle Scholar
  26. 26.
    Cornips E, Habets J, van Kranen-Mastenbroek V et al (2017) Anterior transthoracic surgery with motor evoked potential monitoring for high-risk thoracic disc herniations: technique and results. World Neurosurg 105:441–455. CrossRefGoogle Scholar
  27. 27.
    Sutter M, Deletis V, Dvorak J et al (2007) Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries. Eur Spine J 16(Suppl 2):S232–S237. CrossRefGoogle Scholar
  28. 28.
    Yanni DS, Connery C, Perin NI (2011) Video-assisted thoracoscopic surgery combined with a tubular retractor system for minimally invasive thoracic discectomy. Neurosurgery 68:138–143; discussion 143. Google Scholar
  29. 29.
    Fan G, Han R, Gu X et al (2017) Navigation improves the learning curve of transforamimal percutaneous endoscopic lumbar discectomy. Int Orthop 41:323–332. CrossRefGoogle Scholar
  30. 30.
    Yoshihara H, Yoneoka D (2014) Comparison of in-hospital morbidity and mortality rates between anterior and nonanterior approach procedures for thoracic disc herniation. Spine 39:E728–E733. CrossRefGoogle Scholar
  31. 31.
    Arts MP, Bartels RHMA (2014) Anterior or posterior approach of thoracic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies. Spine J 14:1654–1662. CrossRefGoogle Scholar
  32. 32.
    Kato S, Murakami H, Demura S et al (2015) Gradual spinal cord decompression through migration of floated plaques after anterior decompression via a posterolateral approach for OPLL in the thoracic spine. J Neurosurg Spine 23:479–483. CrossRefGoogle Scholar
  33. 33.
    Stillerman CB, Chen TC, Day JD et al (1995) The transfacet pedicle-sparing approach for thoracic disc removal: cadaveric morphometric analysis and preliminary clinical experience. J Neurosurg 83:971–976. CrossRefGoogle Scholar
  34. 34.
    Carr DA, Volkov AA, Rhoiney DL et al (2017) Management of thoracic disc herniations via posterior unilateral modified transfacet pedicle-sparing decompression with segmental instrumentation and interbody fusion. Glob Spine J 7:506–513. CrossRefGoogle Scholar
  35. 35.
    Stillerman CB, Weiss MH (1992) Management of thoracic disc disease. Clin Neurosurg 38:325–352Google Scholar
  36. 36.
    Xiaobing Z, Xingchen L, Honggang Z et al (2018) “U” route transforaminal percutaneous endoscopic thoracic discectomy as a new treatment for thoracic spinal stenosis. Int Orthop.
  37. 37.
    Wang K, Hong X, Zhou B-Y et al (2015) Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation. Int Orthop 39:1599–1604. CrossRefGoogle Scholar
  38. 38.
    Foreman PM, Naftel RP, Moore TA, Hadley MN (2016) The lateral extracavitary approach to the thoracolumbar spine: a case series and systematic review. J Neurosurg Spine 24:570–579. CrossRefGoogle Scholar
  39. 39.
    Oppenlander ME, Clark JC, Kalyvas J, Dickman CA (2013) Surgical management and clinical outcomes of multiple-level symptomatic herniated thoracic discs. J Neurosurg Spine 19:774–783. CrossRefGoogle Scholar
  40. 40.
    Quillo-Olvera J, Lin G-X, Suen T-K et al (2018) Anterior transcorporeal tunnel approach for cervical myelopathy guided by CT-based intraoperative spinal navigation: technical note. J Clin Neurosci 48:218–223. CrossRefGoogle Scholar
  41. 41.
    Berjano P, Garbossa D, Damilano M et al (2014) Transthoracic lateral retropleural minimally invasive microdiscectomy for T9-T10 disc herniation. Eur Spine J 23:1376–1378. CrossRefGoogle Scholar
  42. 42.
    Wait SD, Fox DJ, Kenny KJ, Dickman CA (2012) Thoracoscopic resection of symptomatic herniated thoracic discs: clinical results in 121 patients. Spine 37:35–40. CrossRefGoogle Scholar
  43. 43.
    Elhadi AM, Zehri AH, Zaidi HA et al (2015) Surgical efficacy of minimally invasive thoracic discectomy. J Clin Neurosci 22:1708–1713. CrossRefGoogle Scholar
  44. 44.
    Russo A, Balamurali G, Nowicki R, Boszczyk BM (2012) Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations. Eur Spine J 21(Suppl 2):S212–S220. CrossRefGoogle Scholar
  45. 45.
    Bartels RHMA, Peul WC (2007) Mini-thoracotomy or thoracoscopic treatment for medially located thoracic herniated disc? Spine 32:E581–E584. CrossRefGoogle Scholar
  46. 46.
    Xu B-S, Xu H-W, Yuan Q-M et al (2016) Thoracic endoscopic-assisted mini-open surgery for thoracic and thoracolumbar spinal cord compression. Orthop Surg 8:523–526. CrossRefGoogle Scholar
  47. 47.
    Dietze DD, Fessler RG (1993) Thoracic disc herniations. Neurosurg Clin N Am 4:75–90CrossRefGoogle Scholar
  48. 48.
    Vanichkachorn JS, Vaccaro AR (2000) Thoracic disk disease: diagnosis and treatment. J Am Acad Orthop Surg 8:159–169CrossRefGoogle Scholar
  49. 49.
    Krauss WE, Edwards DA, Cohen-Gadol AA (2005) Transthoracic discectomy without interbody fusion. Surg Neurol 63:403–408; discussion 408-409. CrossRefGoogle Scholar
  50. 50.
    Quraishi NA, Khurana A, Tsegaye MM et al (2014) Calcified giant thoracic disc herniations: considerations and treatment strategies. Eur Spine J 23(Suppl 1):S76–S83. CrossRefGoogle Scholar
  51. 51.
    Anand N, Regan JJ (2002) Video-assisted thoracoscopic surgery for thoracic disc disease: classification and outcome study of 100 consecutive cases with a 2-year minimum follow-up period. Spine 27:871–879CrossRefGoogle Scholar
  52. 52.
    Strom RG, Mathur V, Givans H et al (2015) Technical modifications and decision-making to reduce morbidity in thoracic disc surgery: an institutional experience and treatment algorithm. Clin Neurol Neurosurg 133:75–82. CrossRefGoogle Scholar
  53. 53.
    Gille O, Soderlund C, Razafimahandri HJC et al (2006) Analysis of hard thoracic herniated discs: review of 18 cases operated by thoracoscopy. Eur Spine J 15:537–542. CrossRefGoogle Scholar
  54. 54.
    Sandon LHD, Choi G, Park E, Lee H-C (2016) Abducens nerve palsy as a postoperative complication of minimally invasive thoracic spine surgery: a case report. BMC Surg 16(47).
  55. 55.
    Ohana N, Benharroch D, Sheinis D (2018) Pleural dural fistula after anterior excision of thoracic disc hernia: suggested repair procedure. Ann Thorac Surg.
  56. 56.
    Knafo S, Parker F, Herbrecht A et al (2013) Percutaneous treatment of subarachnoid-pleural fistula with onyx. J Neurosurg Spine 18:378–381. CrossRefGoogle Scholar
  57. 57.
    Le Roux PD, Haglund MM, Harris AB (1993) Thoracic disc disease: experience with the transpedicular approach in twenty consecutive patients. Neurosurgery 33:58–66Google Scholar
  58. 58.
    Currier BL, Eismont FJ, Green BA (1994) Transthoracic disc excision and fusion for herniated thoracic discs. Spine 19:323–328CrossRefGoogle Scholar
  59. 59.
    Kerezoudis P, Rajjoub KR, Goncalves S et al (2018) Anterior versus posterior approaches for thoracic disc herniation: association with postoperative complications. Clin Neurol Neurosurg 167:17–23. CrossRefGoogle Scholar
  60. 60.
    Fessler RG, Sturgill M (1998) Review: complications of surgery for thoracic disc disease. Surg Neurol 49:609–618CrossRefGoogle Scholar
  61. 61.
    Maiman DJ, Larson SJ, Luck E, El-Ghatit A (1984) Lateral extracavitary approach to the spine for thoracic disc herniation: report of 23 cases. Neurosurgery 14:178–182CrossRefGoogle Scholar
  62. 62.
    Dickman CA, Rosenthal D, Regan JJ (1999) Reoperation for herniated thoracic discs. J Neurosurg 91:157–162CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2018

Authors and Affiliations

  1. 1.Orthopedic and Traumatology Surgery Department (Pr Ch Court), Bicetre University Hospital, Assistance Publique Hôpitaux de ParisParis-Sud University ORSAYLe Kremlin-BicêtreFrance

Personalised recommendations