Stillerman C B, Chen T C, Couldwell W T, Zhang W, Weiss M H
University of North Dakota School of Medicine and Trinity Medical Center, Minot, USA.
J Neurosurg. 1998 Apr;88(4):623-33. doi: 10.3171/jns.1998.88.4.0623.
The authors aimed to develop management strategies for the treatment of herniated thoracic discs and to define indications for selection of surgical approaches. Symptomatic thoracic discs requiring surgery are rare. Between 1971 and 1995, 71 patients with 82 herniated thoracic discs were surgically treated by the authors. The treated group included 34 men and 37 women whose ages ranged from 19 to 75 years, with a mean age of 48 years. The most common sites of disc herniation requiring surgery were from T-8 to T-11. Evidence of antecedent trauma was present in 37% of the patients. Preoperative symptoms included pain (localized, axial, or radicular) in 54 (76%) of the 71 patients, evidence of myelopathy, that is, motor impairment in 43 (61%), hyperreflexia and spasticity in 41 (58%), sensory impairment in 43 (61%), and bladder dysfunction in 17 (24%).
Radiological diagnosis for the patients in this series was accomplished by means of myelography, computerized tomography myelography, or magnetic resonance imaging. Classification of the disc location into two groups reveals that 94% were centrolateral and 6% were lateral. Evidence of calcification was present in 65% of patients, and in 7% intradural extension was noted at surgery. Ten patients (14%) were found to have multiple herniations. Four surgical approaches were used for the removal of these 82 disc herniations: transthoracic in 49 (60%), transfacet pedicle-sparing in 23 (28%), lateral extracavitary in eight (10%), and transpedicular in two (2%). Postoperative evaluation revealed improvement or resolution of pain in 47 (87%) of 54, hyperreflexia and spasticity in 39 (95%) of 41, sensory changes in 36 (84%) of 43, bowel/bladder dysfunction in 13 (76%) of 17, and motor impairment in 25 (58%) of 43. Complications occurred in a total of 12 (14.6%) of 82 discs treated surgically. Major complications were seen in three patients and included perioperative death from cardiopulmonary compromise, instability requiring further surgery, and an increase in the severity of a preoperative paraparesis.
Review of this series, with the attendant complications, together with evaluation of several contemporary thoracic disc series, has facilitated the authors' decision-making process when considering the comprehensive management of these patients, including the selection of a surgical approach.
作者旨在制定治疗胸椎间盘突出症的管理策略，并明确选择手术入路的指征。需要手术治疗的有症状胸椎间盘突出症较为罕见。1971年至1995年间，作者对71例患有82个胸椎间盘突出症的患者进行了手术治疗。治疗组包括34名男性和37名女性，年龄在19岁至75岁之间，平均年龄为48岁。需要手术的椎间盘突出最常见部位为胸8至胸11。37%的患者有既往创伤证据。术前症状包括71例患者中的54例（76%）有疼痛（局部、轴向或神经根性），43例（61%）有脊髓病证据即运动障碍，41例（58%）有反射亢进和痉挛，43例（61%）有感觉障碍，17例（24%）有膀胱功能障碍。
本系列患者的放射学诊断通过脊髓造影、计算机断层扫描脊髓造影或磁共振成像完成。将椎间盘位置分为两组显示，94%为中央旁侧型，6%为外侧型。65%的患者有钙化证据，7%在手术中发现硬膜内扩展。10例患者（14%）发现有多个椎间盘突出。采用四种手术入路切除这82个椎间盘突出：经胸入路49例（60%），保留小关节突椎弓根入路23例（28%），外侧腔外入路8例（10%），经椎弓根入路2例（2%）。术后评估显示，54例中的47例（87%）疼痛改善或缓解，41例中的39例（95%）反射亢进和痉挛改善，43例中的36例（84%）感觉改变，17例中的13例（76%）肠道/膀胱功能障碍改善，43例中的25例（58%）运动障碍改善。在手术治疗的82个椎间盘中，共有12个（14.6%）发生并发症。3例患者出现严重并发症，包括围手术期因心肺功能不全死亡、需要进一步手术的不稳定以及术前轻瘫严重程度增加。
回顾本系列病例及其伴随的并发症，以及对几个当代胸椎间盘病例系列的评估，有助于作者在考虑这些患者的综合管理（包括选择手术入路）时的决策过程。
