Surgical management of giant herniated thoracic discs: analysis of 20 cases

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Object. The authors evaluated the clinical and surgical outcomes obtained in patients with giant herniated thoracic discs (HTDs), defined as occupying more than 40% of the spinal canal. Surgery-related considerations and functional outcomes in patients with small- and medium-sized HTDs were compared.

Methods. The authors reviewed 140 cases of surgically treated HTDs, 20 (14%) of which were giant. Before and after surgery, all patients underwent computerized tomography myelography, magnetic resonance imaging, or both. Functional outcomes were assessed using the Frankel grading system preoperatively, immediately after surgery, and at long-term follow-up examination. The results observed in patients with giant HTDs were compared with those with small- and medium-sized HTDs. The mean overall follow-up period was 2.6 years.

Sixty-six patients (47%) presented with myelopathy, including 19 (95%) with a giant HTD. Of the latter, 16 (80%) underwent anterior, eight thoracoscopic, and eight open thoracotomy approaches. Four patients (20%) with laterally oriented giant HTDs within the spinal canal underwent surgery via a posterolateral approach.

Based on analysis of long-term follow-up data, 53% of patients with giant HTDs improved neurologically by one Frankel grade. Progression of myelopathy was arrested in 42%, and in 5% the Frankel grade worsened by one. In patients with small- and medium-sized HTDs, the Frankel grade improved by one in 77%, stabilized in 23%, and worsened in 0%. Patients with giant HTDs who underwent thoracoscopic surgery had worse short- and long-term functional outcomes than those in whom open thoracotomy was performed.

Conclusions. Patients with giant HTDs presented more frequently with myelopathy and experienced worse functional outcomes than those with smaller HTDs. Based on their experience, the authors recommend open thoracotomy rather than thoracoscopy for the treatment of midline giant HTDs.

Article Information

Address reprint requests to: Curtis A. Dickman, M.D., Neuroscience Publications, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013. email: neuropub@chw.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    Various representative CT scans. Left: Axial CT scan of the thoracic spine revealing a calcified giant HTD occupying the spinal canal (arrow). Evidence of the prior laminectomy site is visible on the left side. Center: Sagittal CT reconstruction demonstrating the location of the disc material in relation to the disc space and adjacent VB. Right: Sagittal CT reconstruction confirming complete removal of the ossified giant HTD and revealing interbody strut and screwplate reconstruction of the spine.

  • View in gallery

    Preoperative axial (left) and sagittal (center) T2-weighted images revealing a calcified giant HTD compromising the spinal cord. Right: Postoperative CT scan of the thoracic spine demonstrating the surgically created corridor and resection of the giant HTD.

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