European Spine Journal

, Volume 23, Supplement 1, pp 76–83 | Cite as

Calcified giant thoracic disc herniations: considerations and treatment strategies

  • N. A. QuraishiEmail author
  • A. Khurana
  • M. M. Tsegaye
  • B. M. Boszczyk
  • S. M. H. Mehdian
Original Article



Giant herniated thoracic discs (GHTD) remain a surgical challenge. When combined with calcification, these discs require altered surgical strategies and have only been infrequently described. Our objective was to describe our surgical approaches in the management of calcified GHTD.


This was a retrospective cohort study of all patients with calcified GHTD operated between 2004 and 2012. Data were collected from review of patients’ notes and radiographs and included basic demographic and radiological data, clinical presentation and outcome, operative procedure and complications.


During the study period, there were 13 patients with calcified GHTD, including 6 males and 7 females (mean age 55 years, range 31–83 years). The average canal encroachment was 62 % (range 40–90 %); mean follow-up 37 months (12–98). All patients were treated with anterior thoracotomy, varying degrees of vertebral resection, removal of calcified disc and with or without reconstruction. The average time for surgery was 344 min (range 212–601 min) and estimated blood loss 1,230 ml (range 350–3,000 ml). Post-operatively, 8 patients improved by 1 Frankel grade (62 %), 2 improved by 2 grades (15 %) and 3 did not change their grade (23 %). The complication rate was 4/13 (31 %; 3 patients with durotomies (2 incidental, 1 intentional) and 1 with recurrence).


Calcified GHTD remain a surgical challenge. Anterior decompression through a thoracotomy approach, and varying degrees of vertebral resection with or without reconstruction allowed us to safely remove the calcified fragment. All patients remained the same (23 %) or improved by at least 1 grade (77 %) neurologically, without radiographic failure at final follow-up.


Giant calcified thoracic disc herniation Surgical strategies Complications  Mini-open thoracotomy Vertebral resection 


Conflict of interest



  1. 1.
    Okada Y, Shimizu K, Ido K, Kotani S (1997) Multiple thoracic disc herniations: case report and review of the literature. Spinal Cord 1997(35):183–186CrossRefGoogle Scholar
  2. 2.
    Stillerman CB, Chen TC, Couldwell WT, Zhang W, Weiss MH (1998) Experience in the surgical management of 82 symptomatic herniated thoracic discs and review of the literature. J Neurosurg 88:623–633PubMedCrossRefGoogle Scholar
  3. 3.
    Vollmer DG, Simmons NE (2000) Transthoracic approaches to thoracic disc herniations. Neurosurg Focus 2000(9):e8Google Scholar
  4. 4.
    Hott JS, Feiz-Erfan I, Kenny K, Dickman CA (2005) Surgical management of giant herniated thoracic discs: analysis of 20 cases. J Neurosurg Spine 3(3):191–197PubMedCrossRefGoogle Scholar
  5. 5.
    Barbanera A, Serchi E, Fiorenza V, Nina P, Andreoli A (2009) Giant calcified thoracic herniated disc: considerations aiming a proper surgical strategy. J Neurosurg Sci 53(1):19–25 (discussion 25–26)PubMedGoogle Scholar
  6. 6.
    Moran C, Ali Z, McEvoy L, Bolger C (2012) Mini-open retropleural transthoracic approach for the treatment of giant thoracic disc herniation. Spine (Phila Pa 1976) 37(17):E1079–E1084CrossRefGoogle Scholar
  7. 7.
    Maiman DJ, Larson SJ, Luck E et al (1984) Lateral extracavitary approach to the spine for thoracic disc herniation: report of 23 cases. Neurosurgery 14:178–182PubMedCrossRefGoogle Scholar
  8. 8.
    Mulier S, Debois V (1998) Thoracic disc herniations: transthoracic, lateral, or posterolateral approach? A review. Surg Neurol 49:606–608CrossRefGoogle Scholar
  9. 9.
    Bilsky MH (2000) Transpedicular approach for thoracic disc herniations. Neurosurg Focus 9(4):e3PubMedCrossRefGoogle Scholar
  10. 10.
    Bransford R, Zhang F, Bellabarba C, Konodi M, Chapman JR (2010) Early experience treating thoracic disc herniations using a modified transfacet pedicle-sparing decompression and fusion. J Neurosurg Spine 12(2):221–231PubMedCrossRefGoogle Scholar
  11. 11.
    Chi JH, Dhall SS, Kanter AS, Mummaneni PV (2008) The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment. Neurosurg Focus 25(2):E5PubMedCrossRefGoogle Scholar
  12. 12.
    Dinh DH, Tompkins J, Clark SB (2001) Transcostovertebral approach for thoracic disc herniations. J Neurosurg 94(1 Suppl):38–44PubMedGoogle Scholar
  13. 13.
    Le Roux PD, Haglund MM, Harris AB (1993) Thoracic disc disease: experience with the transpedicular approach in twenty consecutive patients. Neurosurgery 33:58–66PubMedCrossRefGoogle Scholar
  14. 14.
    Stillerman CB, Chen TC, Day JD, Couldwell WT, Weiss MH (1995) The transfacet pedicle-sparing approach for thoracic disc removal: cadaveric morphometric analysis and preliminary clinical experience. J Neurosurg 83:971–976PubMedCrossRefGoogle Scholar
  15. 15.
    Thambiraj S, Quraishi NA (2012) Intra-operative localisation of thoracic spine level: a simple “‘K’-wire in pedicle” technique. Eur Spine J 21(Suppl 2):S221–S224. doi: 10.1007/s00586-012-2193-3 PubMedCrossRefGoogle Scholar
  16. 16.
    Lewis SJ, Kulkarni AG, Rampersaud YR, Jhaveri S, Quraishi N, Bacon SA, Magana SP (2012) Posterior column reconstruction with autologous rib graft after en bloc tumor excision. Spine 37(4):346–350PubMedCrossRefGoogle Scholar
  17. 17.
    Khurana A, Brousil J, Russo A, Evans A, Quraishi NA, Boszczyk BM (2013) Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision. Eur Spine J 22(9):2047–2054Google Scholar
  18. 18.
    Cornips EM, Janssen ML, Beuls EA (2011) Thoracic disc herniation and acute myelopathy: clinical presentation, neuroimaging findings, surgical considerations, and outcome. J Neurosurg (Spine) 14(4):520–528CrossRefGoogle Scholar
  19. 19.
    Wood KB, Blair JM, Aepple DM, Schendel MJ, Garvey TA, Gundry CR, Heithoff KB (1997) The natural history of asymptomatic thoracic disc herniations. Spine (Phila Pa 1976) 22(5):525–529 (discussion 529–530)CrossRefGoogle Scholar
  20. 20.
    Patterson RH Jr, Arbit E (1978) A surgical approach through the pedicle to protruded thoracic discs. J Neurosurg 48:768–772PubMedCrossRefGoogle Scholar
  21. 21.
    Deviren V, Kuelling FA, Poulter G, Pekmezci M (2011) Minimal invasive anterolateral transthoracic transpleural approach: a novel technique for thoracic disc herniation. A review of the literature, description of a new surgical technique and experience with first 12 consecutive patients. J Spinal Disord Tech 24(5):E40–E48. doi: 10.1097/BSD.0b013e318220af6f PubMedCrossRefGoogle Scholar
  22. 22.
    Kahn E (1944) The role of dentate ligaments in spinal cord compression and the syndrome of lateral sclerosis. J Neurosurg 4:191–199CrossRefGoogle Scholar
  23. 23.
    Dommisse GF (1974) The blood supply of the spinal cord: a critical vascular zone in spinal surgery. JBJS Br 56:225–235PubMedGoogle Scholar
  24. 24.
    Severi P, Ruelle A, Andrioli G (1992) Multiple calcified thoracic disc herniations: a case report. Spine 17:449–451PubMedCrossRefGoogle Scholar
  25. 25.
    Fujimaki Y, Kawahara N, Tomita K et al (2006) How many ligations of bilateral segmental arteries cause ischemic spinal cord dysfunction?: an experimental study using a dog model. Spine 31:E781–E789PubMedCrossRefGoogle Scholar
  26. 26.
    Russo A, Balamurali G, Nowicki R, Boszczyk BM (2012) Anterior thoracic foraminotomy through mini-thoracotomy for the treatment of giant thoracic disc herniations. Eur Spine J 21(Suppl 2):S212–S220. doi: 10.1007/s00586-012-2263-6 PubMedCrossRefGoogle Scholar
  27. 27.
    McInerney J, Ball PA (2000) The pathophysiology of thoracic disc disease. Neurosurg Focus 9(4):e1 (Review)PubMedCrossRefGoogle Scholar
  28. 28.
    McCormick WE, Will SF, Benzel EC (2000) Surgery for thoracic disc disease Complication avoidance: overview and management. Neurosurg Focus 9(4):e13PubMedCrossRefGoogle Scholar
  29. 29.
    Börm W, Bäzner U, König RW, Kretschmer T, Antoniadis G, Kandenwein J (2011) Surgical treatment of thoracic disc herniations via tailored posterior approaches. Eur Spine J 20(10):1684–1690. doi: 10.1007/s00586-011-1821-7 PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Debnath UK, McConnell JR, Sengupta DK, Mehdian SM, Webb JK (2003) Results of hemivertebrectomy and fusion for symptomatic thoracic disc herniation. Eur Spine J 12(3):292–299PubMedCentralPubMedGoogle Scholar
  31. 31.
    Stillerman CB, Weiss MH (1992) Management of thoracic disc disease. Clin Neurosurg 38:325–352PubMedGoogle Scholar
  32. 32.
    Horowitz MB, Moossy JJ, Julian T, Ferson PF, Huneke K (1994) Thoracic discectomy using video assisted thoracoscopy. Spine (Phila Pa 1976) 19(9):1082–1086CrossRefGoogle Scholar
  33. 33.
    Logue V (1952) Thoracic intervertebral disc prolapse with spinal cord compression. J Neurol Neurosurg Psychiatry 15(4):227–241PubMedCentralPubMedCrossRefGoogle Scholar
  34. 34.
    Cho JY, Lee SH, Jang SH, Lee HY (2012) Oblique paraspinal approach for thoracic disc herniations using tubular retractor with robotic holder: a technical note. Eur Spine J 21(12):2620–2625PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Moon SJ, Lee JK, Jang JW, Hur H, Lee JH, Kim SH (2010) The transdural approach for thoracic disc herniations: a technical note. Eur Spine J 19(7):1206–1211PubMedCentralPubMedCrossRefGoogle Scholar
  36. 36.
    Coppes MH, Bakker NA, Metzemaekers JD, Groen RJ (2012) Posterior transdural discectomy: a new approach for the removal of a central thoracic disc herniation. Eur Spine J 21(4):623–628PubMedCentralPubMedCrossRefGoogle Scholar
  37. 37.
    Mayer HM (2006) Microsurgical anterior approach to T5–T10 (Mini-TTA). In: Mayer HM (ed) Minimally invasive spine surgery. Springer, Berlin, pp 129–137CrossRefGoogle Scholar
  38. 38.
    McAfee PC, Regan JR, Zdeblick T et al (1995) The incidence of complications in endoscopic anterior thoracolumbar spinal reconstructive surgery: a prospective multicenter study comprising the first 100 consecutive cases. Spine 20:1624–1632PubMedCrossRefGoogle Scholar
  39. 39.
    Anand N, Regan JJ (2002) 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 (Phila Pa 1976) 27:871–879CrossRefGoogle Scholar
  40. 40.
    Uribe JS, Smith WS, Pimenta L et al (2012) Minimally invasive lateral approach for symptomatic thoracic disc herniation:initial multicenter clinical experience. J Neurosurg Spine 16:264–279PubMedCrossRefGoogle Scholar
  41. 41.
    Hammett TC, Boreham B, Quraishi NA, Mehdian SM (2013) Intraoperative spinal cord monitoring during the surgical correction of scoliosis due to cerebral palsy and other neuromuscular disorders. Eur Spine J 22(Suppl 1):S38–S41PubMedCrossRefGoogle Scholar
  42. 42.
    Quraishi NA, Lewis SJ, Kelleher MO, Sarjeant R, Rampersaud YR, Fehlings MG (2009) Intraoperative multimodality monitoring in adult spinal deformity: analysis of a prospective series of one hundred two cases with independent evaluation. Spine (Phila Pa 1976) 34(14):1504–1512CrossRefGoogle Scholar
  43. 43.
    Vanichkachorn JS, Vaccaro AR (2000) Thoracic disk disease: diagnosis and treatment. J Am Acad Orthop Surg 8:159–169PubMedGoogle Scholar
  44. 44.
    Brown CW, Deffer PA Jr, Akmakjian J, Donaldson DH, Brugman JL (1992) The natural history of thoracic disc herniation. Spine (Phila Pa 1976) 17(6 Suppl):S97–S102CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2014

Authors and Affiliations

  • N. A. Quraishi
    • 1
    Email author
  • A. Khurana
    • 1
  • M. M. Tsegaye
    • 1
  • B. M. Boszczyk
    • 1
  • S. M. H. Mehdian
    • 1
  1. 1.Centre for Spine Studies and Surgery, Queens Medical CentreNottinghamUK

Personalised recommendations