A challenging recurrent thoracic disc herniation

Abstract

Background: Thoracic disc herniations are rare and occur at the rate of 1/1,000,000/year. Surgical approach must be individually tailored to the size, location, and consistency of the herniated disc. Notably, here, we report the unusual recurrence of a thoracic herniated disc.

Case description: In 2014, a 53-year-old female presented with thoracic back pain, and paraparesis, attributed to an magnetic resonance imaging/computed tomography (CT)-documented left paramedian T8-T9 calcific disc herniation. She underwent a left hemilaminectomy/costotrasversectomy following which she experienced complete regression of her symptoms. Notably, the postoperative radiological studies at that time demonstrated some residual although asymptomatic calcific disc herniation. Eight years later, she again presented, but now with the chief complaint of difficulty breathing. The new CT scan showed a new calcified herniated disc fragment superimposed on the previously documented residual disc. Through a posterolateral transfacet approach, she underwent resection of the disc complex. An intraoperative CT scan confirmed complete removal of the recurrent calcified disc herniation. Following the second surgery, the patient fully recovered and remains asymptomatic.

Conclusion: A 53-year-old female first presented with a left-sided T8/T9 thoracic calcified disc herniation that was initially partially resected). When another larger fragment appeared 8 years later, superimposed on the previously documented residual disc, it was successfully removed through a posterolateral transfacet approach completed with CT guidance and neuronavigation.

Keywords: Residual thoracic hernia; Thoracic disc herniation; Thoracic herniation recurrence; Thoracic myelopathy.

Figure 1:

2014 preoperative magnetic resonance imaging, median sagittal T2-weighted sequence (a) and T8–T9 axial T2 weighted sequence (b), and preoperative computed tomography scan, median sagittal (c), and T8–T9 axial (d) planes, demonstrating a left paramedian T8–T9 calcific disc herniation. There was dural compression, right dislocation of the spinal cord, and an hyperintense signal, standing for myelopathy.

Figure 2:

2014 postoperative computed tomography scan (a) median sagittal, (b) T8–T9 axial, and (c) left paramedian sagittal planes. It was appreciable the residual shell of the calcified disc herniation (white rings in a and b) and the surgical wedge (white arrow in c) created by partial corpectomy of the T8–T9 vertebral bodies.

Figure 3:

(a) 2015 Thoracic column magnetic resonance imaging (MRI) in median sagittal T2-weighted sequence, (b) T8–T9 axial T2-weighted sequence, (c) 2017 Thoracic column MRI in median sagittal T2-weighted sequence, and (d) T8–T9 axial T2-weighted sequence. Follow-up MRI scans demonstrated the stability of the residual calcific disc herniation in time.

Figure 4:

(a) 2014 postoperative computed tomography (CT) scan in T8–T9 axial plane and (b) 2022 CT scan in T8–T9 plane. The comparison between the 2014 postoperative CT scan and the 2022 control CT scan at the same level confirmed the presence of the residual calcific disc at the T8–T9 level, with a new calcified herniated fragment on the left (white arrow in b).

Figure 5:

(a) Intraoperative T8–T9 axial computed tomography (CT) scan with navigation probe, (b) intraoperative left paramedian sagittal CT scan with navigation probe (green line), and (c) intraoperative T8–T9 axial CT scan showing the known small median calcific residual tightly attached to the dura (white arrow) and the complete removal of the recurrent herniated disc (white dotted arrow).

Figure 6:

(a) Thoracic column magnetic resonance imaging (MRI), midline sagittal T2-weighted sequence and (b) thoracic column MRI, T8–T9 axial T2-weighted sequence. One-month postoperative MRI scan evidenced the presence of the median residual, a left paramedian liquor collection, and the removal of the recurrent thoracic disc herniation.