Operative treatment of calcified thoracic disc herniation: a case report on natural fusion method following spinal canal decompression

Bojan Jelača; Nebojša Lasica; Jagoš Golubović; Filip Pajičić; Milorad Bijelović; Djula Djilvesi

doi:10.2298/VSP240513067J

Bojan Jelača University Clinical Center of Vojvodina, Clinic of Neurosurgery, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia https://orcid.org/0000-0003-3243-3196
Nebojša Lasica University Clinical Center of Vojvodina, Clinic of Neurosurgery, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia https://orcid.org/0000-0002-4600-7756
Jagoš Golubović University Clinical Center of Vojvodina, Clinic of Neurosurgery, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia https://orcid.org/0000-0001-5524-246X
Filip Pajičić University Clinical Center of Vojvodina, Clinic of Neurosurgery, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia https://orcid.org/0000-0002-8460-1350
Milorad Bijelović University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia; Institute for Pulmonary Diseases of Vojvodina, Clinic for Thoracic Surgery, Novi Sad, Serbia https://orcid.org/0000-0002-0977-5780
Djula Djilvesi University Clinical Center of Vojvodina, Clinic of Neurosurgery, Novi Sad, Serbia; University of Novi Sad, Faculty of Medicine, Novi Sad, Serbia https://orcid.org/0000-0003-3131-7855

DOI: https://doi.org/10.2298/VSP240513067J

Keywords: intervertebral disc displacement;, spinal cord compression;, spinal fusion;, surgical procedures, operative;, thorax.

Abstract

Introduction. The literature describes several ways to approach the thoracic spinal segment, but there are still many dilemmas regarding what is best to do after a complete discectomy, regardless of the surgical approach chosen. The incidence of postoperative kyphosis is higher if a posterior surgical approach to the spine is performed, and there are no clearly defined indications for the application of intervertebral fusion (IF) after an anterior ap-proach. The aim of the paper was to highlight the low morbidity of the transthoracic multidisciplinary approach, as well as a potential solution for a good, natural IF of the adjacent vertebrae without expanding and prolonging the duration of the surgical procedure itself. Case report. A 44-year-old woman presented with severe anterior compressive myelopathy caused by a calcified thoracic disc herniation in the space between the T10-11 vertebrae. A minimally invasive, open, transthoracic approach was performed with decompression of the spinal canal at the specified level and IF was achieved with an autologous rib graft during the same procedure. Despite the relatively low incidence of postoperative spinal instability, one should not overlook a good chance to achieve IF and prevent long-term complications. A control examination of the thoracolumbar segment using the magnetic resonance imaging showed that there is no more compression of the spinal cord and also showed a good IF without an increase in the level of kyphosis. Conclusion. Significant thoracic disc herniation is a rare and challenging surgical lesion. The anterior mini-open transthoracic approach provides good exposure to the relevant structures and is considered minimally invasive. The benefits of subsequent IF after the transthoracic surgical approach should always be taken into account for each individual patient, thus minimalizing the postoperative morbidity.

References

Brown CW, Deffer PA Jr, Akmakjian J, Donaldson DH, Brugman JL. The natural history of thoracic disc herniation. Spine (Phi-la Pa 1976) 1992; 17(6 Suppl): S97–102.

Han S, Jang IT. Prevalence and distribution of incidental tho-racic disc herniation, and thoracic hypertrophied ligamentum flavum in patients with back or leg pain: a magnetic resonance imaging-based cross-sectional study. World Neurosurg 2018; 120: e517–24.

Yuan L, Chen Z, Liu Z, Li W, Sun C, Liu X. Clinical and radi-ographic features of adult calcified thoracic disc herniation: a retrospective analysis of 31 cases. Eur Spine J 2023; 32(7): 2387–95.

Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH. Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neuro-surg 1998; 88(4): 623–33.

Cornips EMJ, Maesen B, Geskes G, Maessen JG, Beuls EAM, Menovsky T. T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach. World Neurosurg 2022; 158: e984–95.

Korovessis PG, Stamatakis MV, Baikousis A, Vasiliou D. Trans-thoracic disc excision with interbody fusion. 12 patients with symptomatic disc herniation followed for 2-8 years. Acta Or-thop Scand Suppl 1997; 275: 12–6.

Feigl GC, Staribacher D, Kuzmin D. Minimally Invasive Dorsal Approach in the Surgery of Giant Thoracic Disk Herniation: Technical Note and Clinical Case Report. World Neurosurg 2022; 165: 154–8.

Otani K, Yoshida M, Fujii E, Nakai S, Shibasaki K. Thoracic disc herniation. Surgical treatment in 23 patients. Spine (Phila Pa 1976) 1988; 13(11): 1262–7.

Krauss WE, Edwards DA, Cohen-Gadol AA. Transthoracic discectomy without interbody fusion. Surg Neurol 2005; 63(5): 403–8.

Quraishi NA, Khurana A, Tsegaye MM, Boszczyk BM, Mehdian SM. Calcified giant thoracic disc herniations: considerations and treatment strategies. Eur Spine J 2014; 23(Suppl 1): S76–83.

Denis F. The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine (Phila Pa 1976) 1983; 8(8): 817–31.

Yuan L, Chen Z, Liu Z, Liu X, Li W, Sun C. Comparison of Anterior Approach and Posterior Circumspinal Decompres-sion in the Treatment of Giant Thoracic Discs. Global Spine J 2023; 13(1): 17–24.

Arts MP, Bartels RH. Anterior or posterior approach of tho-racic disc herniation? A comparative cohort of mini-transthoracic versus transpedicular discectomies. Spine J 2014; 14(8): 1654–62.

Court C, Mansour E, Bouthors C. Thoracic disc herniation: Sur-gical treatment. Orthop Traumatol Surg Res 2018; 104(1S): S31–40.

Oltulu I, Cil H, Ulu MO, Deviren V. Clinical outcomes of symptomatic thoracic disk herniations treated surgically through minimally invasive lateral transthoracic approach. Neurosurg Rev 2019; 42(4): 885–94.

Carl B, Bopp M, Saß B, Pojskic M, Voellger B, Nimsky C. Spine Surgery Supported by Augmented Reality. Global Spine J 2020; 10(2 Suppl): 41S–55S.

Nottmeier EW, Pirris SM. Placement of thoracic transvertebral pedicle screws using 3D image guidance. J Neurosurg Spine 2013; 18(5): 479–83.

Sasani M, Fahir Ozer A, Oktenoglu T, Kaner T, Solmaz B, Canbu-lat N, et al. Thoracoscopic surgery for thoracic disc herniation. J Neurosurg Sci 2011; 55(4): 391–5.

Komp M, Ruetten S. Full-endoscopic anterior excision of tho-racic disc herniations, including giant and calcified discs with spinal cord compression: surgical technique and outcomes. Eur Spine J 2023; 32(8): 2685–93.

Coppes MH, Bakker NA, Metzemaekers JD, Groen RJ. Posterior transdural discectomy: a new approach for the removal of a central thoracic disc herniation. Eur Spine J 2012; 21(4): 623–8.

Currier BL, Eismont FJ, Green BA. Transthoracic disc excision and fusion for herniated thoracic discs. Spine (Phila Pa 1976) 1994; 19(3): 323–8.

Zhao Y, Wang Y, Xiao S, Zhang Y, Liu Z, Liu B. Transthoracic approach for the treatment of calcified giant herniated thorac-ic discs. Eur Spine J 2013; 22(11): 2466–73.