Thoracic Disc Herniation with Progressive Gait Symptoms
A 58-year-old right-handed physician presented with sudden onset of thoracic pain. There is no history of trauma, and there is a 6-week history of progressive gait symptoms and bladder incontinence. She also has right-sided trunk and leg numbness.
3+ Deep Tendon Reflexes, ataxia (unstable gait), and decreased rectal tone. She reports mid-thoracic pain as 8/10. She’s ASIA D.
She had taken oral steroids.
Figure 1: MRI showing large disc herniation at T8-T9 with loss of height and severe spinal cord compression with T2-signal changes inside the cord.
Figure 2: Axial MRI showing right-sided T8-T9 paracentral acute disc herniation with significant right-sided cord compression.
The patient was diagnosed with acute right-sided T8-T9 soft disc herniation with cord compression and incomplete spinal injury.
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The patient had a minimally invasive extracavitary thoracic discectomy and fusion (MI-ECTDF).
The patient was taken semi-electively to the operating room where a minimally invasive extracavitary approach was performed via a tubular approach. A large soft right paracentral disc fragment was encountered after removal of the lateral facet and the superior portion of the right T9 pedicle. The cord was well decompressed and noted to be pulsatile at the end of the procedure, which lasted 2 hours with 25cc of blood loss.
Her inpatient post-operative course was uneventful with minimal pain, and she was ambulatory with physical therapy and discharged to acute spinal cord rehabilitation 36 hours after surgery.
Figure 3: Axial MRI of T8-T9 (left) and lateral MRI (right). Note that the disc herniation is gone, and the cord is decompressed.
Figure 4: The two dots (in each x-ray) indicate the proper position of the interbody fusion cage.
At 24-month follow-up, the patient has no further back pain and is fused. She has full motor recovery (ASIA E), but there is residual mild right numbness in her legs. Her bladder issues are resolved.
Thoracic spinal cord compression from a disc herniation is a serious problem. It is important to develop a treatment strategy that minimizes manipulation of the spinal cord. The minimally invasive extracavitary approach was an excellent choice for this patient, and the outcome was good. The MR suggests there may be calcification of the disc, and this may be an acute herniation in the setting of a prior calcified disc. This situation could be confirmed with a pre-operative CT.
This disc is fairly lateral and probably could have been removed with a transpediclar approach, which also could be performed in a minimally invasive exposure. If this route is chosen and the exposure found to be inadequate, the surgeon should readily convert the exposure to a costotransversectomy.