title: Surgical management and clinical outcomes of multiple-level symptomatic herniated thoracic discs.
abstract: OBJECTIVE
  Symptomatic herniated thoracic discs (HTDs) are rare, and patients infrequently require treatment of 2 or more disc levels. The authors assess the surgical management and outcomes of patients with multiple-level symptomatic HTDs.
  
  
  METHODS
  A retrospective review of a prospectively maintained database was performed of 220 consecutive patients treated surgically for symptomatic HTDs. Clinical and surgical results were compared between patients with single-level disease and patients with multiple-level disease and also among the different approaches used for surgical decompression.
  
  
  RESULTS
  Between 1992 and 2012, 56 patients (mean age 48 years; 26 male, 30 female) underwent 62 procedures for 130 HTDs. Forty-six patients (82%) had myelopathy, and 36 (64%) had thoracic radiculopathy; 24 patients had both conditions in varying degree. Symptom duration averaged 28 months. The surgical approach was dictated by disc size, consistency, and location. Twenty-three thoracotomy, 26 thoracoscopy, and 13 posterolateral procedures were performed. Five patients required a combination of approaches. Patients underwent 2-level (n = 44), 3-level (n = 7), 4-level (n = 4), or 5-level (n = 1) discectomies. Instrumented fusion was performed in 36 patients (64%). Thirteen patients harbored 19 additional discs, which were deemed asymptomatic/nonoperative. The mean hospital stay was 6.5 days. Complete disc resection was verified with postoperative imaging in every patient. The procedural complication rate was 23%, and the nature of complications differed based on approach. No patients had surgery-related spinal cord injury or new myelopathy. At a mean follow-up of 48 months, myelopathy and radiculopathy had resolved or improved at a rate of 85% and 92%, respectively. Using a general linear model, preoperative symptom duration (p = 0.037) and perioperative hospital length of stay (p = 0.004) emerged as negative predictors of myelopathy improvement. Most patients (96%) were satisfied with the surgical results. Compared with 164 patients who underwent single-level HTD decompression, patients requiring surgery for multiple-level HTDs were more often myelopathic (p = 0.012). Surgery for multiple-level HTDs was more likely to require a thoracotomy approach (p = 0.00055) and instrumented fusion (p < 0.0001) and resulted in greater blood loss (p = 0.0036) and higher complication rates (p = 0.0069). The rates of resolution for myelopathy (p = 0.24) and radiculopathy (p = 1.0), however, were similar between the 2 patient groups.
  
  
  CONCLUSIONS
  The management of multiple-level symptomatic HTDs is complex, requiring individualized clinical decision making. The surgical approaches must be selected to minimize manipulation of the compressed thoracic spinal cord, and a patient may require a combination of approaches. Excellent surgical results can be achieved in this unique and challenging patient population.
authors.affiliation: Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.
authors.forename: Mark E
authors.initials: ME
authors.lastname: Oppenlander
authors.forename: Justin C
authors.initials: JC
authors.lastname: Clark
authors.forename: James
authors.initials: J
authors.lastname: Kalyvas
authors.forename: Curtis A
authors.initials: CA
authors.lastname: Dickman
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D007405:Intervertebral Disc Displacement / Q000145:classification / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000009:adverse effects / Q000379:methods* / Q000592:standards; D011446:Prospective Studies; D012189:Retrospective Studies; D013904:Thoracic Vertebrae / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome