Thoracic disc herniations

Ondertitel:an underestimated disease in search for a surgical cure

Although still not widely acknowledged, thoracic disc herniations (TDHs) are not rare lesions that may be observed on MRI scans of asymptomatic individuals (37%; Wood, 1995). Even to date, symptomatic TDHs are underdiagnosed. Their pathogenesis and pathophysiology seems to be different from their cervical and lumbar counterparts, largely involving spinal cord rather than radicular compression. Patients may be incapacitated by myelopathy and/or crippling pain resisting medication, physiotherapy, even invasive pain therapy. Physicians including general practitioners, neurologists, neurosurgeons are insufficiently familiar with their diverse clinical presentation. I started this PhD work to make sure these patients receive the best possible care, regardless whether they are suffering myelopathy or merely pain. I set out to study their very diverse clinical presentation, defining different subgroups encountered in my growing practice, as well as their unique imaging characteristics. Also, after implementation of the thoracoscopic microdiscectomy (TMD) technique (Rosenthal, 1994), I set out to make this technique less invasive, safer, and more efficient. This thesis bundles several papers with regard to these intriguing lesions. First, TDH related acute myelopathy, usually caused by a large preexistent TDH causing important cord compression at the lower end of the thoracic spine, frequently preceeded by dorsalgia. Prognosis tends to be favorable when managed correctly. Second, persisting crippling upper back pain after whiplash and other motor vehicle collisions, caused by a preexistent asymptomatic TDH. Prognosis tends to be favorable when managed correctly. Third, T3-T4 DHs as a unique entity causing severe symptoms despite their usually small dimensions. They can be safely resected using a transaxillary approach. Fourth, a sutureless multi-layer technique to reconstruct the dura during TMD has a 97% success rate in preventing a possibly life-threatening subarachnoid-pleural fistula without converting to open surgery. Fifth, high-risk TDHs which are often giant or massive, calcified, close to the apex of (an accentuated) kyphosis, causing significant spinal canal occupation and spinal cord compression, often accompanied by intramedullary signal changes (myelomalacia). We demonstrate that in experienced hands they can be safely dealt with using TMD with motor evoked potential monitoring support. Finally, TMD-R (“R” meaning rib-preserving) as a safe and effective technique even for the most challenging TDHs, while preserving stability and minimizing acute and chronic postoperative pain, thus opening the door to a more widespread use including patients presenting with merely pain. At the end, some suggestions for future research covering clinical, radiologic, surgical and pathophysiological aspects are discussed.

Jaar van publicatie:2023

Trefwoorden:Doctoral thesis

Toegankelijkheid:Embargoed