Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome

Clinical article

View More View Less
  • Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
Restricted access

Purchase Now

USD  $45.00

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Thoracic disc herniations (TDHs) may occasionally present with an acute myelopathy, defined as a variable degree of motor, sensory, and sphincter disturbances developing in less than 24 hours, and resulting in a Frankel Grade C or worse. Confronted with such a patient, the surgeon has to decide whether to perform an emergency operation and whether to use an anterior or posterior approach. The authors analyze their own experience and the pertinent literature, focusing on clinical presentation, imaging findings, surgical timing, technique, and outcome.

Methods

Among 250 patients who underwent surgery for symptomatic TDH, 209 had at least 1 year of follow-up at the time of writing, including 8 patients who presented with an acute myelopathy. They were surgically treated using standard thoracoscopic microdiscectomy, careful blood pressure monitoring, and intravenous methylprednisolone. The authors analyzed pre- and postoperative neuroimaging, and Frankel scores preoperatively, at discharge, and 1 year postoperatively.

Results

Although 5 patients had multiple TDHs, the symptomatic TDH was invariably situated between T9–10 and T11–12. Seven TDHs were giant, 6 were calcified, 6 were accompanied by myelomalacia, and 4 were accompanied by segmental stenosis. Although sudden dorsalgia was the initial symptom in 6, a precipitating event was noted in only 1. All patients had severe neurological deficits by the time they underwent surgery. Frankel grades improved from B to D in 2 patients, from C to E in 4, and from C to D and B to E in 1 patient each. All patients regained continence and ambulation. Transient complications were CSF leak (in 2 patients), and intraoperative blood loss greater than 1000 ml, reversible ischemic neurological deficit, and subileus (in 1 patient each).

Conclusions

Approximately 4% of TDHs present with an acute myelopathy. They are often situated between T9–10 and T11–12, large or giant, and even calcified. They almost invariably cause important cord compression (sometimes aggravated by an associated segmental stenosis) and myelomalacia. Their clinical presentation may be misleading, and diagnosis may be delayed until other causes (especially vascular) have been excluded and the clinical picture has become more complete. Interestingly, whereas a precipitating event or trauma is rarely present, dorsalgia frequently precedes profound myelopathy and may help to make an early diagnosis. Remarkable recovery is possible even with profound neurological deficit, a delay of several days, in the elderly, and in the presence of myelomalacia, provided the spinal cord is adequately decompressed and intraoperative hypotension is strictly avoided. Although alternative approaches more familiar to most neurosurgeons may be used, the anterior transthoracic approach has the advantage of reaching the TDH in front of the compromised spinal cord, avoiding any manipulation. In experienced hands, thoracoscopic microdiscectomy combines the advantage and versatility of an anterior approach with minimal postoperative discomfort. The authors conclude that TDH-related acute myelopathy may have a favorable outcome when managed correctly, and they strongly recommend that every single patient should undergo surgical treatment.

Abbreviations used in this paper:

MABP = mean arterial blood pressure; TDH = thoracic disc herniation; TMD = thoracoscopic microdiscectomy.

Spine - 1 year subscription bundle (Individuals Only)

USD  $369.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Erwin M. J. Cornips, M.D., Department of Neurosurgery. Maastricht University Medical Center, Oxfordlaan 10, 6229 EV Maastricht, The Netherlands. email: e.cornips@mumc.nl.

Please include this information when citing this paper: published online February 11, 2011; DOI: 10.3171/2010.12.SPINE10273.

  • 1

    Benson MKD, & Byrnes DP: The clinical syndromes and surgical treatment of thoracic intervertebral disc prolapse. J Bone Joint Surg Br 57:471477, 1975

    • Search Google Scholar
    • Export Citation
  • 2

    Bhole R, & Gilmer RE: Two-level thoracic disc herniation. Clin Orthop Relat Res 190 129131, 1984

  • 3

    Bose B: Thoracic extruded disc mimicking spinal cord tumor. Spine J 3:8286, 2003

  • 4

    Bracken MB, , Shepard MJ, , Collins WF, , Holford TR, , Young W, & Baskin DS, et al. : A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study. N Engl J Med 322:14051411, 1990

    • Search Google Scholar
    • Export Citation
  • 5

    Brennan M, , Perrin JC, , Canady A, & Wesolowski D: Paraparesis in a child with a herniated thoracic disc. Arch Phys Med Rehabil 68:806808, 1987

    • Search Google Scholar
    • Export Citation
  • 6

    Chen CF, , Chang MC, , Liu CL, & Chen TH: Acute noncontiguous multiple-level thoracic disc herniations with myelopathy: a case report. Spine 29:E157E160, 2004

    • Search Google Scholar
    • Export Citation
  • 7

    Chi JH, , Dhall SS, , Kanter AS, & Mummaneni PV: The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment. Neurosurg Focus 25:2 E5, 2008

    • Search Google Scholar
    • Export Citation
  • 8

    Cornips E, , Beuls E, , Geskes G, , Janssens M, , van Aalst J, & Hofman P: Preoperative localization of herniated thoracic discs using myelo-CT guided transpleural puncture: technical note. Childs Nerv Syst 23:2126, 2007

    • Search Google Scholar
    • Export Citation
  • 9

    Crock HV, , Yoshizawa H, , Yamagishi M, & Crock MC: Commentary on the prevention of paralysis after traumatic spinal cord injury in humans: the neglected factor—urgent restoration of spinal cord circulation. Eur Spine J 14:910914, 2005

    • Search Google Scholar
    • Export Citation
  • 10

    Fehlings MG, , Sekhon LH, & Tator C: The role and timing of decompression in acute spinal cord injury: what do we know? What should we do?. Spine 26:24 Suppl S101S110, 2001

    • Search Google Scholar
    • Export Citation
  • 11

    Frankel HL, , Hancock DO, , Hyslop G, , Melzak J, , Michaelis LS, & Ungar GH, et al. : The value of postural reduction in the initial management of closed injuries of the spine with paraplegia and tetraplegia. I. Paraplegia 7:179192, 1969

    • Search Google Scholar
    • Export Citation
  • 12

    Hamilton MG, & Thomas HG: Intradural herniation of a thoracic disc presenting as flaccid paraplegia: case report. Neurosurgery 27:482484, 1990

    • Search Google Scholar
    • Export Citation
  • 13

    Hott JS, , Feiz-Erfan I, , Kenny K, & Dickman CA: Surgical management of giant herniated thoracic discs: analysis of 20 cases. J Neurosurg Spine 3:191197, 2005

    • Search Google Scholar
    • Export Citation
  • 14

    Lyu RK, , Chang HS, , Tang LM, & Chen ST: Thoracic disc herniation mimicking acute lumbar disc disease. Spine 24:416418, 1999

  • 15

    Mansour H, , Hammoud F, & Vlahovitch B: [Brown-Séquard syndrome caused by foramen and calcified disk herniation, responsible for direct compression of Adamkiewicz's artery.]. Neurochirurgie 33:478481, 1987. (Fr)

    • Search Google Scholar
    • Export Citation
  • 16

    McInerney J, & Ball PA: The pathophysiology of thoracic disc disease. Neurosurg Focus 9:4 e1, 2000

  • 17

    Morizane A, , Hanakita J, , Suwa H, , Ohshita N, , Gotoh K, & Matsuoka T: Dorsally sequestrated thoracic disc herniation—case report. Neurol Med Chir (Tokyo) 39:769772, 1999

    • Search Google Scholar
    • Export Citation
  • 18

    Mulier S, & Debois V: Thoracic disc herniations: transthoracic, lateral, or posterolateral approach? A review. Surg Neurol 49:599608, 1998

    • Search Google Scholar
    • Export Citation
  • 19

    Overvliet GM, , Beuls EA, , Ter Laak-Poort M, & Cornips EM: Two brothers with a symptomatic thoracic disc herniation at T11–T12: clinical report. Acta Neurochir (Wien) 151:393396, 2009

    • Search Google Scholar
    • Export Citation
  • 20

    Regan JJ, , Mack MJ, & Picetti GD III: A technical report on video-assisted thoracoscopy in thoracic spinal surgery. Preliminary description. Spine 20:831837, 1995

    • Search Google Scholar
    • Export Citation
  • 21

    Rosenthal D, & Dickman CA: Thoracoscopic microsurgical excision of herniated thoracic discs. J Neurosurg 89:224235, 1998

  • 22

    Rosenthal D, , Rosenthal R, & de Simone A: Removal of a protruded thoracic disc using microsurgical endoscopy. A new technique. Spine 19:10871091, 1994

    • Search Google Scholar
    • Export Citation
  • 23

    Ryan MD, & Taylor TKF: Acute spinal cord compression in Scheuermann's disease. J Bone Joint Surg Br 64:409412, 1982

  • 24

    Sasaki S, , Kaji K, & Shiba K: Upper thoracic disc herniation followed by acutely progressing paraplegia. Spinal Cord 43:741745, 2005

  • 25

    Ueyama T, , Tamaki N, , Kondoh T, , Miyamoto H, , Akiyama H, & Nagashima T: Non-traumatic acute paraplegia associated with cervical disc herniation: a case report. Surg Neurol 52:204207, 1999

    • Search Google Scholar
    • Export Citation
  • 26

    Wood KB, , Blair JM, , Aepple DM, , Schendel MJ, , Garvey TA, & Gundry CR, et al. : The natural history of asymptomatic thoracic disc herniations. Spine 22:525530, 1997

    • Search Google Scholar
    • Export Citation
  • 27

    Wood KB, , Garvey TA, , Gundry C, & Heithoff KB: Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg Am 77:16311638, 1995

    • Search Google Scholar
    • Export Citation
  • 28

    Yano S, , Hida K, , Seki T, , Iwasaki Y, , Akino M, & Saitou H: [A case of thoracic disc herniation with sudden onset paraplegia on toilet straining: case report.]. No Shinkei Geka 31:12971301, 2003. (Jpn)

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 1064 387 30
Full Text Views 233 47 4
PDF Downloads 263 35 3
EPUB Downloads 0 0 0