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Study Design: Retrospective analysis of a prospectively collected database of thoracoscopic microdiscectomies performed at the Maastricht University Medical Center., Objective: Many victims of a motor vehicle collision (MVC) report crippling upper back pain resistant to conservative treatment. Although this pain is often regarded as nonspecific or related to a whiplash type of cervical spine injury, this study demonstrates it may be caused by a thoracic disc herniation., Summary of Background Data: Recent literature on bodily pain after whiplash and other MVCs has shown that most patients rather than pain confined to the posterior neck area (0.4%) report pain in multiple body areas, the most frequently affected region being the posterior trunk region, including the posterior neck, posterior shoulder, upper back, lumbar, and buttock areas. Although several patterns determining most variance in pain localization in these patients have been identified, different pathoanatomical and pathophysiological substrates underlying these patterns have not been identified. However, a high incidence of posterior shoulder pain (75%) and upper back pain (66%) is striking., Methods: In a series of 326 thoracoscopic microdiscectomies for one or more symptomatic TDHs, we identified 10 patients whose symptoms had started after an MVC. We analyzed their clinical and radiological presentation, intraoperative findings, and postoperative outcome., Results: All patients (7 females, 3 males; age, 26-58 yr, including 4 with typical whiplash complaints) had reported substantial improvement of their complaints except for their upper back pain. Most hernias were small or medium sized (n = 8), at the apex of the kyphotic curvature (n = 6), and to some extent calcified (n = 7). One year postoperatively, results were excellent in 7, good in 2, and poor in 1., Conclusion: Crippling upper back pain after MVCs may be caused by a (previously asymptomatic) thoracic disc herniation. Although the exact pathophysiological mechanism has not been elucidated, results after thoracoscopic microdiscectomy are quite encouraging.

Object: Thoracic disc herniations (TDHs) may occasionally present with an acute myelopathy, defined as a variable degree of motor, sensory, and sphincter disturbances developing in less than 24 hours, and resulting in a Frankel Grade C or worse. Confronted with such a patient, the surgeon has to decide whether to perform an emergency operation and whether to use an anterior or posterior approach. The authors analyze their own experience and the pertinent literature, focusing on clinical presentation, imaging findings, surgical timing, technique, and outcome., Methods: Among 250 patients who underwent surgery for symptomatic TDH, 209 had at least 1 year of follow-up at the time of writing, including 8 patients who presented with an acute myelopathy. They were surgically treated using standard thoracoscopic microdiscectomy, careful blood pressure monitoring, and intravenous methylprednisolone. The authors analyzed pre- and postoperative neuroimaging, and Frankel scores preoperatively, at discharge, and 1 year postoperatively., Results: Although 5 patients had multiple TDHs, the symptomatic TDH was invariably situated between T9-10 and T11-12. Seven TDHs were giant, 6 were calcified, 6 were accompanied by myelomalacia, and 4 were accompanied by segmental stenosis. Although sudden dorsalgia was the initial symptom in 6, a precipitating event was noted in only 1. All patients had severe neurological deficits by the time they underwent surgery. Frankel grades improved from B to D in 2 patients, from C to E in 4, and from C to D and B to E in 1 patient each. All patients regained continence and ambulation. Transient complications were CSF leak (in 2 patients), and intraoperative blood loss greater than 1000 ml, reversible ischemic neurological deficit, and subileus (in 1 patient each)., Conclusions: Approximately 4% of TDHs present with an acute myelopathy. They are often situated between T9-10 and T11-12, large or giant, and even calcified. They almost invariably cause important cord compression (sometimes aggravated by an associated segmental stenosis) and myelomalacia. Their clinical presentation may be misleading, and diagnosis may be delayed until other causes (especially vascular) have been excluded and the clinical picture has become more complete. Interestingly, whereas a precipitating event or trauma is rarely present, dorsalgia frequently precedes profound myelopathy and may help to make an early diagnosis. Remarkable recovery is possible even with profound neurological deficit, a delay of several days, in the elderly, and in the presence of myelomalacia, provided the spinal cord is adequately decompressed and intraoperative hypotension is strictly avoided. Although alternative approaches more familiar to most neurosurgeons may be used, the anterior transthoracic approach has the advantage of reaching the TDH in front of the compromised spinal cord, avoiding any manipulation. In experienced hands, thoracoscopic microdiscectomy combines the advantage and versatility of an anterior approach with minimal postoperative discomfort. The authors conclude that TDH-related acute myelopathy may have a favorable outcome when managed correctly, and they strongly recommend that every single patient should undergo surgical treatment.

Background: In contrast to what is commonly believed, thoracic disc herniations are not rare lesions. Their etiopathogenesis is largely unknown, but may be linked to trauma, Scheuermann's disease or a degenerative back., Objective: We report two brothers with a symptomatic thoracic disc herniation at T11-T12 and address the possibility of a genetic factor as well as other factors in the etiopathogenesis of (symptomatic) thoracic disc herniations., Clinical Features: Both brothers were in their early thirties and had a physically demanding job, however, only the first one was a smoker and was diagnosed with Scheuermann's disease., Conclusion: The etiology of thoracic disc herniations is likely multifactorial. Their occurrence in siblings may reflect some genetic predisposition or may be merely coincidental, given the high prevalence of thoracic disc herniations in asymptomatic individuals. Further research, including genetic studies, is warranted.

Study Design: This study analyzes the mobility of the aorta relative to the spine in patients with a herniated thoracic disc requiring surgical intervention., Objectives: To determine the mobility of the aorta relative to the spine with the patient in prone and supine position., Summary of Background Data: In anterior scoliosis surgery, safe screw placement is important and knowledge of the position of the aorta relative to the spine is crucial. To the authors' knowledge, there are no studies on the mobility of the aorta relative to the spine with the patient in different positions., Methods: All 50 patients before surgery had a computed tomography (CT) and/or magnetic resonance (MR) scans of the involved spinal segment in supine position, as well as a CT with intrathecal contrast in prone position. The aorta-vertebral angle and the aorta-vertebral distance were measured on as many levels as possible., Results: In supine position, the aorta is positioned left lateral to the vertebral body at midthoracic levels (T4-T8) and more anterior to the vertebral body at lower thoracic levels (T9-L2). In prone position, the aorta moves to a more anteromedial position relative to the vertebra, which is most significant at levels T4 to T8. The mediolateral aorta-vertebral distance according to Sevastik is shorter in prone position, whereas the anterior-posterior distance according to Sucato is larger, especially at levels T5 to T10., Conclusions: We demonstrate a substantial difference in the position of the aorta relative to the spine in prone and in supine position, which is most markedly seen at levels T4 to T8. The aorta is positioned posterolateral to the spine in supine position and more anteromedial in prone position. Before performing anterior thoracolumbar spine surgery, we suggest to measure vertebral body width, as well as the position of the aorta in the prone and in the supine patient to decide if his approach is technically feasible, or if an alternative (contralateral) approach is preferable.