T1 – T2 Thoracic Disc Extrusion

Vinod NaneriaGirish Yeotikar

Arjun WadhwaniChoithram Hospital & Research centre,

Indore, India

Case History

• A 50 years Male,• Acute onset of severe radicular pain right arm.• The right arm is kept in 90 abduction.• Unable to bring arm close to chest due to pain.• Clinically there was no detectable neurological

deficit in any dermatome on right side. Planter were down going.

• MRI was showing lateral extruded disc at T1 – T2 with proximal migration.

December 2010

December 2010

December 2010

Conservative Tx

• Rest• Observation for any neurological deterioration• Steroids• Analgesics and Anti-acids• Gabapentin + Methyl Cholamine (B12)• Heat therapy with local rubrificient ointments.

Follow up - Aug 2012

Follow up - Aug 2012

D1

D3

Disc fragment

Disc

Dec 2010 Aug 2012

Dec 2010 Aug 2012

Disc fragmentDisc fragment

Follow up - Aug 2012

Disc fragment

Review Literature – Incidence & Site• Thoracic disc herniation accounts for 0.15-4.4% of all disc

herniations. • 75 % of all thoracic disc problems occur below T8, with a peak of

26% at T11-12. • The upper thoracic spine (T1-5) is the region least often affected,

with only 6% of all thoracic disc herniations occurring here.• To date, a total of 31 cases of T1-2 disc herniation have been

reported in the literature and all but one of these was diagnosed by myelography, computed tomography (CT), or CT myelography. Posterior surgical approaches were performed in all except one case, in which an anterior approach was used.

Magnetic Resonance Image Findings and Surgical Considerations in T1-2 Disc HerniationH. Caner, B.F. Kilinçoglu, S. Benli, N. Altinörs, M. Bavbek; Can. J. Neurol. Sci. 2003; 30: 152-154

Clinical presentation

• Upper thoracic disc herniation is rare. Patients can easily be misdiagnosed with cervical disc herniation or thoracic outlet syndrome.

• The common complaints in cases of this type are pain in the arm, shoulder, and neck (60%), as well as sensory (23%) and motor changes (18%).

• Radiculopathy is the most frequent finding (87%) in published cases, and Horner.s syndrome is seen in 21% of patients.

• Cervical MRI extended to include the upper thoracic region is diagnostic.

Brown CW, Deffer PA Jr, Akmakjian J, et al: The natural history of thoracic disc herniation. Spine 17(Suppl):S97–S102, 1992

• Brown, et al.,6 retrospectively reviewed data obtained in 55 patients with 72 thoracic disc herniations.

• They found that 15 (27%) of these patients eventually required surgery, especially if they presented with signs of myelopathy.

• The vast majority of patients, however, did not require surgery and have continued to perform activities of daily living, including vigorous sports activities.

• There was no correlation between radiographic depiction and the patient’s symptoms.

operative treatment of thoracic discs

• Posterior approach - transpedicular, transfacet;

• Posterolateral approach modified costotransversectomy, lateral extracavitary;

• Anterolateral approach - transthoracic;• Thoracoscopic approach

Thoracic herniated disc surgery is reserved for cases of myelopathy, progressive lower extremity weakness, and intolerable radicular pain that does not get better with non-surgical treatments.

operative treatment of thoracic discs

• Sharan et al reported that anterior discectomy without sternotomy.

• Rossitti et al reported an approach - anterior discectomy with sternotomy.

• Total disc excision is not possible when posterior or posterolateral approaches are used.

• posterior approaches, including laminectomy with foraminotomies, laminectomy with transdural disc excision, and thoracotomy with lateral extracavitary exposure.

Disc herniation at T1–2Report of four cases and literature reviewHoward Morgan, M.D., M.A., and Christopher Abood, M.D.Journal of Neurosurgery; January 1998 / Vol. 88 / No. 1 / Pages 148-150

• Intervertebral thoracic disc herniations are uncommon and high thoracic disc herniations are rare. In the upper third of the thoracic spine, T1–2 is the most common level for disc ruptures.

• In reviewing the literature on thoracic disc herniation, the authors found 27 cases at the T1–2 level, 23 of which were lateral disc herniations that produced radiculopathy and four of which were central disc herniations that caused myelopathy.

The anterior approach to high thoracic (T1-T2) disc herniation; 1993, Vol. 7, No. 2 , Pages 189-192. By - Sandro Rossitti, Hannes Stephensen, Sven Ekholm and Claes Von Essen

• A patient with a T1-T2 disc herniation, operated on via the anterior approach, is presented. In a search of the literature we found 18 reported cases, all operated on by posterior or posterolateral approaches. The feasibility of the anterior discectomy in our case was established by preoperative magnetic resonance imaging of the upper thorax. We think that an anterior discectomy at the level of the upper thoracic spine can be easily performed in selected cases. The clinical picture of T1 root compression is described.

Neurologic manifestations of compressive radiculopathy of the first thoracic rootKerry H. Levin, MD

From the Department of NeurologyCleveland Clinic Foundation, Cleveland, OH.

• Neurologic deficits in the first thoracic (T1) root distribution are uncommon and not easily defined. Myotomal charts indicate that distal arm and hand muscles receive significant contributions from both the C8 and T1 roots.

• A patient with focal T1 radiculopathy is presented who demonstrated motor axon loss isolated to the abductor pollicis brevis muscle. This finding provides another source of evidence that the abductor pollicis brevis is the primary T1 motor structure in the upper extremity, improving precision in clinical and electromyographic diagnosis.

Disc herniation at T1–2Report of four cases and literature reviewHoward Morgan, M.D., M.A., and Christopher Abood, M.D.Journal of Neurosurgery; January 1998 / Vol. 88 / No. 1 / Pages 148-150

• The T-1 radiculopathy usually involves weakness of the intrinsic muscles of the hand.

• The motor deficit of C-8 radiculopathy involves the intrinsic muscles of the hand and most of the flexors and extensors of the fingers and wrist.

• The T-1 radiculopathy may produce Horner's syndrome (oculosympathetic paralysis) and diminished sensation in the axilla, which are not found with C-8 radiculopathy.

• In clinical presentation as well as in treatment, the lateral T1–2 disc herniation resembles a cervical disc herniation, whereas the central T1–2 disc herniation displays the usual appearance of a thoracic disc herniation.

High thoracic disc herniation. (PMID:3762895)Alberico AM, Sahni KS, Hall JA Jr, Young HFNeurosurgery [1986, 19(3):449-451]

• A case of T-1, T-2 disc herniation is reported. The patient presented with diminished hand strength, medial arm and shoulder pain, and medial arm, forearm, and hand paresthesias.

• After surgical decompression and removal of a disc fragment, the patient made a complete recovery.

• Routine cervical myelography was considered inadequate in view of this patient's symptoms. High thoracic myelography followed by computed tomographic scanning should be considered for patients with this presentation.

Thoracic intervertebral disc herniations: diagnostic value of magnetic resonance imaging. (PMID:3173662)

Blumenkopf BDepartment of Neurological Surgery, Vanderbilt University,

Nashville, Tennessee. Neurosurgery[1988, 23(1):36-40]

Thoracic disc herniation is relatively rare and frequently poses a challenge in clinical diagnosis. These protrusions have been categorized into two major anatomical types and three main clinical syndromes. A number of characteristic radiographic features have been reported. Recently, magnetic resonance imaging (MRI) has gained popularity as a neurodiagnostic imaging tool.A series of nine cases of thoracic intervertebral disc herniation is reported. The clinical aspects of the cases are discussed, and the potential value of spine MRI for thoracic disc herniation diagnosis is emphasized.

Eur Spine J. 1995;4(6):366-7.First thoracic disc herniation with myelopathy.Nakahara S, Sato T.Department of Orthopaedic Surgery, Okayama University Medical School, Japan.• The case of a patient with progressive

paraparesis due to first thoracic disc herniation is reported. He was treated successfully with anterior interbody fusion by the Smith-Robinson approach.

• An anterior approach is desirable for surgical treatment of T1/2 disc herniation, and up to this level the Smith-Robinson approach, without thoracotomy, is entirely possible.

Awwad EE, Martin DS, Smith KR Jr, et al: Asymptomatic versus symptomatic herniated thoracic discs: their frequency and characteristics as detected by computed tomography after myelography. Neurosurgery 28:180–186, 1991

• Awwad, et al., in a retrospective review they compared myelography studies obtained in 68 patients harboring asymptomatic herniated thoracic discs with those obtained in five patients harboring symptomatic thoracic herniated discs.

References• Rossitti S, Stephensen H, Ekholm S, von Essen C. The anterior approach to

high thoracic (T1-T2) disc herniation. Br J Neurosurg 1993; 7:189-192.• Winter RB, Siebert R. Herniated thoracic disc at T1-T2 with paraparesis.

Transthoracic excision and fusion - case report with 4-year follow-up. Spine 1993; 18:782-784.

• Hamlyn PJ, Zeital T, King TT. Protrusion of the first thoracic disc. Surg Neurol 1991; 35:329-331.

• Korovessis PG, Stamatakis M, Michael A, Baikousis A. Three-level thoracic disc herniation: case report and review of the literature. Eur Spine J 1997; 6:74-76.

• Kumar R, Buckley TF. First thoracic disc protrusion. Spine 1986; 11:499-501.

• Morgan H. Abood C. Disc herniation at T1-2. J Neurosurg 1998; 88: 148-150.

References• Gelch MM. Herniated thoracic disc at T1-2 level associated with

Horner.s syndrome. Case report. J Neurosurg 1978; 48:128-130.• Hammon WM. Extruded upper thoracic disc causing Horner.s

syndrome. Report of a case. Med Ann Dist Columbia 1968; 37:541-542.

• Lloyd TV, Johnson JC, Paul DJ, et al. Horner.s syndome secondary to herniated disc at T1-T2. AJR Am J Roentgenol 1980;134:184-185.

• Sharan AD, Przybylski GJ, Tartaglino L. Approaching the upper thoracic vertebrae without sternotomy or thoracotomy: a radiographic analysis with clinical application. Spine 2000;

• 25:1910-1916,• Nakahara S, Sato T. First thoracic disc herniation with myelopathy.

Eur Spine J 1995, 4:366-367

DISCLAIMER Information contained and transmitted by this presentation is

based on personal experience and collection of cases at Choithram Hospital & Research centre, Indore, India, during last 32 years. It is intended for use only by the students of orthopaedic surgery. Views and opinion expressed in this presentation are personal opinion. Depending upon the x-rays and clinical presentations viewers can make their own opinion. For any confusion please contact the sole author for clarification. Every body is allowed to copy or download and use the material best suited to him. I am not responsible for any controversies arise out of this presentation. There is no direct or indirect involvement of finances in preparation of this presentation. For any correction or suggestion please contact naneria@yahoo.com