T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach

Erwin M J Cornips*, Bart Maesen, Gijs Geskes, Jos G Maessen, Emile A M Beuls, Tomas Menovsky

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


OBJECTIVE: To describe a cohort of T3-T4 thoracic disc herniations (TDHs), their clinical and radiologic characteristics, and unique thoracoscopic transaxillary approach (TAA).

METHODS: All patients operated on for a T3-T4 TDH with minimal follow-up of 1 year were selected.

RESULTS: Eight TAA procedures (6 males and 2 females) were included (1.4%). Six patients reported axial pain, irradiating in 2, 4 sensory changes, 1 objective and 1 merely subjective motor weakness. Only 1 TDH was calcified, none was giant, 2 were accompanied by myelomalacia, and 2 by a small segmental syrinx. A cardiothoracic surgeon helped with exposure through a curved axillary incision using anterior cervical and more recently double-ring wound retractors. All patients were operated on using a 10-mm 30° rigid (three-dimensional) high-definition scope. There were no major complications and a good outcome with symptomatic relief in 7 of 8 patients.

CONCLUSIONS: T3-T4 TDHs are infrequent but may be underdiagnosed because they tend to be small and their signs and symptoms may mimic a cervical problem involving the shoulders and even the arms. There may be a male predominance. The TAA is straightforward, safe, efficacious, and well tolerated despite the supposed vulnerability of the upper thoracic spinal cord. Dissection between large crowded subpleural veins characteristic for the upper thoracic spine and ensuring adequate dura decompression when the steep angle may partially obscure the tip of the instruments does require some extra time. Thorough knowledge of the unique anatomy of the upper thorax is mandatory and the assistance of a cardiothoracic surgeon is highly recommended.

Original languageEnglish
Pages (from-to)e984-e995
Number of pages12
JournalWorld Neurosurgery
Early online date4 Dec 2021
Publication statusPublished - Feb 2022


  • Clinical characteristics
  • Radiologic characteristics
  • Thoracic disc herniation
  • Thoracoscopic microdiscectomy
  • Transaxillary approach
  • PAIN


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