AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Thoracic disc injury, first described in 1838, is an uncommon site of injury owing to the stabilizing effect of the rib cage.¹ The similarity of symptoms to lumbar disc herniation makes the diagnosis of a thoracic disc injury difficult,^{2, 3, 4, 5, 6} but the process tends to be self-limiting and rarely requires surgical intervention.⁴

(See also the eMedicine articles Disk Herniation and Thoracic Spine, Trauma [in the Radiology section], Thoracic Discogenic Pain Syndrome [in the Sports Medicine section], Lumbar Disc Disease [in the Neurosurgery section], and Herniated Nucleus Pulposus [in the Orthopedic Surgery section], as well as Return to Contact Sports After Spinal Surgery and Thoracoscopic Spine Surgery for Decompression and Stabilization of the Anterolateral Thoracic and Lumbar Spine on Medscape.)

For excellent patient education resources, visit eMedicine's Bone Health Center, Back, Ribs, Neck, and Head Center, Back, Neck, and Head Injury Center, and Muscle Disorders Center. Also, see eMedicine's patient education articles Back Pain and Chronic Pain.

Frequency

United States

The incidence of thoracic disc injuries is 1 in 1 million persons per year, and these injuries account for 0.25-0.75% of all disc herniations.⁷

Functional Anatomy

The thoracic discs are unusually stable compared with the cervical and lumbar discs. The stability of the thoracic discs is secondary to the surrounding rib cage, with the stabilizing effect of the rib articulations. However, the blood supply of the thoracic spine is more tenuous than the cervical and lumbar spine, especially at the T4-T9 watershed area, which is more prone to ischemic injury.

Sport-Specific Biomechanics

The facet orientation in the thoracic spine is vertical, with a slight medial angulation. This orientation allows for easier lateral bending and rotation versus pure bending. Biomechanical studies have shown that intervertebral discs are at the highest risk of injury when combined with bending and torsional forces. Therefore, the thoracic spine discs are at a decreased risk of injury because of the decreased bending potential in this segment of the spine.

The spinal cord-to-canal ratio (the ratio of the cross-sectional area of the cord to the cross-sectional area of the spinal canal) is 40% in the thoracic spine versus 25% in the cervical spine. The thoracic spine is also naturally kyphotic. These 2 facts make the thoracic spine more sensitive to cord compression from disc herniation.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Determine the location and type of the patient's pain. Is the pain mainly located in the thoracolumbar spine, and is it radicular or mechanical in nature?

• Thoracic disc disease may emulate the symptoms of lumbar disc disease.
• • Shooting pain down the legs implies nerve root irritation versus cord compression.
  • Pain in the thoracic area signifies mechanical pain that is possibly secondary to fractures, degenerative disc disease, tumors, or infections. (See also the eMedicine articles Degenerative Disk Disease and Thoracic Spine Fractures and Dislocations [in the Orthopedic Surgery section].)
  • Night pain that wakes the patient is suggestive of infection or an oncologic process.
• Cord compression is present with myelopathy, which requires immediate attention.² (See also the eMedicine articles Spinal Stenosis [in the Orthopedic Surgery section] and Spinal Cord, Topographical and Functional Anatomy [in the Neurology section].) Myelopathy is seen with the following:
• • The presence of clonus or a positive Babinski reflex
  • Bowel and bladder dysfunction (seen in up to 20% of symptomatic discs)
• High thoracic (T2-T5) herniation mimics cervical disc disease. (See also the eMedicine article Cervical Disc Disease.)
• • Patients can present with upper extremity involvement, including Horner syndrome. (See also the eMedicine articles Horner Syndrome [in the Ophthalmology section] and Horner Syndrome [in the Oncology section].)
  • If myelopathy is present, a negative result from the Hoffmann test makes cervical spine involvement unlikely. A positive result from the Hoffmann test is seen when the middle-finger metacarpophalangeal joint and the proximal interphalangeal joints are kept extended; a flexion reflex of the thumb is seen when the distal interphalangeal joint is flicked or suddenly extended. This is known as the Hoffmann sign.
• Radicular symptoms include pain/paresthesias or dysesthesias in a dermatomal distribution. Dermatome T10 is usually involved.

Physical

The physical examination for thoracic disc injuries includes the following: palpation over the thoracic spine; range-of-motion (ROM) examination of the hips, knees, and ankles; straight leg-raise test; motor and sensory examination; and reflex examination.

• Palpation
• • Palpate the entire region of the thoracic spine.
  • Muscle spasms can be identified by palpation.
• ROM examination
• • Assess the patient's ROM throughout the hips, knees, and ankles.
  • A ROM examination, especially of the hip, can confirm the presence of radiculopathy versus referred pain from hip/knee pathology (eg, arthritis). (See also the Arthritis Resource Center on Medscape.)
  • ROM in the thoracic spine can be affected by the type of pathology. Arthritic changes that cause mechanical pain usually limit extension; radiculopathy that is seen with disc herniation generally causes increasing pain with flexion.
  • Bilateral straight leg-raise tests should be completed, and the patient's available ROM and symptoms should be noted and documented.
• Motor examination of all the lumbar roots, including L2-L4 (knee extension), L4 (inversion), L5 (dorsiflexion), and S1 (eversion and plantar flexion) is helpful for evaluating nerve root involvement in the lumbar spine and cord compression in the thoracic spine.
• Sensory examination
• • Sensory examination of the dermatomes, especially in the thoracoabdominal region, can help the clinician identify the level of involvement.
  • The nipple is innervated by T4; the xiphoid, T7; the umbilicus, T10; and the inguinal region, T12.
• Reflex testing
• • The knee (L4) and ankle (S1) reflexes should be tested.
  • The abdominal reflexes and cremasteric reflex (check for symmetry and presence) can help the clinician identify myelopathy and cord compression.
• Vascular examination of the dorsalis pedis artery, posterior tibial artery, and femoral artery can rule out other causes of the patient's symptoms.

Causes

The progressive wear and tear that is noted with degenerative disc disease increases the risk of injury via trauma. Contributing factors to disc injury include the following:

• Age
• Trauma
• Smoking
• Obesity
• Sedentary lifestyle
• Poor physical fitness

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to Be Considered

Fractures, Rib

Herpes Zoster (in the Infectious Diseases section) (See also the eMedicine articles Postherpetic Neuralgia [in the Neurology section], Herpes Zoster [in the Emergency Medicine section], and Herpes Zoster [in the Dermatology section].)

Intrathoracic conditions - Cardiovascular, pulmonary, and mediastinal processes

Intra-abdominal causes - Hepatobiliary and gastrointestinal fibromyalgia

Osteoporosis (See also the eMedicine articles Osteoporosis (Primary), Osteoporosis (Secondary), and Osteoporosis and Spinal Cord Injury [in the Physical Medicine and Rehabilitation section], as well as Osteoporosis Resource Center and MORES May Help Identify Men at Risk for Osteoporosis on Medscape.)

Scoliosis (See also the eMedicine article Scoliosis, Idiopathic [in the Radiology section], as well as The Effect of Scoliosis Fusion on Spinal Motion: a Comparison of Fused and Nonfused Patients With Idiopathic Scoliosis, A Prospective Study of Brace Treatment Versus Observation Alone in Adolescent Idiopathic Scoliosis: a Follow-up Mean of 16 Years After Maturity, and Natural History of Progressive Adult Scoliosis on Medscape.)

Spinal causes - Infectious, neoplastic

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Laboratory testing is helpful in screening for the differential diagnosis.
• Serology
• • Obtain a complete blood cell (CBC) count to check for the patient's white blood cell count and hematocrit level to rule out other disorders such as infection or multiple myeloma.

    (See also the eMedicine articles Multiple Myeloma [in the Hematology section], Multiple Myeloma [in the Radiology section], and Myeloma [in the Orthopedic Surgery section], as well as Lenalidomide Can Significantly Extend Survival in Multiple Myeloma, Lenalidomide Plus Dexamethasone Effectivefor Newly  Diagnosed Multiple Myeloma, and Thalidomide Improves Survival for Older Patients With Multiple Myeloma on Medscape.)

  • Obtain serum protein electrophoresis results to evaluate for multiple myeloma.
  • Obtain a Westergren sedimentation rate measurement and C-reactive protein level to assess for osteomyelitis and/or infection.

    (See also the eMedicine articles Osteomyelitis, Acute Pyogenic and Osteomyelitis, Chronic [in the Radiology section] and Osteomyelitis [in the Emergency Medicine section], as well as Osteomyelitis Concurrently Caused by Staphylococcus aureus and Mycobacterium tuberculosis on Medscape.)

Imaging Studies

Imaging studies are essential for making a diagnosis of disc injury.^{4, 8, 9}

• Radiography
• • Should be the initial examination that is ordered
  • Unable to distinguish actual disc herniation
  • May identify disc calcification (seen with degenerative disease in older patients)
  • May help to identify infectious or oncologic causes for the patient's pain
• Magnetic resonance imaging (MRI)
• • Both T1- and T2-weighted imaging are needed.¹⁰
  • Sensitive for identification of disc herniation
  • T2-weighted images exaggerate findings.
  • Identifies calcification by low signal in T1- and T2-weighted images.
  • Can identify the bony inflammation that is seen with tumors/infection
• Computed (CT) myelogram¹¹
• • Has improved bony visualization compared with MRI
  • Not as sensitive for disc sequestration/migration
  • Invasive relative to MRI
• Discogram
• • Controversial
  • Used for provocative testing for the level of involvement before surgery

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Acute Phase

Rehabilitation Program

Physical Therapy

For the acute phase of a thoracic disc injury, the focus of physical therapy is to decrease the patient's symptoms with cold/heat therapy, ultrasound, and rest. Mild ROM exercises and very low-impact exercises that do not worsen the patient's symptoms are acceptable.

Medical Issues/Complications

Activity modification to minimize the patient's symptoms is important. Proper posture can help to prevent further disc injury. If oral drug usage fails to alleviate the patient's symptoms, consider steroid injection for intercostal nerve blocks. An orthosis (ie, brace) is initially acceptable for pain control but causes deconditioning over time. Thus, long-term bracing should be avoided.

Surgical Intervention

Surgical decompression is indicated in patients with myelopathy (unless improving), progressive neurologic symptoms, and worsening symptoms^{12, 13, 14} or lack of improvement in the patient's symptoms by 4-6 weeks of conservative management.¹⁰

Consultations

Myelopathy and progressive neurologic symptoms require emergent neurosurgical/orthopedic consultation.

Recovery Phase

Rehabilitation Program

Physical Therapy

When the patient's acute symptoms have resolved, general cardiovascular conditioning and abdominal muscle strengthening with ROM may be introduced.¹⁵

Maintenance Phase

Rehabilitation Program

Physical Therapy

Home exercises for abdominal and paraspinal muscle strengthening and cardiovascular conditioning is helpful in preventing recurrences.¹⁵

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medications are used to minimize pain and inflammation. In the early phase of a disc herniation, nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended. If NSAIDs are not effective, a tapering course of steroids, such as with methylprednisolone, can be used to try to minimize the inflammatory process. In cases of severe pain, narcotics can be used in the acute phases; if pain has become a chronic problem, narcotics then become the primary modality for pain control. Muscle relaxants can be utilized to potentiate the effectiveness of NSAIDs, narcotics, or steroids.

Drug Category: Nonsteroidal anti-inflammatory drugs

NSAIDs are used to decrease the inflammatory process that is involved in disc herniation and nerve root irritation; furthermore, NSAIDs can help to decrease the pain that is associated with disc herniation.

Drug Category: Corticosteroids

Corticosteroids are potent anti-inflammatory agents that are used to relieve inflammation of the nerve roots and surrounding tissue.

Drug Category: Muscle relaxants

Muscle relaxants reduce muscle spasms in the paraspinal muscles.

Drug Category: Narcotic analgesics

Narcotic analgesics are used for short-term pain control.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Return to Play

Thoracic disc disease is usually self-limiting; return to play depends on the success of conservative management in controlling the pain/radiculopathy that is associated with the disc herniation.

Complications

The most serious but rare complication of thoracic disc disease is myelopathy. Myelopathic features, including hyperreflexia, weakness, and bowel/bladder dysfunction, may not improve after surgical decompression. Worsening myelopathic findings are an absolute indication for surgical decompression.

Prevention

Exercises, including cardiovascular training and abdominal/lumbar muscle training, are the primary preventive measure for thoracic disc disease.

Prognosis

Thoracic disc disease is essentially self-limiting and rarely requires surgical intervention. Most cases resolve within the first 4-6 weeks following onset.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to consider an alternative diagnosis such as intrathoracic lesions
• Failure to inform patients of the potential dangers of the diagnosis, including myelopathy with bowel or bladder dysfunction

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Dec 21, 2007