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 NSAIDS, 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