Reoperation for herniated thoracic discs

Object. In this review the authors address the surgical strategies required to resect residual herniated thoracic discs. Methods. Data obtained in 15 patients who had undergone prior thoracic disc ectomy and who harbored residual or incompletely excised symptomatic thorac ic discs were reviewed retrospectively. The surgical procedures that had fa iled to excise the herniated discs completely included 11 posterolateral ap proaches, one thoracotomy, and three thoracoscopy-guided surgical procedure s. Of the lesions that were incompletely resected or residual, there were 1 3 central calcified, two soft, 12 extradural, and three intradural discs. I ndications for reoperation were often multiple in each patient and included misidentification of the level of disc disease at the initial operation (f ive cases), abandoning the procedure because of intraoperative spinal cord injury (three cases), inadequate visualization of the pathological entity ( eight cases), migration of a soft disc fragment within the spinal canal (on e case). and intradural disc extension (three cases). The symptoms at the t ime of reoperation included myelopathy in 13 patients and radicular pain in two patients. The mean interval before reoperation was 150 days (range 1 d ay-4 years). The reoperation procedures included one thoracotomy and 14 vid eo-assisted thoracoscopic procedures performed ipsilateral (1 1 cases) or c ontralateral (four cases) to the site of the initial surgery. The herniated disc material was excised completely in all 15 cases without causing new neurological deficits. Reoperation complications included atele ctasis in three patients, intercostal neuralgia in two, a loosened screw th at required removal in one, residual intradural disc herniation that requir ed a second reoperation in one patient, and a cerebrospinal fluid leak in o ne patient. Of the 13 patients who experienced myelopathy prior to operatio n, 10 recovered neurological function and three stabilized. All patients wi th radicular pain improved. Conclusions. Calcified, large, broad-based, centrally located, or transdura l thoracic disc herniations can be difficult to resect. These lesions requi re a ventral operative approach to visualize the dura adequately for a safe and complete resection.