Thoracic Herniated Disc
The patient is a 58-year-old man who has had mid-back pain since 1990. The patient saw a neurosurgeon in 2007 who did not recommend surgery at that time.
The patient presented to our office reporting pain that wraps around his rib cage to the front of his chest and intermittent "electric-shock" sensation to his left anterior thigh.
Although he mentioned more recent difficulty with walking, his chief complaint still was mid-back pain. The patient reported no bowel or bladder dysfunction.
Prior to presentation in our office, the patient's mid-back pain had been treated with:
- pain medication (pain varies from 7 to 8 out of 10 with analgesics)
- physical therapy
His neurological exam was normal with normal reflexes and grossly normal gait.
Figure 1: Sagittal MRI shows T6-7 disc herniation with spinal cord compression.
Figure 2A: CT myelogram with sagittal reconstructed view shows calcified disc occupying about 50% of the spinal canal.
Figure 2B: Axial image at T6-T7 level showing the central location of the disc.
Thoracic herniated disc.
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The patient underwent a mini-open thoracotomy with right T7 rib head resection, T6-T7 partial corpectomy, T6-T7 microdiscectomy, and T6-T7 instrumented fusion using rib autograft with lateral plate and screws.
Fig 3A: Intra-operative photograph showing lateral decubitus positioning of the patient.
Figure 3B: Skin incision right over the rib.
Figure 3C: Resected rib during exposure to be used as a strut graft.
Figure 4A: Intra-operative C-arm image showing the position of the retractor blades.
Figure 4B: AP image after placement of the implants.
At the one-month follow-up appointment, the patient reported mild intercostal pain. Overall, he was very satisfied with the outcome of the surgery, reporting much reduced mid-back pain. At the 6-month follow-up appointment, the patient had no mid-back pain and no left anterior thigh pain with resolution of intercostal pain.
Figure 5: Post-operative MRI showing good spinal cord decompression.
Figure 6A: Post-operative sagittal CT showing the extent of the partial corpectomy to safely remove the herniated disc.
Figure 6B: Axial CT showing the decompression and rib strut and plate placed for arthrodesis.
Thoracic herniated discs are the most delayed problem that exists in the spine. Patients usually present having had an extensive work-up by their PMD for other abdominal problems, only to finally have an MRI of the thoracic spine due to residual sensory deficits that mimic Herpes Zoster, as found in this patient.
The average time to diagnose a thoracic herniated disc is usually 4 to 6 months. Patients rarely present with neurological deficits and usually only have sensory findings or mild to moderate thoracic pain. In a minority of cases, patients will have myelopathic findings, such as gait abnormalities or issues with bowel or bladder control.
In patients who only have sensor findings or pain, I like to try an epidural steroid injection (ESI). This is the only non-operative treatment for this problem because physical therapy is not used for thoracic herniated discs. If patients do not respond to an ESI or are myelopathic, then surgical intervention is indicated.
Thoroscopic discectomies have fallen out of vogue, and I feel they can only be performed in a small amount of patients with a specific type of herniated disc (such as a soft HNP that is more laterally positioned). In this case, the disc is calcified, so a thoroscopic discectomy would not be appropriate. I would do a mini open or open thorocotomy with discectomy/interbody fusion using the rib graft and stabilization with either screw/staple or anterior plate. The other choices listed are not appropriate for this diagnosis. I totally agree with Dr. Kim's surgical choice, and he appears to have done an excellent job.