A 61-year-old man presented with left lower back pain and left leg weakness and numbness, unable to walk. He has a history of lumbar and cervical spine surgeries. MRI showed stenosis at C3-C4 and L2-L3 as well as a disc herniation at T10-T11. The discussion focused on the rare occurrence of thoracic disc herniations and surgical approaches for addressing the T10-T11 herniation.

1. Spine Conference Friday October 21, 2022
Thoracic Disc Herniations

2. 61 year old man cc: LBP L>>R LE
weakness, numbness unable to
ambulate; uses a rolling walker; 10
days prior to presentation left knee
arthroscopy’ presented 9/14/22
PMH: L3L5 PSF 2008, C4C7
ACDF 2012, opiate dependency
since 13 years
MEDS: oxycodone 15mg five
times a day, ASA, inhaler
SH: disabled laborer since 2009
PE: 5’11” 244 lb
BLE: diffuse ⅖ pain , diffuse
weakness
Xray 6/28/22
I called the ER and discussed case

5. 6/19/22 ER tertiary care center,
3 months prior with similar
symptoms, postvoid residual>200
L1L2
L2L3
L3L4

7. Emergency room MRI lumbar spine and cervical spine next day; I
requested a thoracic MRI but they performed a lumbar MRI

8. L1L2
L2L3
L3L4
L4L5
L5S1

11. Describe spinal cord shape at each level

14. There is no
danger until you
get 6 inches
from the edge

20. Are you doing surgery on my neck
when it’s my leg that hurts?

21. 10

23. 61 year old man
Left LE weakness
Unable to walk
Left LE pain
Opiate dependency
C3C4 severe stenosis
Moderate L2L3 stenosis
T10T11 stenosis

25. Disc herniations
All discs: 450/1 million people
Thoracic: 1 in a million people
Baltimore Metropolitan area: 2.8M
75% below T7T8 and T11T12 most
common
About half are soft v. calcified

27. Left T9T12
Dominant arterial spinal feeder

28. Albert Wojciech Adamkiewicz (1850–1921)
From 1879 until 1892, he was
chief of general and
experimental pathology at the
Jagiellonian University in
Cracow.[2]
Adamkiewicz is remembered for
his pathological examinations of
the central nervous system. His
research of the variable
vascularity of the spinal cord
was an important contribution to
the development of modern
clinical vascular surgery. He is
credited with describing the
major anterior segmental
medullary artery, which is also
known as the Artery of
Adamkiewicz.[2]

29. 10
How do you know you are at the right level intraoperatively?

30. They all look the same

31. Leapfrog technique to identify thoracic level

32. Spinal cord
compression study
Scout images
Entire spine can be
imaged on sagittal
view

34. Move image rostral…

35. Move image rostral…

37. Interesting case………..

38. 72 year old woman with L lower extremity weakness and pain, unable to ambulate for the
last 2 months not improving with a brace, PT, time
T12

47. Costotransversectomy approach

48. Lateral extracavitary approach

58. Ravens
flying over
the
acropolis
in
waterpaint

59. 61 year old man
Left LE weakness
Unable to walk
Left LE pain
Opiate dependency
C3C4 severe stenosis
Moderate L2L3 stenosis
T10T11 stenosis
What approach?

62. THANKS!!