SpineUniverse Case Study Library

Large Partially Calcified Thoracic Disc Herniation

History

A 48-year-old female with obesity presents with severe right leg pain and paraparesis.

Pretreatment Imaging

CT/myelogram of the thoracic spine reveals a large partially calcified right-sided T10-T11 thoracic disc herniation with marked spinal cord compression (Figures 1A, 1B).

Figure 1A. Sagittal CT/myelogram shows a large partially calcified T10-T11 right-sided disc herniation with marked spinal cord cFigure 1A. Sagittal CT/myelogram shows a large partially calcified T10-T11 right-sided disc herniation with marked spinal cord compression.

Figure 1B. Axial CT/myelogram shows a large partially calcified T10-T11 right-sided disc herniation with marked spinal cord compFigure 1B. Axial CT/myelogram shows a large partially calcified T10-T11 right-sided disc herniation with marked spinal cord compression.

Diagnosis

Large partially calcified right-sided T10-T11 thoracic disc herniation with marked spinal cord compression

Suggest Treatment

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Selected Treatment

Because of the location and marked compression of the spinal cord by a partially calcified thoracic disc herniation, as well as the presentation of severe bilateral leg weakness, an anterior approach was chosen. To reduce postoperative pain and discomfort, a minimally invasive thoracotomy approach was chosen. The patient was informed of the gravity of the case and that her leg weakness might not improve, or she could become paraplegic even with surgical intervention. She chose to proceed with the surgery.

  • The patient was intubated and intraoperative monitoring placed, including SSEP and MEP. The patient was placed on a bean bag and secured in the lateral position with her right-side up.
  • The level was identified using fluoroscopy and by counting from the sacrum to the level of the pathology, as well as by counting the rib heads.
  • The incision was made directly over the T10-T11 disc space, and a unique retractor was placed (Figs. 2A, 2B) (Alexis® Orthopaedic Protector, Applied Medical, Rancho Santa Margarita, CA).

Figure 2A. Intraoperative views with the retractor.Figure 2A. Intraoperative views with the retractor.

Figure 2B. Lateral aspect of the thoracic spine overlying the T10-T11 disc space.Figure 2B. Lateral aspect of the thoracic spine overlying the T10-T11 disc space.

  • The microscope was brought into the operative field. The pleurae were taken down over the T10 and T11 vertebrae, as well as the T10 rib head.
  • A long tapered drill (Stryker® TPS™, Kalamazoo, MI) was used to drill the rib head and underlying pedicle in order to enter the spinal canal and identify the location of the spinal cord.
  • Once confirmed, a partial corpectomy of T10 and T11 was performed, as well as a T10-T11 discectomy. With adequate space created ventral to the disc herniation, the large disc herniation was pushed away from the spinal cord into the ventral surgical defect. Brisk bleeding was controlled with gel foam, surgifoam, and cottonoid pledget.
  • Complete decompression of the spinal cord was achieved.
  • An expandable cage was filled with morselized autograph collected from the same surgical field using the BoneBac® Press (Thompson MIS, Salem, MA) and positioned to fill the defect. An anterior thoracic plate was applied as well, by first applying two screw bolts and then locking the plate in place. Additional morselized autograph bone was placed around the construct.
  • A chest tube was left it place. The rib was reconstructed with a rib plate, and the incision was closed in a routine fashion (Figures 3A-3H).

Figure 3A. Intraoperative microscopic view of the large herniated thoracic disc compressing the spinal cord.Figure 3A. Intraoperative microscopic view of the large herniated thoracic disc compressing the spinal cord.

Figure 3B. Surgical field after decompression of the spinal cord.Figure 3B. Surgical field after decompression of the spinal cord.

Figure 3C. Intraoperative view of the expandable cage.Figure 3C. Intraoperative view of the expandable cage.

Figure 3D. The plate in place.Figure 3D. The plate in place.

Figure 3E. Axial CT shows the implants and decompression of the spinal cord.Figure 3E. Axial CT shows the implants and decompression of the spinal cord.

Figure 3F. Postoperative reconstructive coronal CT shows the implants and decompression of the spinal cord.Figure 3F. Postoperative reconstructive coronal CT shows the implants and decompression of the spinal cord.

Figure 3G. Postoperative AP.Figure 3G. Postoperative AP.

Figure 3H. Lateral view shows the plate reconstruction of rib.Figure 3H. Lateral view shows the plate reconstruction of rib.

Postoperative Care

The patient was initially managed in the ICU with the chest tube in place.

Early ambulation was encouraged. The patient started physical therapy soon after surgery with deep vein thrombosis (DVT) prophylaxis, including compression stockings and a pneumatic compression device on her legs bilaterally. Careful monitoring and care of bladder and bowel function were performed. The patient wore a thoracolumbar brace while ambulating.

Surgeon's Rationale and Operative Nuances

It should be understood that patients who present with a large calcified thoracic disc with paraparesis may progress to paraplegia even with surgical intervention. To avoid manipulation of the spinal cord, we prefer an anterior approach. To help reduce or avoid post thoracotomy pain and discomfort, we use a soft retractor system and reconstruct the thoracic rib with a plate. Anticipate brisk venous bleeding when resecting these lesions; hemostatic agents are critical. Early mobilization of these patients can help reduce DVTs.

Operative Nuances

  • A careful preoperative work-up can help in the approach decision-making process. We prefer CT/myelogram, as it helps to define whether the disc is calcified or not.
  • Sagittal reconstructive CTs or MRIs from the sacrum to the level of pathology can help to accurately identify the level.
  • Removal of the rib head and pedicle at the level of the pathology will identify the location of the spinal canal and helps to orient the surgeon during surgery.
  • Hemostatic agents are necessary as brisk venous bleeding is expected.
  • Expandable cage technology helps to assure a solid final construct.
  • Anterior plate instrumentation leads to further construct strength and avoidance of the need for posterior instrumentation.
  • Chest tube placement can avoid the need for thoracentesis postop.

Outcome

The patient’s postoperative recovery was unremarkable. She quickly recovered ambulatory status and had complete resolution of her right leg pain. At her 3-month follow-up she was ambulating independently and without pain. She returned to her activities of daily living. She continues to be without pain at 6-month follow-up.

Case Discussion

This is a challenging case of a symptomatic, partially calcified thoracic disc herniation expertly managed by Dr. Perez-Cruet. Attention to detail, regardless of open or MIS approach, is essential. The use of intraoperative neuromonitoring (IOM) and identifying the correct level by using at least two methods (counting from the sacrum and the ribs in this case) is imperative. Knowledge of the regional neurovascular anatomy is paramount, particularly when using less invasive approaches.1,2 Identifying the source of bleeding, and knowing how to control it is necessary. This is usually either from the neural foramen above and below the pedicle, from the epidural veins, or less often the segmental vessels. Proficiency with MIS instruments and narrow working spaces is mandatory before these procedures are undertaken.3 Some argue against the need for fusion after thoracic disc resection, but it is certainly indicated if the ipsilateral spinal column is significantly destabilized, particularly at the thoracolumbar junction as in this case. In summary, this is an excellent teaching case that highlights every key step needed to safely execute these types of challenging procedures.

References
1. Papadimitriou KP, Amin AG, Kretzer RM, Chaput C, Tortolani J, Wolinsky JP, Gokaslan ZL, Baaj AA. The rib head as a landmark in the anterolateral approach to the thoracic spine: A computed tomography-based morphometric study. JNS Spine. 2013;18(5):484-9.
2. Papadimitriou KP, Amin AG, Kretzer RM, Wolinsky JP, Gokaslan ZL, Baaj AA. Surgical anatomy of the diaphragm in the anterolateral approach to the spine. Journal of Spinal Disorders and Techniques. 2014;Jun;27(4):220-3.
3. Uribe JS, Smith WD, Pimenta L, Hartl R, Dakwar E, Modhia UM, Pollock GA, Nagineni V, et al. Minimally invasive lateral approach for symptomatic thoracic disc herniation: initial multicenter clinical experience. J Neurosurg Spine. 2012;16(3)264-79.

Community Case Discussion (2 comments)

SpineUniverse invites spine professionals to share their thoughts on this case.


The initial (pre-test) description was that of a severe right leg pain/paraplegia and not of the bilateral leg weakness, therefore the posterior approach would seem preferable and less complex. However, given the patient's weight problem, the MIS was chosen.
The surgical intervention was definitely a challenge, but the outcome justified it.
Congratulation to the patient and a lot of respect to Dr. Perez-Cruet's operative skills.

Dr. Etela Neumann

There are many ways to approach this disk herniation, but fusion is not a required part of the treatment unless the exposure removes too much of the inherent stability of this relatively meta-stable region. The extreme laterality does make it amenable to a tubular costo-transversectomy approach which would NOT require instrumentation and fusion, and there's nothing in the size or calcification of the disk that would preclude this approach (having performed it on dozens of patients with similar radiographic findings).

It's location does suggest, if there are no other obvious local landmarks (like a large osteophyte not readily visible on the provided scans) that pre-operative marking with a metallic coil or marker ( like a GDC coil) into the fibers of the costo-transverse junction to prevent migration would help prevent localization problems that often accompany thoracic spine surgery, especially in the obese patient.

Monitoring is a critical part of this procedure, and most important is being comfortable with the approach you use (one shouldn't try a new approach on a patient with challenging anatomy). So well done the way it was performed, and there are many different anterolateral and posterolateral approaches that one could take to get to this (including an open lateral extracavitary approach, an open costotransversectomy approach, an open or thoracoscopic transthoracic approach), and the decision to fuse would only depend on the removal of the stabilizing bone elements that have to be removed in the approach, not the inherent stability of the disk after removal of the disk fragments and a small intradiskal decompression.

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