Elsevier

Surgical Neurology

Volume 63, Issue 5, May 2005, Pages 403-408
Surgical Neurology

Spine
Transthoracic discectomy without interbody fusion

https://doi.org/10.1016/j.surneu.2004.06.026Get rights and content

Abstract

Background

Transthoracic discectomy is an established surgical procedure for the treatment of thoracic disk disease. Most authors advocate interbody fusion after transthoracic discectomy. The purpose of this study was to determine if there were any adverse consequences in foregoing interbody fusion after transthoracic discectomy.

Methods

Eighteen consecutive patients underwent transthoracic discectomy without fusion between 1996 and 2002 at Mayo Clinic (Rochester, MN). There were 11 women and 7 men with the mean age of 54 years (range, 28-84 years). Surgical indications were radiculopathy in 1 patient and myelopathy in 17. Follow-up data were obtained from the clinic visits and telephone surveys. We used the available pre- and postoperative radiographs for 16 patients at the last follow-up to establish the incidence of postoperative kyphosis and/or scoliosis at the operated level. Mean duration of the radiographic follow-up was 22 ± 24 (SD) months.

Results

None of the patients reported the onset of a new axial spine pain postoperatively. No patient developed segmental kyphosis or scoliosis at the operated level during the follow-up period. Fifteen of 18 (83%) patients had significant improvement in their neurological symptoms and signs. Two patients remained unchanged. An 83-year-old patient had a slight worsening of her gait after surgery. Specifically, the only 3 nonambulatory patients regained ambulation after discectomy. There were 4 complications: 1 wound infection, 1 pleural effusion requiring pleurodesis, 1 cerebrospinal fluid leak, and 1 case of disabling intercostal neuralgia.

Conclusions

These results indicate that interbody fusion may not be necessary for selected patients undergoing transthoracic discectomy. Further long-term follow-up is needed to evaluate the development of late spinal instability and resultant deformity after this procedure.

Introduction

Herniated thoracic disks are rare entities and their surgical treatment comprises 0.15% to 4% of all disk operations [2], [3], [8], [10], [13], [16], [19], [21], [23]. Surgical approaches have included pediculectomy, costotransversectomy, lateral extracavitary, transthoracic thoracotomy, and thoracoscopy. The factors that determine the surgical approach include disk size, location, extent of calcification, surgeon experience, degree of spinal cord deformation, and the medical condition of the patient [22].

For patients who undergo anterior procedures such as transthoracic discectomy, some authors recommend interbody fusion for the presumed risk of postoperative progressive kyphotic deformity, axial spine pain, and neurological deterioration [5], [7], [12], [15]. The authors of the present study have analyzed the clinical and radiological outcomes of a consecutive series of patients who underwent transthoracic discectomy without interbody fusion. To the authors' knowledge, there has been no clinical series directly addressing the important question regarding the need for interbody arthrodesis after transthoracic discectomy.

Section snippets

Patient population

Eighteen consecutive patients underwent transthoracic discectomy without interbody fusion by a single neurosurgeon (WEK) at Mayo Clinic (Rochester, MN) between 1996 and 2002. The Mayo Clinic Investigational Review Board approved this study and all patients gave consent regarding their participation. There were 11 women and 7 men with a mean age of 54 years (range, 28-84 years). All patients underwent a complete preoperative neurological evaluation by a staff neurologist and a preoperative

Surgical technique

A thoracic surgeon performed the exposure in all cases. The ipsilateral rib head abutting the affected disk was removed to expose the disk. The neuroforamen superior and inferior to the disk was exposed. The ipsilateral pedicle immediately below the affected disk space was partially resected using a high-speed drill, and the posterolateral portions of the vertebral bodies above and below the disk space were drilled to expose the disk herniation (Fig. 2, Fig. 3). Using a flat probe and disk

Results

Of our 18 patients, 15 were available for a telephone survey with a mean follow-up of 28 ± 20 (SD) months. Preoperative and postoperative x-ray radiographs were available for comparison for 16 patients with a mean follow-up of 22 ± 24 (SD) months.

Clinically, 15/18 patients (83%) demonstrated improvement in their preoperative symptoms and signs; 2 patients were unchanged (11%) and 1 patient suffered from a worsening of her gait (6%). No patient had a new onset of axial spine pain. The 2 patients

Discussion

The aim of this study was to determine the safety of foregoing interbody arthrodesis after transthoracic discectomy. Transthoracic discectomy typically involves removal of the ipsilateral rib head, ipsilateral pedicle, and posterior vertebral bodies bordering the disk space. In the present series, most of the anterior part of the disk was left intact, preserving the anterior and posterior columns as described by Denis [6], thereby maintaining the normal intervertebral height and sagittal

Conclusions

The results of this study demonstrate the safety of foregoing bone grafting in patients undergoing thoracic discectomy. Clinical results are similar to the series in which grafting was performed. Radiographic follow-up did not demonstrate a deterioration in spinal alignment or axial spine pain. The need for fusion after transthoracic discectomy should be considered carefully and individualized. Future studies may better define the indications for interbody fusion after transthoracic discectomy.

Acknowledgment

The authors greatly thank Mr David Factor for the preparation of illustrations.

References (25)

  • C.A. Arce et al.

    Thoracic disc herniation. Improved diagnosis with computed tomographic scanning and a review of the literature

    Surg. Neurol.

    (1985)
  • N. Floch et al.

    Aortoesophageal fistula after reconstruction of the thoracic spine

    Ann. Thorac. Surg.

    (1995)
  • N. Anand et al.

    Video-assisted thoracoscopic surgery for thoracic disc disease: classification and outcome study of 100 consecutive cases with a 2-year minimum follow-up period

    Spine

    (2002)
  • E.E. Awwad et al.

    Asymptomatic versus symptomatic herniated thoracic discs: their frequency and characteristics as detected by computed tomography after myelography

    Neurosurgery

    (1991)
  • G. Broc et al.

    Biomechanical effects of transthoracic microdiscectomy

    Spine

    (1997)
  • B.L. Currier et al.

    Transthoracic disc excision and fusion for herniated thoracic discs

    Spine

    (1994)
  • F. Denis

    The thee column spine and its significance in the classification of acute thoracolumbar spinal injuries

    Spine

    (1983)
  • C.A. Dickman et al.

    Reoperation for herniated thoracic discs

    J. Neurosurg.

    (1999)
  • M. el-Kalliny et al.

    Surgical approaches to thoracic disc herniations

    Acta Neurochir.

    (1991)
  • M. Feiertag et al.

    The effect of different surgical releases on thoracic spinal motion

    Spine

    (1995)
  • M.W. Fidler et al.

    Excision of prolapse of thoracic intervertebral disc. A transthoracic technique

    J. Bone Joint Surg. Br.

    (1984)
  • P.G. Korovessis et al.

    Transthoracic disc excision with interbody fusion. 12 patients with symptomatic disc herniation followed for 2-8 years

    Acta Orthop. Scand. Suppl.

    (1997)
  • Cited by (0)

    View full text