Thoracic Disc Herniation

Introduction
Relatively uncommon and makes up only 1% of all HNP. Epidemiology demographics most commonly seen between 4th and 6th decades of life as the disc desiccates it is less likely to actually herniate location usually involves middle to lower levels T11-T12 most common level 75% of all thoracic disc herniations occur between T8 and T12 risk factors underlying Scheuermann's disease may predispose to thoracic HNP
Classification
Herniation type bulging nucleus annulus remain intact extruded disc through annulus but confined by PLL sequestered disc material free in canal Location classification central posterolateral lateral
Presentation
Symptoms pain axial back or chest pain is most common symptom thoracic radicular pain band-like chest or abdominal pain along course of intercostal nerve arm pain (see with HNP at T2 to T5) neurologic numbness, paresthesias, sensory changes myelopathy paraparesis bowel or bladder changes (15% - 20% of patients) sexual dysfunction Physical exam localized tenderness root symptoms dermatomal sensory changes (paresthesias and dysesthesia) cord compression and findings of myelopathy weakness weakness or mild paraparesis abnormal rectal tone upper motor neuron findings hyperreflexia sustained clonus positive Babinski sign gait changes wide based spastic gait Horner's syndrome seen with HNP at T2 to T5
Imaging
Radiographs lateral radiographs may show disc narrowing may show calcification (osteophytes) MRI most useful and important imaging method to demonstrate thoracic disc herniation allows for identification of neoplastic pathology can see intradural pathology will show myelomalacia may not fully demonstrate calcified component of herniated disc disadvantage is high false positive rate in a study looking at asymptomatic individuals 73% had thoracic disk abnormalities 37% had frank herniations 29% of these had cord compression.
Treatment
Nonoperative activity modification, physical therapy, and symptomatic treatment indications the majority of cases modalities include immobilization and short term rest analgesic progressive activity restoration injections may be useful for symptoms of radiculopathy outcomes majority improve with nonoperative treatment Operative discectomy with possible hemicorpectomy or fusion indications surgery indicated in minority of patients acute disc herniation with myelopathic findings attributable to the lesion, especially if there is progressive neurologic deterioration persistent and intolerable pain technique debate between discectomy with or without fusion is controversial. most studies do indicate that anterior or lateral (via costotransversectomy) is the best approach see below for different approaches
Surgical Techniques
Transthoracic discectomy indications best approach from central disc herniations complications intercostal neuralgia techniques can be done with video assisted thoracic surgery (VATS) Costotransversectomy indications lateral disc herniation extruded or sequestered disc

Surgical Management of a Patient With Thoracic Spinal Cord Herniation

Oral Boards: Thoracic Disc Herniation