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Introduction
  • Relatively uncommon and makes up only 1% of all HNP.
  • Epidemiology
    • demographics
      • most commonly seen between 4th and 6th decades of life
        • as the disc desiccates it is less likely to actually herniate
    • location
      • usually involves middle to lower levels
      • T11-T12 most common level
      • 75% of all thoracic disc herniations occur between T8 and T12
    • risk factors
      • underlying Scheuermann's disease may predispose to thoracic HNP
Classification
  • Herniation type
    • bulging nucleus
      • annulus remain intact
    • extruded disc
      • through annulus but confined by PLL
    • sequestered
      • disc material free in canal
  • Location classification
    • central
    • posterolateral
    • lateral
Presentation
  • Symptoms
    • pain
      • axial back or chest pain is most common symptom
      • thoracic radicular pain
        • band-like chest or abdominal pain along course of intercostal nerve
      • arm pain (see with HNP at T2 to T5)
    • neurologic
      • numbness, paresthesias, sensory changes
      • myelopathy
      • paraparesis
      • bowel or bladder changes (15% - 20% of patients)
      • sexual dysfunction
  • Physical exam
    • localized tenderness
    • root symptoms
      • dermatomal sensory changes (paresthesias and dysesthesia)
    • cord compression and findings of myelopathy
      • weakness
        • weakness or mild paraparesis
        • abnormal rectal tone
      • upper motor neuron findings
        • hyperreflexia
        • sustained clonus
        • positive Babinski sign
      • gait changes
        • wide based spastic gait
    • Horner's syndrome
      • seen with HNP at T2 to T5
Imaging
  • Radiographs
    • lateral radiographs
      • may show disc narrowing
      • may show calcification (osteophytes)
  • MRI
    • most useful and important imaging method to demonstrate thoracic disc herniation
      • allows for identification of neoplastic pathology
      • can see intradural pathology
      • will show myelomalacia
      • may not fully demonstrate calcified component of herniated disc
    • disadvantage is high false positive rate
      • in a study looking at asymptomatic individuals 
        • 73% had thoracic disk abnormalities 
        • 37% had frank herniations
        • 29% of these had cord compression.
Treatment
  • Nonoperative
    • activity modification, physical therapy, and symptomatic treatment 
      • indications
        • the majority of cases
      • modalities include
        • immobilization and short term rest
        • analgesic
        • progressive activity restoration
        • injections may be useful for symptoms of radiculopathy
      • outcomes
        • majority improve with nonoperative treatment
  • Operative
    • discectomy with possible hemicorpectomy or fusion 
      • indications
        • surgery indicated in minority of patients
        • acute disc herniation with myelopathic findings attributable to the lesion, especially if there is progressive neurologic deterioration
        • persistent and intolerable pain
      • technique
        • debate between discectomy with or without fusion is controversial.
          • most studies do indicate that anterior or lateral (via costotransversectomy) is the best approach
        • see below for different approaches
Surgical Techniques
  • Transthoracic discectomy
    • indications
      • best approach from central disc herniations
    • complications
      • intercostal neuralgia q 
    • techniques
      • can be done with video assisted thoracic surgery (VATS)
  • Costotransversectomy
    • indications
      • lateral disc herniation
      • extruded or sequestered disc
 

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(OBQ06.168) 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? Review Topic

QID: 354
1

Increased kyphosis

3%

(69/2602)

2

Pseudarthrosis

3%

(76/2602)

3

Intercostal neuralgia

74%

(1930/2602)

4

Pneumothorax

20%

(517/2602)

5

Cardiac tamponade

0%

(2/2602)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ09.190) 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? Review Topic

QID: 3003
FIGURES:
1

Observation

6%

(131/2054)

2

Physical therapy

13%

(266/2054)

3

Epidural injection

3%

(66/2054)

4

Laminectomy

17%

(342/2054)

5

Anterior diskectomy

61%

(1243/2054)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

(OBQ07.131) 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? Review Topic

QID: 792
FIGURES:
1

A repeat MRI with gadolinium

4%

(120/3115)

2

CT of chest, abdomen, and pelvis followed by a CT guided biopsy of the spinal lesion

4%

(113/3115)

3

Physical therapy and NSAIDs

80%

(2505/3115)

4

Surgical decompression using a midline posterior approach

5%

(171/3115)

5

Surgical decompression using a transthoracic approach

6%

(196/3115)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3
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