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Average 3.8 of 39 Ratings
A 29-year-old male presents with numbness and tingling in his lower extremities and gait instability for two weeks duration. Physical exam shows 3+ brisk patellar reflexes. Magnetic-resonance-imaging is shown in Figure A. What is the most appropriate first line of treatment?
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The clinical presentation and imaging studies are consistent with a thoracic disk herniation with spinal cord compression causing symptoms of thoracic myelopathy. This is an indication for surgery. Thoracic level disk herniations are treated with anterior diskectomy with or without fusion.
Bohlman and Zdeblick reviewed 22 cases of thoracic level disc herniations in 19 patients. They found the anterior transthoracic or costotransversectomy diskectomy provided complete pain relief in 10 patients, partial pain relief in 8 patients, and no pain relief in 1 patient at a mean of 48 month follow-up.
Currier et al. reviewed the treatment of 19 patients with thoracic level herniations with diskectomy and fusion. They found the results of diskectomy and fusion were excellent in 6, good in 6, fair in 1, and poor in 1 patients.
Bohlman HH, Zdeblick TA.
J Bone Joint Surg Am. 1988 Aug;70(7):1038-47. PMID: 3403572 (Link to Abstract)
Bohlman, JBJS 1988
Currier BL, Eismont FJ, Green BA.
Spine (Phila Pa 1976). 1994 Feb 1;19(3):323-8. PMID: 8171365 (Link to Abstract)
Currier, SPINE 1994
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Average 3.0 of 37 Ratings
A 47-year-old male presents with back pain of 2 weeks duration. He denies night sweats, fevers, or weight loss. He localizes his symptoms to a dermatomal distribution along the rib cage on the right. On physical exam he has mild paraspinal tenderness, normal patellar reflexes, normal muscle strength in his lower extremities, and a normal gait exam. An MRI is shown in Figure A and B. What is the most appropriate first step in management?
A repeat MRI with gadolinium
CT of chest, abdomen, and pelvis followed by a CT guided biopsy of the spinal lesion
Physical therapy and NSAIDs
Surgical decompression using a midline posterior approach
Surgical decompression using a transthoracic approach
The clinical presentation and imaging studies are consistent with a thoracic disc herniation. Although less common than lumbar disc herniation, thoracic disc herniations are a recognized cause of back pain. For patients with prolonged symptoms, Blumenkopft and Maiman contend that MRI is the study of choice in evaluation of disc herniations. The downside of MRI is that it can have high false positive rates. In a retrospective study, Wood et. al showed that in asymptomatic individuals 73% had thoracic disc abnormalities and 37% showed frank herniations, 29% of these had cord compression. 75% of herniations occur between T8 and T12. Because the MRI in this question is highly characteristic of a thoracic disc herniation, the suspicion for a malignant or infectious process is low and an MRI with gadolinium, biopsy, and cancer staging are not indicated. The majority of these patient improve with nonoperative management including physical therapy. Because this patient has no neurologic deficits, surgery would not be indicated.
Neurosurgery. 1988 Jul;23(1):36-40. PMID: 3173662 (Link to Abstract)
Blumenkopf, NEUROS 1988
Maiman DJ, Daniels D, Larson SJ.
J Spinal Disord. 1988;1(2):134-8. PMID: 2980069 (Link to Abstract)
Maiman, JSDT 1988
Wood KB, Blair JM, Aepple DM, Schendel MJ, Garvey TA, Gundry CR, Heithoff KB
Spine. 1997 Mar;22(5):525-9; discussion 529-30. PMID: 9076884 (Link to Abstract)
Wood, SPINE 1997
Average 3.0 of 23 Ratings
A 55-year-old woman undergoes endoscopic transthoracic anterior surgery for a herniated disk in the thorax. What is the most likely complication following surgery?
Intercostal neuralgia is the most common complication following endoscopic transthoracic anterior surgery for a herniated disk.
In the cited study the authors address the surgical strategies required to resect residual herniated thoracic discs. Endoscopic surgery requires establishment of portals between the ribs and frequently causes compression of the intercostal nerves. Therefore, the most common complication is intercostal neuralgia. Pneumothorax and cardiac tamponade are extremely rare.
Stillerman et al present a review of 71 patients with 82 herniated thoracic discs that underwent transthoracic, transfacet pedicle-sparing, lateral extracavitary, or transpedicular approaches for removal of the herniation.
Dickman CA, Rosenthal D, Regan JJ.
J Neurosurg. 1999 Oct;91(2 Suppl):157-62. PMID: 10505498 (Link to Abstract)
Dickman, JNEURS 1999
Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH
J. Neurosurg.. 1998 Apr;88(4):623-33. PMID: 9525706 (Link to Abstract)
Stillerman, JNEURS 1998
Average 2.0 of 38 Ratings
Intraoperative video of a left-sided transpedicular approach to the T3-4 disk sp...