Updated: 6/24/2021

Thoracic Disc Herniation

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  • summary
    • Thoracic Disc Herniations are rare, causes of midline back pain and sensory changes around the rib cage. 
    • Diagnosis is made with MRI studies of the thoracic spine. 
    • Treatment is usually activity modification, physical therapy, and pain management. Surgical management is indicated in patients with persistent pain or progressive neurological symptoms. 
  • Epidemiology
    • Incidence
      • relatively uncommon and makes up only 1% of all HNP
      • rare due to decrease motion of the thoracic spine and decreased disc height
    • Demographics
      • most commonly seen between 4th and 6th decades of life
      • as the disc desiccates it is less likely to actually herniate
    • Anatomic 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, non-narcotic medication, steroid injections
        • indications
          • the majority of cases
        • modalities include
          • activity modification
            • immobilization and short term rest
            • progressive activity restoration
          • physical therapy
            • range of motion and strengthening
          • medications
            • NSAIS, tylenol, gabapentin
          • injections
            • injections may be useful for symptoms of radiculopathy
        • outcomes
          • majority improve with nonoperative treatment
    • Operative
      • discectomy with possible hemicorpectomy or fusion
        • indications
          • acute disc herniation with myelopathic findings attributable to the lesion, especially if there is progressive neurologic deterioration
          • persistent and intolerable pain
          • surgery rarely indicated
        • 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
  • 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
  • Complications
    • Intercostal neuralgia
      • associated with transthoracic discectomy

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(SBQ12SP.98) A 48-year-old woman presents to your clinic with 3 weeks of worsening leg heaviness and difficulty with balance. She denies any bladder or bowel issues. On examination, she has 3/5 strength in the bilateral iliopsoas and quadriceps. Sagittal and axial T2 MRI sequences are shown in Figures A and B, respectively. Cervical MRI is unremarkable. What is the next most appropriate step in management?

QID: 3796
FIGURES:
1

NSAIDs and physical therapy

5%

(80/1651)

2

Epidural steroid injection

2%

(27/1651)

3

Thoracic laminectomy

28%

(457/1651)

4

Thoracic laminectomy and instrumented fusion

12%

(204/1651)

5

Thoracic laminectomy with transpedicular discectomy and instrumented fusion

53%

(873/1651)

L 4 C

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(OBQ09.190) A 29-year-old male presents with numbness and tingling in his lower extremities and gait instability for two weeks duration. Physical exam shows 3+ brisk patellar reflexes. Magnetic-resonance-imaging is shown in Figure A. What is the most appropriate first line of treatment?

QID: 3003
FIGURES:
1

Observation

6%

(157/2767)

2

Physical therapy

12%

(333/2767)

3

Epidural injection

3%

(71/2767)

4

Thoracic Laminectomy

17%

(458/2767)

5

Thoracic Discectomy

63%

(1733/2767)

L 3 C

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(OBQ07.131) A 47-year-old male presents with back pain of 2 weeks duration. He denies night sweats, fevers, or weight loss. He localizes his symptoms to a dermatomal distribution along the rib cage on the right. On physical exam he has mild paraspinal tenderness, normal patellar reflexes, normal muscle strength in his lower extremities, and a normal gait exam. An MRI is shown in Figure A and B. What is the most appropriate first step in management?

QID: 792
FIGURES:
1

A repeat MRI with gadolinium

4%

(161/3890)

2

CT of chest, abdomen, and pelvis followed by a CT guided biopsy of the spinal lesion

4%

(167/3890)

3

Physical therapy and NSAIDs

79%

(3076/3890)

4

Surgical decompression using a midline posterior approach

6%

(239/3890)

5

Surgical decompression using a transthoracic approach

6%

(232/3890)

L 2 C

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(OBQ06.168) A 55-year-old woman undergoes endoscopic transthoracic anterior surgery for a herniated disk in the thorax. What is the most likely complication following surgery?

QID: 354
1

Increased kyphosis

3%

(111/4169)

2

Pseudarthrosis

3%

(134/4169)

3

Intercostal neuralgia

73%

(3045/4169)

4

Pneumothorax

21%

(860/4169)

5

Cardiac tamponade

0%

(4/4169)

L 2 D

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