AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

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

INTRODUCTION

Section 2 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Thoracic disk herniation (TDH) is an uncommon and underreported entity that is often challenging to diagnose because of a relative paucity of examination findings and because of its nonspecific presentation. The number of patients with objective neurologic findings due to TDH is low, and most patients can be treated with a conservative approach without surgical intervention.

Frequency

United States

Asymptomatic TDHs are relatively common in the general population. Autopsy studies have shown that the prevalence rate ranges from 7-15%. The prevalence of asymptomatic disk herniations found radiographically varies with the imaging modality used. Awwad et al showed that 11-13% of asymptomatic subjects were found to have TDH on CT myelograms, while Wood et al showed 37% were found to have TDH on MRIs.

Despite the relatively high frequency of asymptomatic disk herniations, symptomatic disk herniations occur in a range from 1 in 1000 to 1 in 1 million persons. The number of patients with objective neurologic findings due to TDH is thought to be closer to 1 in 1 million annually.

Although the frequency of thoracic diskectomies is increasing, they are still performed much less frequently than diskectomies in the cervical or lumbar regions. They represent approximately 0.13-0.15% of admissions for disk disease and from 0.2-4% of all diskectomies.

Functional Anatomy

The thoracic region of the spine is relatively inflexible and functions primarily to provide erect posture and assist in weightbearing of the trunk, head, and upper extremities during daily activities. The vertebral bodies are taller posteriorly than anteriorly, resulting in an anterior concavity and normal thoracic kyphosis.

In the thoracic spine, the addition of the sternum, the ribs, and their associated ligamentous structures provide additional support and rigidity. The 10 most superior ribs articulate anteriorly with the sternum and posteriorly with the transverse processes and vertebral bodies. These ribs are oriented vertically, with slight medial angulation in the coronal plane. This arrangement provides the thoracic spine with relatively good stability in the midsagittal plane. However, it affords less stability in the lateral and rotational planes. Biomechanical studies have shown that thoracic intervertebral disks are most susceptible to injury when torsional and lateral forces are applied in tandem.

Several features of the thoracic spine increase its susceptibility to spinal cord compression associated with TDH, as follows:

• The ratio of the spinal canal to the thoracic spinal cord is smaller than that found in the cervical and lumbar regions. Although the cross-sectional diameter of the thoracic cord is smaller than that of its cervical or lumbar counterparts, the diameter of the spinal canal is proportionally even smaller. Thus, the ratio of the spinal cord to the canal in the thoracic spine is 40%, whereas this ratio in the cervical spine is only 25%.

• The dentate ligaments situated between the spinal cord and the nerve roots restrict posterior movement of the spinal cord within the canal. This makes the thoracic spine prone to vertical compression from anterior disk and bony prominences.

• The natural kyphosis of the thoracic spine places the spinal cord in close proximity to the posterior longitudinal ligament and the posterior aspects of both the vertebral bodies and the disks in the thoracic region. This makes the thoracic cord especially susceptible to ventral compression from herniations.

• Central protrusions may cause spinal cord compression, and patients may present with myelopathic symptoms, such as increased muscle tone, hyperreflexia, abnormal gait, and urinary/bowel incontinence. 



• Centrolateral protrusions may result in a presentation resembling Brown-Séquard syndrome, with ipsilateral weakness and contralateral pain or sensory disturbances.



• Lateral herniations may cause nerve root compression, and patients may present with a radiculopathy.

Sport Specific Biomechanics

In patients with symptomatic TDHs for which trauma is implicated as the cause, a twisting or torsional movement is often involved. Participation in any sport that involves axial rotation of the spine can potentially increase the risk of disk herniation. These types of forces may be observed in sports such as golf, in which axial rotation of the spine is required at the top of the backswing, with subsequent uncoiling and hyperextension observed through the downswing and follow-through.

Minimizing forces on the spine through proper mechanics in specific sporting activities is important. Additionally, the dynamic stabilizers of the spine should also be strengthened to counteract the significant forces exerted on the spine during certain athletic activities.

CLINICAL

Section 3 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

The diagnosis of TDP syndrome can be challenging. The relative rarity of the condition makes it a diagnosis that is not often considered. Further, the presentation is variable and may resemble that of cervical or lumbar diskogenic pain, which is much more common.  When considering the diagnosis of TDP syndrome, pertinent aspects of the patient history include the duration of symptoms, the extent of pain and weakness, and the presence of bowel or bladder symptoms.  
 
Duration of symptoms
 
TDP syndrome most commonly manifests insidiously, with no history of a significant trauma.   The initial symptom is usually pain, which then progresses to either radiculopathy or myelopathy to varying degrees.  Nannapaneni and Marks describe a subset of patients that is young and often presents with a more definite history of trauma.  These patients tend to have centrolateral disk herniations that either precipitate initial symptoms or intensify existing ones.  These patients also tend to present with contralateral pain and sensory disturbances with ipsilateral weakness resembling Brown-Séquard syndrome. 
 
Pain
 
Pain is the most common symptom in TDP syndrome and is the presenting symptom in approximately 60% of patients. The quality and location of the pain depend on the location of the disk pathology and whether neural elements have been compromised. Purely diskogenic pain may be dull and localized to the thoracic spine. Although less common, upper TDHs may manifest as cervical pain and lower TDHs may manifest as lumbar back pain. Pain may also be referred to the retrogastric, retrosternal, or inguinal areas, resulting in misdiagnoses such as cholecystitis, myocardial infarction, hernia, or nephrolithiasis.
 
According to Schellhas et al, annular tears may also have referral patterns based on the anatomical location of the tear. Anterior tears may refer pain to anterior extraspinal sites, such as the ribs, chest wall, sternum, or visceral structures.  Lateral tears can produce radicular pain to either visceral or musculoskeletal sites. Posterior tears typically produce back pain, in either a local or diffuse pattern.
 
When a herniated disk compromises thoracic nerve roots, the patient may present with the symptoms listed above as well radicular pain.  This pain may be intermittent or constant and is usually described as electric, burning, or shooting in nature. The distribution is often bandlike, spanning the anterior chest wall.  The T10 dermatomal region is most often described as the focus of pain, irrespective of the level involved. When cord compression and myelopathy are present, pain can be in any dermatome distal to the site of compression.
 
Sensory disturbances 
 
Sensory disturbances may be the presenting symptom in approximately 25% of patients with TDP syndrome. Numbness is the most commonly reported sensory disturbance, but dysesthesias and paresthesias in a dermatomal distribution may also be reported. The absence of these findings does not exclude TDP syndrome, but, when present, they are highly suggestive of the diagnosis. A more concerning presentation of sensory disturbances is a wider distribution below the suspected TDH. This is consistent with myelopathy due to cord compression.  
 
Weakness
 
Weakness may be the presenting symptom in 17% of patients.  The motor nerves of the thoracic spinal segments supply the abdominal and intercostal muscles.  Although weakness of these muscles may occur, it is unlikely to be an early presenting symptom.  Patients are more likely to present with weakness in the lower extremities when compression and myelopathy are present.  
 
Bladder symptoms
 
Bladder symptoms (eg, incontinence) are the presenting symptom in only 2% of patients.  However, bladder symptoms are not uncommon when cord compression and myelopathy have occurred. These patients also may have bowel incontinence.

Physical

Musculoskeletal
 
The musculoskeletal assessment should include a thorough examination of the cervical, thoracic, and lumbar spine and an evaluation of the abdominal and hip musculature. The findings are nonspecific in the diagnosis of TDP syndrome, but they may reveal concomitant myofascial pain or patterns of weakness and/or inflexibility that can predispose the patient to TDP syndrome. These findings are crucial in tailoring conservative treatment to the specific needs of the patient. 
 
Sensory
 
A patient with a thoracic radiculopathy from a herniated thoracic disk may have altered sensation to light touch or pinprick along a dermatomal pattern. However, if a sensory level is established, such that sensation is consistently altered below a specific dermatome, cord compression and myelopathy should be strongly considered. The thoracic dermatomes generally follow a bandlike distribution across the back and chest. Some common landmarks to aid in examination are the nipples for T4, the xiphoid process for T7, and the umbilicus for T10. 
 
Motor
 
Motor examination should include testing of muscle strength and an evaluation of muscle tone.  Strength testing of the abdominal muscles is often not part of a routine examination, but it should be performed in the evaluation of TDP syndrome. Lesions at T9 and T10 can paralyze the lower abdominal muscles but spare the upper abdominal muscles, producing the Beevor sign, which is an upward movement of the umbilicus when the abdominal wall contracts. Having the patient sit upright and observing for any asymmetric contractions of the rectus abdominus also may be helpful. A pattern of lower extremity weakness associated with spasticity or hyperactive reflexes is a serious finding in patients with TDP syndrome; it is indicative of myelopathy. Care must be taken to exclude other more common causes of these findings, such as cervical and lumbar myelopathy.
 
Reflexes
 
A careful examination of the reflexes is critical when determining the degree of upper and lower motor neuron involvement. Hyperactive reflexes signify an upper motor neuron lesion above the level at which the spine is being tested, while diminished reflexes indicate a lower motor neuron lesion in the dermatomes being evaluated. 
 
Testing of the abdominal reflex can be performed by stimulating the skin overlying the abdominals. The expected response is contraction of the underlying muscles. Testing of the cremasteric reflex can be performed by stroking the skin on the medial side of the thigh next to the scrotum. The normal response is the scrotum on the side being tested is pulled superiorly. 
 
Upper extremity reflexes should be normal unless the patient has concomitant cervical pathology. Patellar and Achilles reflexes are normal in patients with purely diskogenic pain or a thoracic radiculopathy. Hyperactive patellar reflexes, Achilles reflexes, or clonus may be seen in persons with cord compression and myelopathy. If decreased patellar or Achilles reflexes are found, lumbosacral pathology should be considered.
 
Provocative maneuvers
 
Physical examination maneuvers that induce nerve root tension and provoke radicular pain should be performed to help rule out cervical and lumbosacral pathology and to evaluate for TDP syndrome. The Spurling maneuver, consisting of cervical compression, extension, and ipsilateral rotation, may reproduce symptoms due to cervical radiculopathy. A straight-leg raise test or slump test may reproduce symptoms from a lumbosacral radiculopathy. Neck flexion can provoke symptoms due to thoracic disk protrusions below the midthoracic level.
 
Gait
 
A number of gait deviations may be observed in patients with TDP syndrome. These may be due to a pain avoidance strategy or to weakness if myelopathy is present. A common gait deviation in patients with herniated disks is the “sciatic list.”  Patients often lean away form the herniated disk in order to relieve pressure on the disk and reduce symptoms.

Causes

Up to 90% of herniated disks in the thoracic spine are due to a degenerative process. As a normal part of aging, the water content of disks decreases, leading to decreased disk height and impaired capability to absorb the axial loads of the spine. Disk herniations, annular tears, and endplate degeneration all can occur.
 
Trauma can be an important factor in 10-20% of patients. In patients with symptomatic TDHs for which trauma is implicated as the cause, a twisting or torsional movement is often involved. Participation in any sport that involves axial rotation of the spine can potentially increase the risk of disk herniation. These types of forces may be observed in sports such as golf, in which axial rotation of the spine is required at the top of the backswing, with subsequent uncoiling and hyperextension observed through the downswing and follow-through.
 

DIFFERENTIALS

Section 4 of 10  

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• Differentials
• Workup
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• References

Other Problems to be Considered

Amyotrophic lateral sclerosis
Multiple sclerosis
Transverse myelitis
Intramedullary and extramedullary spinal cord tumors, demyelinating disease
Herpes zoster
Intercostal neuralgia
Parasagittal brain tumors
Cerebral ischemia and infarct and arteriovenous malformations
Cholecystitis
Aneurysms
Retroperitoneal neoplasms
Plexopathy
Peripheral neuropathy
Root avulsion
Psychiatric disorders

WORKUP

Section 5 of 10  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Imaging Studies

Plain radiography
 
The primary role of radiographs in the evaluation of back pain is to evaluate for fracture, tumors, or infection. However, radiographs can also provide some useful information when evaluating for TDHs. Osteophyte formation, disk-space narrowing, and kyphosis are signs of disk degeneration and often occur in conjunction with disk herniation. However, these findings have a low specificity for the diagnosis of TDH. Although not diagnostic, disk calcification is a more reliable finding when evaluating for TDH on radiographs. It is present in up to 70% of patients with TDH and is seen in only 4-6% of patients without TDH.
 
CT myelography
 
With the advent of MRI, CT myelography is used less frequently in the evaluation of TDP syndrome. MRI has diagnostic advantages and does not involve injection of contrast into the epidural space. However, CT myelography is good for diagnosing lateral herniations and calcification and is often used in preoperative planning.  
 
Magnetic resonance imaging
 
MRI is the most commonly used diagnostic test in the evaluation of TDH. It is the screening test of choice and is extremely sensitive for detecting disk abnormalities. Advantages of MRI compared with CT scanning or CT with myelography include better visualization of the soft tissue structures, earlier recognition of disk degeneration, and the ability to evaluate in the sagittal plane. 
 
MRI can be used to determine the size and location of the disk herniation and to characterize it as a protrusion, extrusion, or sequestration. Although helpful in preoperative planning, these features may not be helpful in determining a prognosis. Brown et al retrospectively reviewed the MRI results of 55 patients with symptomatic TDHs. Fifteen patients ultimately needed surgery and 40 patients did well with conservative management. MRI could not help distinguish the disks in the surgically treated group from the disks in the conservatively treated group. A more useful way of determining the severity of TDH with MRI may be quantifying the amount of neural compression. One such grading system suggested by Kaplan is as follows: 

• Mild: The anterior epidural fat is not obliterated.



• Moderate: The epidural fat is obliterated, and the thecal sac is displaced.



• Severe: The cord is effaced or the nerve root(s) is displaced.

Despite the usefulness of MRI, it does have limitations. As technology has improved, TDHs are more easily recognized. However, all of these TDHs may not be clinically significant.  Wood et al evaluated 90 individuals without thoracic pain to determine the frequency of abnormalities.  Intervertebral degenerative changes, annular abnormalities, or both were found in 73% of the subjects; herniation was seen in 37% of the subjects. MRI is also less sensitive for the evaluation of annular tears, particularly in the thoracic region. The high-intensity zone that commonly represents radial tears in cervical and lumbar MRIs is not seen as often in the thoracic region. These limitations underscore the importance of the history and physical examination. MRI plays an important role in the evaluation of TDP, but the results must be interpreted in light of the clinical findings and with knowledge of its limitations.

Other Tests

Electrodiagnosis
 
Electrodiagnostic studies, including nerve conduction study (NCS), needle electromyography (EMG), and somatosensory evoked potentials (SSEPs), can be useful adjuncts to the history and physical examination. NCS and EMG can be used in the evaluation of thoracic radiculopathy; however, their utility is limited by the limited number of tests, the lack of their ability to localize the level of involvement, and the risk of pneumothorax or penetration of the abdominal cavity with some techniques. However, NCS and EMG can be extremely useful in excluding other possible diagnoses, such as cervical radiculopathy, lumbosacral radiculopathy, and peripheral neuropathy.  SSEPs should be considered in cases in which it is unclear if clinical symptoms are due to an upper motor neuron or lower motor neuron process. SSEPs can help make this distinction and can assist in directing subsequent treatment accordingly.  
 
Diskography
 
Thoracic diskography may be considered in patients who are considering surgical intervention for predominantly axial back pain that is thought to be diskogenic in nature. Diskograms are most useful when they demonstrate single-level concordant pain associated with endplate irregularities or annular tears and normal disks at adjacent levels. However, the results of thoracic diskography should be interpreted with caution.  
 
Wood et al showed that 55% of diskograms performed in patients with symptomatic thoracic pain revealed concordant pain. Whether this large number of positive results represents multilevel disease or a high false-positive rate in the population is unclear.  Further, 2 of 10 asymptomatic patients demonstrated pain that could be interpreted as a positive result.  Wood et al concluded that long-term prospective studies of surgical outcomes and their correlation with diskography results are warranted.

Procedures

Epidural corticosteroid injections
 
For patients with a thoracic radiculopathy as a result of a TDH who have not responded to conservative therapy, thoracic epidural steroid injections are a reasonable treatment option. The efficacy of epidural corticosteroid injections has been documented in cervical and lumbar radiculopathies. However, because of the small number of documented cases of TDP syndrome, no study has been performed to evaluate efficacy for this specific condition.

TREATMENT

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Acute Phase

Rehabilitation Program

Physical Therapy

During the acute phase of a rehabilitation program for TDH, the focus of treatment is reducing pain symptoms. Instruction in posture and body mechanics in activities of daily living is aimed at protecting injured structures, reducing symptoms, and preventing further injury. Educate patients to avoid positions that increase intradiskal pressure, such as sitting, bending, and lifting.

A short course of bed rest of 2 days or shorter may provide some beneficial effects secondary to pain modulation and reduction of intradiskal pressure. However, longer courses of bed rest may have detrimental effects on bones, connective tissue, muscle, and cardiovascular fitness. Emphasis on activity modification, rather than strict bed rest, is recommended to avoid the unwanted effects of immobilization.

Modalities such as electrical stimulation should be limited to the initial stages of treatment so that patients can progress quickly to more active treatment that addresses restoration of motion and strengthening.

Surgical Intervention

Surgery for removal of a herniated thoracic disk is often a technically difficult procedure.  The limited space available for spinal cord manipulation and the relatively tenuous blood supply increase the susceptibility of the spinal cord to injury during decompression. However, in the hands of a competent surgeon, carefully selected patients have had good outcomes.
 
No strict evidence-based indications have been developed for surgical thoracic diskectomy; however, general guidelines have been determined. The general agreement is that surgery is indicated when myelopathic signs are present. These patients may benefit from early surgery because the rate of recovery diminishes when more advanced neurologic deficits are present.  Surgical indications in cases of radiculopathy are less clear because many patients respond to conservative management. However, surgery is a viable option for patients with radicular symptoms who have not responded to conservative care. Patients with purely diskogenic or axial pain are not generally treated surgically.   
 
Many approaches can be used to remove herniated thoracic disks. The earliest surgical approach, used in the early 1900s, was a posterior laminectomy. That technique was used for many years until numerous studies demonstrated it produces poor results and has an unacceptable complication rate. In current practice, many other surgical options are available for TDHs, all of which are modifications of 3 basic approaches.
 
The 3 approaches are the anterolateral, the lateral, and the posterolateral. The anterolateral approaches include transthoracic, trans-sternal, and thoracoscopic. The lateral approaches include costotransversectomy, lateral extracavitary, and parascapular. The posterolateral approaches are transpedicular or transfacet pedicle-sparing procedure.
 
The decision regarding the most appropriate surgical approach is individualized and based on the consistency of the compressive disk, the level of herniation, its relationship to the spinal cord, and the likelihood of dural involvement. The surgeon’s familiarity with the particular approach must also be taken into consideration.

Consultations

The presence of significant myelopathic signs or progressive neurologic deficit is an absolute indication for immediate consultation with and intervention by a neurosurgeon. 

Other Treatment

Thoracic epidural steroid injections should be reserved for patients with an unacceptable level of pain that has not responded to other conservative treatments. No rationale exists for performing a series of injections.

Recovery Phase

Rehabilitation Program

Physical Therapy

Physical therapy should emphasize extension-based strengthening exercises, postural training, and education in proper posture and body mechanics. Pain during this phase should be judiciously managed with nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, or other oral agents to allow the patient to adequately participate in therapy.

With the progression of therapy and control of painful symptoms, a spine stabilization program should follow. With spine stabilization exercises, the goal is to teach the patient how to find and maintain a neutral spine during everyday activities. The neutral spine position is specific to the individual and is determined by the pelvic and spine posture that places the least stress on the elements of the spine and supporting structures. In classic diskogenic pain, the neutral spine has an extension bias.

In classic posterior element pain and spinal stenosis, both of which may result from the ongoing degenerative cascade initiated by disk degeneration, the neutral spine may have a mild flexion bias. Dynamic spinal stabilization may be used with the McKenzie approach to provide dynamic muscular control and to protect the spine from biomechanical stresses, including tension, compression, torsion, and shear. Spinal stabilization emphasizes the synergistic activation of the trunk and spinal musculature in the midrange position.

Strengthening of the abdominal and gluteal muscle groups is emphasized because these muscles attach to the thoracolumbar fascial support system, one of the potential spine stabilizing structures. The overall goals of this comprehensive exercise program are to reduce pain, to develop the muscular support of the trunk and spine, and, ultimately, to diminish the overall stress to the intervertebral disk and other static stabilizers of the spine.

Surgical Intervention

See Surgical Intervention under Acute Phase.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The maintenance phase represents the final phase of the rehabilitation process. Eccentric muscle strengthening exercises, including more dynamic conditioning exercises, are added to the program. In addition, sport-specific training should be incorporated so that the athlete can maintain a neutral spine in all recreational activities.

The goals of a comprehensive spine rehabilitation program are met when the individual no longer demonstrates the original symptoms and when (1) full range of motion of the spine, (2) normal strength and flexibility, and (3) normal sport-specific mechanics are demonstrated.

MEDICATION

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Various medications can be used in the treatment of symptomatic TDHs, including acetaminophen, NSAIDs, muscle relaxants, opioid analgesics, oral corticosteroids, and antidepressants. Before prescribing these medications, the physician should be aware of the contraindications, common adverse effects, and mode of action of each agent.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Acetaminophen is used for its anti-inflammatory effects. The dose needed to produce anti-inflammatory effects substantially differs from that for analgesic effects. Most NSAIDs achieve only analgesic effects because the dosage prescribed is too small and too infrequent to produce an anti-inflammatory effect. The risks associated with NSAIDs are particularly pertinent in elderly persons and patients with a history of peptic ulcer diseases, hypertension, or renal insufficiency. Newer-generation NSAIDs selectively interact with the cyclooxygenase-2 receptors and have a lower gastrointestinal risk. Prolonged use of these medications generally is not recommended for most low-back problems.

Drug Category: Analgesics

Use of opioids should be limited to pain that is unresponsive to alternative medication. Opioids can be prescribed for acute disk herniation to facilitate participation in an active rehabilitation program. They should be used on a defined dosing schedule and not on an as-needed basis. An adequate baseline dose should be established to achieve analgesia. Use of nonopioid analgesics, such as tramadol, is also an option.

Drug Category: Muscle relaxants

Medications categorized as muscle relaxants may be helpful in some patients with low back pain; these agents seem to have additional beneficial effects when used in conjunction with NSAIDs. Muscle relaxants can be used as short-term adjunctive medications, and they should be taken at bedtime to take advantage of their sedating effects.

Drug Category: Corticosteroids

Potent anti-inflammatory medications. They represent a theoretically useful agent in the treatment of patients with radiculopathy due to local inflammation resulting from disk injury or herniation.

FOLLOW-UP

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Return to Play

Return-to-play criteria require the athlete to be free of signs or symptoms due to the original injury, to have full range of motion, to have normal strength and flexibility, and to have healthy sport-specific mechanics. Athletes must be aware of their own limitations, a concept that is particularly important for individuals gradually returning to a competitive level of activity after an injury.

Prevention

Trauma and strain due to sport-related injuries or other causes is implicated in only 20% of patients with TDHs. In many of these cases, a twisting or torsional movement is involved. Minimizing forces on the spine through the use of proper mechanics in specific sporting activities is important. Additionally, strengthening the dynamic stabilizers of the spine to counteract the significant forces exerted on the spine during certain athletic activities is also important.

Maintaining proper flexibility plays a significant role in the prevention of injury in athletes of all ages. Additionally, an improvement in aerobic fitness can increase blood flow and oxygenation to all tissues, including the muscles, bones, and ligaments of the spine. Aerobic conditioning is a reasonable addition to any rehabilitation and prevention program.

Prognosis

The progression of symptoms in patients with TDH varies considerably. When seen in younger patients, traumatic disk herniations may later cause myelopathy. In middle-aged persons, in whom degenerative disk herniation is more common, the course of symptoms involving spinal cord compression is often more protracted.

In patients who present with unilateral symptoms, the progression of symptoms is often slower than that of patients who have a bilateral presentation. In any case, a patient without evidence of myelopathy should receive conservative treatment. A return to previous activity level occurs in approximately 80% of patients treated with nonsurgical measures. Patients with intractable pain, progressive neurologic deficits, or bilateral involvement often require surgical intervention.

Education

See Prevention.

MULTIMEDIA

Section 9 of 10  

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• Differentials
• Workup
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• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Axial MRI of a thoracic herniated disk.
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Media type:  MRI

Media file 2:  Sagittal MRI of a lower thoracic herniated disk.
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Media type:  MRI

REFERENCES

Section 10 of 10

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

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• Lesoin F, Rousseaux M, Autricque A, Reesaul Y, Villette L, Clarisse J, et al. Thoracic disc herniations: evolution in the approach and indications. Acta Neurochir (Wien). 1986;80(1-2):30-4. [Medline].
• Maiman DJ, Larson SJ, Luck E, El-Ghatit A. Lateral extracavitary approach to the spine for thoracic disc herniation: report of 23 cases. Neurosurgery. Feb 1984;14(2):178-82. [Medline].
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• Ohnishi K, Miyamoto K, Kanamori Y, Kodama H, Hosoe H, Shimizu K. Anterior decompression and fusion for multiple thoracic disc herniation. J Bone Joint Surg Br. Mar 2005;87(3):356-60. [Medline].
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Article Last Updated: May 23, 2006