Severe Thoracic Pain
A pleasant 37-year-old female presents with severe midline thoracic pain at and just below her bra line. The pain started about 12 months ago but has significantly worsened during the past 3 months making wearing a bra painful. She has no history of shingles or trauma.
Pain is consistent regardless of position (eg, standing) and physical activities such as household chores or moving, worsens her pain. The pain makes sleeping difficult.
- Diffuse tenderness in the mid thoracic spine around the bra line
- No rash or lesions noted
- No muscle wasting or atrophy
- No long track/ upper motor neuron findings
- No reflex asymmetry in the lower extremities
Current and Prior Treatment
After spine evaluation, the patient received a T8 selective nerve block (right side) that offered near resolution of her symptoms for 3 days. She was able to sleep through the night and do the laundry without pain medications for those 3 days.
Currently, she uses a TENS unit and daily medications (naprosyn, flexeril, norco). These treatments only provide short-term improvement in symptoms.
Prior treatments included a trial of physical therapy (short-term benefits) and a series of epidural steroid injections that provided 2 to 3 days of pain improvement.
- Normal kyphosis and lordosis as expected in the thoracic and lumbar spine
- No scoliosis on inspection or radiographically
- Scattered degenerative changes on plain radiographs
- MRI demonstrates a moderately large disc herniation on the right at T8-T9
Figure 1. Sagittal MRI T8-T9 disc herniation
Figure 2a. Axial MRI T8-T9
Figure 2b. Axial MRI T8-T9
Figure 3. Lateral thoracolumbar radiograph
Right paracentral disc hernation at T8-T9
Suggest TreatmentIndicate how you would treat this patient by completing the following brief survey. Your response will be added to our survey results below.
Retropleural approach with interbody fusion at T8-T9.
Figures 4a, 4b. Intraoperative fluoroscopy of retropleural approach
Figures 5a, 5b. Final intraoperative fluoroscopy
This case demonstrates the unique approach to the thoracic spine via retropleural exposure. The approach negates the need for a chest tube and significantly decreases the associated morbidity.
Postoperatively, the patient did very well and serial chest x-rays failed to demonstrate any pneumothorax. Her preoperative pain was resolved and she was discharged to home 48-hours after surgery.
Drs. Piper and Hemmer present a challenging case of a patient with a symptomatic thoracic disc herniation. They employed the minimally invasive lateral retropleural approach and obtained an excellent early outcome through indirect decompression and interbody fusion. This strategy is increasingly utilized in this condition. Traditional large thoracotomy exposures subject the patient to potentially higher risks of postoperative pulmonary complications and pain. The need to fuse after discectomy in the thoracic spine is debatable, and depends on the degree of bony resection and instability. In this case, the interbody spacer indirectly decompressed the canal thus fusion was necessary.
Because of the nature of the paracentral disc herniation, this surgery required a direct decompression of the conus medullaris. The surgery consisted of the retropleural approach followed by preliminary discectomy. Next we did wedge osteotomies of the inferior endplate of T8 and the superior endplate of T9 to create space to push the hard disc fragment anteriorly. We completely removed the posterior annulus and exposed the entire conus from pedicle to pedicle. The decompression, therefore, was DIRECT, and the interbody spacer was placed to effect a fusion in the interspace. This technique is well described in the literature and was employed in this instance because the “hard” disc fragment directly impinged on the thoracic cord.