Severe Back Pain with Radiation Around Right Abdomen

History

The patient is a 39-year-old male who presents with severe back pain that radiates around the right abdomen to just below the navel.

Examination

The examination found the following:

• 4/5 IP strength
• Legs “don’t feel right,” but PP intact
• Babinski upgoing on right, equivocal on left

Prior Treatment

The patient has tried physical therapy.

Pre-treatment Images

Figure 1: T2-weighted sagittal MRI showing very large right and central disc herniation at T11-T12 with severe cord compression.

Figure 2: T2-weighted axial MRI showing very large right and central disc herniation at T11-T12 with severe cord compression.

Diagnosis

T11-T12 disc herniation

Selected Treatment

The patient had MED. This changed the operation from a large in-patient procedure to an outpatient procedure with minimal disruption of tissue. The in-patient procedure—particularly if it were a thoracotomy—would be destructive of the normal anatomy.

Outcome

The patient is now several years post-operative, and his complaints have been resolved. His neurological examination returned to normal, and he returned to all normal activities with no restriction.

Case Discussion

Ali A. Baaj, MD

Assistant Professor of Neurological Surgery

Weill Cornell Medical College, Cornell University

This patient presents clinically with myelopathy, and radiographically with a T11-12 disc herniation and significant spinal cord compression.  The selected procedure was a minimally-invasive MicroEndoscopic Discectomy (MED).  The patient is doing well at 2 years with complete resolution of symptoms.

The surgical treatment of symptomatic thoracic disc herniation (TDH) is technically challenging.  The simple, posterior decompressive laminectomy approach is associated with a high neurological complication rate and is thus not recommended.  A more definitive direct disc resection through posterolateral (transpedicular, costotransversectomy, lateral extracavitary) or ventral (thoracotomy) approaches is now standard.  Though effective if properly executed, these techniques are nonetheless invasive and can be associated with significant blood loss, postoperative pain, and spinal destabilization requiring internal fixation. 

Minimally invasive techniques, like the MED (Smith et al. World Neurosurg. Oct 2012) or the mini-open lateral retropleural approach (Uribe et al. JNS Spine. Mar 2012), are appealing alternatives.  They are associated with less blood loss, less pain, smaller incisions and less risk of infection.  They are likely more cost-effective as well.  The biggest hurdle is the steep learning curve associated with these techniques precluding their widespread adoptability.  The arduous task of advocating and teaching MIS spine, particularly by experts like Dr. Fessler, is essential for the field (and patients) of spine surgery.

With regards to the nuances of this case, there are several issues that are inherent to TDH work-up that were undoubtedly performed but not explicitly stated in this case presentation.  These include:  1) Unenhanced CT is essential to determine extent of disc calcification. 2) An open, posterolateral or ventral, approach, may be more appropriate for calcified, central disc herniations. 3) The use of intraoperative neuromonitoring is recommended. 4) Spending time to correctly localize the level is important. One option is to have the patient undergo preoperative percutaneous PMMA placement at the adjacent level (Hsu W et al. JSDT Feb 2008). The PMMA is very easily detected with intraoperative fluoroscopy.