Introduction: Thoracic disc herniations are uncommon and are estimated to comprise 0.2-4% of all herniations. Although the incidence is low, these herniations may cause debilitating pain, weakness, and myelopathy. In patients with intractable symptoms, surgical decompression is generally recommended. Thoracic disc herniations pose a challenge to the surgeon as access to the disc is difficult and extreme care must be taken to avoid iatrogenic spinal cord injury. Furthermore, it is difficult to visualize when the disc herniation has been removed and spinal cord decompression is complete. We have employed intraoperative ultrasound imaging to help guide the resection of thoracic disc fragments located ventral to the thecal sac. In our experience, this technique has proved useful in achieving complete decompression.
Methods: Departmental records were searched for all thoracic discectomies performed by a single surgeon in 2015. Cases where intraoperative ultrasound was used to guide decompression were identified and reviewed in detail.
Results: Two patients were identified who both underwent a right-sided T10-11 transpedicular approach for thoracic discectomy and posterolateral fusion with the use of intraoperative ultrasound. Both patients were female and the average age was 57. They each presented with symptoms of spinal cord compression including bilateral lower extremity numbness and worsening gait difficulty. MRI and CT scans were performed which demonstrated large, central disc herniations at T10-11 with spinal cord compression. Both patients underwent uncomplicated surgical procedures and, in both cases, the use of intraoperative ultrasound was crucial in identifying retained disc fragments that could not have been visualized directly. Both patients experienced complete resolution of their symptoms by 6-week follow up.
Conclusions: The use of intraoperative ultrasound to evaluate thoracic disc herniations is a simple, safe and effective way to identify residual disc fragments that cannot be directly visualized and to ensure that adequate decompression is achieved at the time of surgery.
Patient Care: Our paper describes a surgical technique which may be used to ensure that the surgeon has performed adequate decompression during the resection of a centrally located thoracic disc herniation. When used appropriately, we believe this technique will improve patient outcomes and limit the risk of intraoperative complications.
Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the clinical significance of thoracic disc herniations, 2) Discuss in small groups the challenges of approaching a centrally located thoracic disc herniation, 3) Identify situations in which intraoperative ultrasound might be useful during surgery for thoracic disc herniations.