summary Thoracic disc herniations are rare causes of midline back pain and sensory changes around the rib cage Diagnosis is made using MRI 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 limited motion of the thoracic spine and short disc heights Demographics most commonly occurs between the 4th and 6th decades of life as the disc desiccates, it becomes less likely to herniate Anatomic location usually involves the middle and lower levels T11-12 most common 75% of all thoracic disc herniations occur between T8-12 Risk factors underlying Scheuermann's disease Classification Herniation type bulging nucleus pulposus annulus remains intact extruded disc through annulus, but remains confined by PLL sequestered disc material floats freely into canal Location classification central posterolateral lateral Presentation Symptoms pain axial back or chest pain is the most common symptom thoracic radicular pain band-like chest or abdominal pain along the course of the intercostal nerve arm pain (with HNP at T2-5) 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 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 with HNP at T2-5 Imaging Radiographs lateral disc narrowing calcifications (osteophytes) MRI most useful and important imaging method to demonstrate thoracic disc herniation identification of neoplastic pathology intradural pathology myelomalacia may not fully demonstrate calcified component of herniated disc high false positive rate in a study of asymptomatic individuals: 73% had thoracic disc abnormalities 37% had frank herniations 29% had cord compression Treatment Nonoperative activity modification, physical therapy, non-narcotic medication, and steroid injections indications majority of cases modalities include activity modification immobilization and short-term rest progressive activity restoration physical therapy range of motion and strengthening medications NSAIDs, Tylenol, gabapentin injections may be useful for radiculopathy outcomes majority improve with nonoperative treatment Operative discectomy with possible hemicorpectomy or fusion indications acute disc herniation with myelopathic findings attributable to the disc herniation, especially if there is progressive neurologic deterioration persistent and intolerable pain rarely indicated technique discectomy with or without fusion is controversial most studies indicate that anterior or lateral (via costotransversectomy) are the best approaches see below for different approaches Techniques Transthoracic discectomy indications best approach for 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