Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
Copyright ©2007 Lippincott Williams & Wilkins
> Table of Contents > Thoracic Disc Herniation
Thoracic Disc Herniation
Dhruv B. Pateder MD
BasicsDescription
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Thoracic disc herniation is a difficult
condition to diagnose and treat given its vague symptoms, which are
often similar to those of other conditions. -
These difficulties are compounded by the
fact that a high prevalence occurs of asymptomatic thoracic disc
abnormalities and herniation.
Epidemiology
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Symptomatic thoracic disc disease most commonly occurs in the 5th decade.
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A slight male predominance is noted.
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Up to 50% of patients report some traumatic event before the onset of symptoms (1–4).
Incidence
Symptomatic herniations occur in 1 per 1,00,000 patients per year (1–4).
Prevalence
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Up to 73% of patients have some thoracic disc abnormalities on MRI (4).
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37% have asymptomatic disc herniations (4).
Risk Factors
Genetics
No known genetic link
Pathophysiology
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Symptomatic disc herniations can lead to spinal cord or nerve root compression.
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Spinal cord compression can lead to signs of myelopathy without upper extremity involvement.
Associated Conditions
Adolescents with Scheuermann disease often present with acute disc herniation.
DiagnosisSigns and Symptoms
Patients may present with axial pain (localized from the
middle to lower thoracic spine), radicular pain (T10 dermatomal is most
common), or myelopathy (bowel and bladder dysfunction are seen in up to
20% of patients with symptomatic disc herniation) (1–6).
middle to lower thoracic spine), radicular pain (T10 dermatomal is most
common), or myelopathy (bowel and bladder dysfunction are seen in up to
20% of patients with symptomatic disc herniation) (1–6).
History
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This disorder has a very extensive
differential diagnosis given the vague signs and symptoms, depending on
the level of disc herniation. -
2 separate clinical courses:
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Young patients (usually <40 years old) with a soft disc herniation:
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Usually present after a traumatic event
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Usually have acute spinal cord compression
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Respond well to nonoperative and operative treatment
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Older patients (usually >40 years old) with long-standing symptoms and degenerative calcified discs:
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Have no history of trauma
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Have chronic cord or root compression
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Physical Exam
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Neurologic examination:
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Signs of myelopathy
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Asymmetric contraction of rectus abdominus during sit-up
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Superficial cremasteric reflex
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Sensory levels:
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T4: Nipple line
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T7: Xiphoid process
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T10: Umbilicus
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T12: Inguinal crease
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-
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Gait
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ROM
Tests
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Asymmetric contraction of rectus abdominus during sit-up
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Superficial cremasteric reflex
Lab
Complete blood cell count, ESR, and C-reactive protein usually are used if infection or cancer is in the differential.
Imaging
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Radiography:
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AP and lateral radiographs of the spine
show degenerative changes or spondylolisthesis and rule out fractures,
infection, or tumor. -
Radiographs should include the 1st rib, 12th rib, and sacrum to allow for appropriate localization of the level of abnormality.
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MRI:
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Shows compression of neural elements
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The sagittal and axial T1- and T2-weighted images should be used to evaluate the disc herniation.
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Special attention should be given to confirming the level of the disc herniation.
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A sagittal localizer pulse sequence should be used to count down from C2 and count up from the sacrum.
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Correlation should be made with the conventional radiographs.
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CT-myelography is comparable to MRI in
showing neural compression, but it is an invasive procedure (dye
injection associated with subsequent headache).
Diagnostic Procedures/Surgery
Discography is controversial but often used to evaluate
for axial back pain when multilevel disease or severe pain occurs in
the presence of relatively normal imaging studies.
for axial back pain when multilevel disease or severe pain occurs in
the presence of relatively normal imaging studies.
Differential Diagnosis
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An extensive differential
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Intrathoracic abnormality
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Intra-abdominal abnormality
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Infectious
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Neoplastic
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Degenerative
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Metabolic
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Deformity
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Neurogenic
TreatmentGeneral Measures
Acute thoracic disc herniations have a natural history
similar to that of lumbar disc herniations and are managed similarly
with nonoperative treatment in the absence of neurologic compromise.
similar to that of lumbar disc herniations and are managed similarly
with nonoperative treatment in the absence of neurologic compromise.
Activity
As tolerated, as long as no other abnormality (e.g., fractures, gross instability, etc.) is present
Special Therapy
Physical Therapy
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Acute phase:
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Passive modalities:
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Heat
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Ice
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Ultrasound
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After overcoming the acute phase:
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ROM
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Flexibility
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Strengthening exercises
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Hyperextension exercises
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Medication
No role for maintenance opiates
First Line
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Anti-inflammatory medications (as long as no gastrointestinal side effects occur)
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Enteric-coated aspirin (fewer gastrointestinal side effects)
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Acetaminophen
Second Line
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COX-2 inhibitors (be aware of changing side-effect profile)
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Epidural or intercostals steroid injections
Surgery
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Indicated when nonoperative treatment fails and the patient cannot attain a tolerable quality of life
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Preoperative clearance by an internist, cardiologist, and/or anesthesiologist is necessary.
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Correct level of surgical excision is ensured by use of intraoperative radiographs.
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Anterior transthoracic approach is used most commonly.
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Posterior pediculofacetectomy is the only recommended posterior approach.
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Very high risk of neurologic injury with thoracic laminectomy (not recommended)
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Lateral extracavitary and costotransversectomy are the 2 lateral approaches.
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Video-assisted thoracoscopic surgery is a new, minimally invasive procedure.
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Thoracic fusion is controversial because
some contend that the rib cage gives the thoracic spine inherent
stability, whereas other surgeons cite the possibility of deformity and
instability.
P.445
Follow-upRoutine follow-up is at 6 weeks, 3 months, 6 months, 1 year, 2 years, and then every 2 years.
Disposition
Issues for Referral
Patients should be referred to appropriate specialists
(thoracic or general surgeons, rheumatologists, etc.) if other
conditions cannot be ruled out as part of the differential diagnosis.
(thoracic or general surgeons, rheumatologists, etc.) if other
conditions cannot be ruled out as part of the differential diagnosis.
Prognosis
Most patients who undergo disc excision have excellent or good long-term results (6).
Complications
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The overall surgical complication rate after thoracic disc excision was 14.6% in a series of 82 patients (6).
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The most serious complication is paralysis or paraparesis.
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Myelopathy and/or neurologic compromise is also a potential complication of nonoperative treatment.
Patient Monitoring
Patients are monitored for resolution of symptoms, fusion (if arthrodesis was performed), and development of any complications.
References
1. Brown CW, Deffer PA Jr, Akmakjian J, et al. The natural history of thoracic disc herniation. Spine 1992;17:S97–S102.
2. Carson J, Gumpert J, Jefferson A. Diagnosis and treatment of thoracic intervertebral disc protrusions. J Neurol Neurosurg Psychiatry 1971;34:68–77.
3. Vanichkachorn JS, Vaccaro AR. Thoracic disc disease: Diagnosis and treatment. J Am Acad Orthop Surg 2000;8:159–169.
4. Wood KB, Garvey TA, Gundry C, et al. Magnetic resonance imaging of the thoracic spine. Evaluation of asymptomatic individuals. J Bone Joint Surg 1995;77A:1631–1638.
5. Regan JJ. Percutaneous endoscopic thoracic discectomy. Neurosurg Clin N Am 1996;7:87–98.
6. Stillerman
CB, Chen TC, Couldwell WT, et al. Experience in the surgical management
of 82 symptomatic herniated thoracic discs and review of the
literature. J Neurosurg 1998;88:623–633.
CB, Chen TC, Couldwell WT, et al. Experience in the surgical management
of 82 symptomatic herniated thoracic discs and review of the
literature. J Neurosurg 1998;88:623–633.
Additional Reading
Simpson
JM, Silveri CP, Simeone FA, et al. Thoracic disc herniation:
Re-evaluation of the posterior approach using a modified
costotransversectomy. Spine 1993;18:1872–1877.
JM, Silveri CP, Simeone FA, et al. Thoracic disc herniation:
Re-evaluation of the posterior approach using a modified
costotransversectomy. Spine 1993;18:1872–1877.
MiscellaneousCodes
ICD9-CM
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722.11 Thoracic intervertebral disc without myelopathy
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722.72 Intervertebral disc disorder with myelopathy, thoracic region
Patient Teaching
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Patients should be educated about:
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Being aware of progressive motor weakness and bladder/bowel dysfunction
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The natural history of the condition
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FAQ
Q: What is the most common surgical approach to perform a thoracic discectomy?
A: Anterior approach.