Thoracic Disc Syndrome: Difference between revisions

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* Thoracic foramina are much wider, bony narrowing such as is seen in the [[Cervical Anatomy|cervical spine]], is hardly ever seen here.<ref name="p1" />
* Thoracic foramina are much wider, bony narrowing such as is seen in the [[Cervical Anatomy|cervical spine]], is hardly ever seen here.<ref name="p1" />
* The thoracic spine - relatively rigid part of the spine (compared to the cervical and lumbar spine).  
* The thoracic spine - relatively rigid part of the spine (compared to the cervical and lumbar spine).  
* Stability - direct result of the attachment to the rib cage.  
* Stability - direct result of the attachment to the [[Ribs|rib]] cage.  
* Facets of the T1-T10 vertebral bodies are oriented vertically (with slight medial angulation in the coronal plane) there is significant stability during flexion and extension, while allowing greater movement in lateral bending and rotation<ref name=":0" />.
* Facets of the [[Thoracic Vertebrae|T1-T10 vertebral bodies]] are oriented vertically (with slight medial angulation in the coronal plane) there is significant stability during flexion and extension, while allowing greater movement in lateral bending and rotation<ref name=":0" />.
The active movements (average) in the thoracic spine: [[File:Vertebra anatomy.png|554x554px|right|frameless]]
The active movements (average) in the thoracic spine: [[File:Vertebra anatomy.png|554x554px|right|frameless]]


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• Rotation, left and right (35° to 50°).<ref name="p1" />
• Rotation, left and right (35° to 50°).<ref name="p1" />
== Epidemiology/Etiology  ==
== Etiology  ==
Because the thoracic discs and vertebral bodies must carry the entire burden, we find more vertebral compression fractures and protrusions of disc tissue through the vertebral body end plates into the cancellous bone. The pressure also leads to premature regressive changes (particularly in the middle and lower thoracic section) and can involve extensive spondylosis and osteochondrosis. However, these changes are usually <u>asymptomatic</u> and only noticed incidentally on radiological studies.  
Intervertebral disc degeneration primarily causes thoracic discogenic pain syndrome.  


Thoracic disc lesions are primarily degenerative of nature and affect mostly the lower part of the thoracic spine.<ref name=":0" />&nbsp;Three quarters of incidence occurs below T8, with T11-T12 being most common.<ref name=":1" /><ref name=":2" /> The exact cause of disc degeneration is believed to be multifactorial, factors that can attribute include:
* Trauma
* Metabolic abnormalities
* Genetic predisposition
* Vascular problems
* Infections
The effects of trauma as previously mentioned is less devasting on the thoracic spine as compared to the cervical and lumbar spine because the thoracic spine participates in less weight-bearing activities and the rib cage and coronal orientation of the facet joints make it more stable, hence less prone to degenerative disc disease. With trauma, chronic overload from the lifting of heavy objects or chronic multi-trauma from individuals participating in sports leads to the repeated rotation of the axial spine, causing vertebral instability with alteration of the of the spinal alignment that accelerates the risk of developing disc degeneration.<ref name=":3">Fogwe DT, Zulfiqar H, Mesfin FB. [https://www.ncbi.nlm.nih.gov/books/NBK470388/ Thoracic Discogenic Syndrome]. InStatPearls [Internet] 2019 Jun 25. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK470388/ (last accessed 2.5.2020)</ref>
== Epidemiology ==
Why clinically significant thoracic disc disease is less common, has essentially two causes:
Why clinically significant thoracic disc disease is less common, has essentially two causes:
* As opposed to the cervical or lumbar spine, the intervertebral foramina of the thoracic spine are located at the level of the body, as opposed to directly behind the discs.  
* As opposed to the cervical or lumbar spine, the intervertebral foramina of the thoracic spine are located at the level of the body, as opposed to directly behind the discs.  
* There is relatively little movement in the thoracic motion segments, so the anatomical relationship of neural structures to their surroundings remains constant.<ref name="p1" />
* There is relatively little movement in the thoracic motion segments, so the anatomical relationship of neural structures to their surroundings remains constant.<ref name="p1" />


Thoracic disc herniation is rare and asymptomatic in 70% of the cases, making up only 0.5% to 4.5% of all disc ruptures and 0.15%-1.8% of surgically treated herniations.  
Thoracic disc herniation is rare and usually asymptomatic.


Most patients (80%) that present with problems are between 30-40 years old. Han & Jang demonstrated a relatively even distribution in prevalence across age groups: higher in male participants (8.0%) than in female participants, and more frequent in patients with lumbar surgical lesions (8.2%) than without surgical lesions.
Often found incidentally with MRI.


<br>Thoracic disc lesions are primarily degenerative of nature and affect mostly the lower part of the thoracic spine.<ref name=":0" />&nbsp;Three quarters of incidence occurs below T8, with T11-T12 being most common.<ref name=":1" /><ref name=":2" /> The exact cause of disc degeneration is believed to be multifactorial, factors that can attribute include:
Herniation of the intervertebral disc in the thoracic region makes up:
* Trauma
* 0.5% to 4.5% of all disc ruptures
* Metabolic abnormalities
* 0.25-0.75 of all symptomatic disc herniation  
* Genetic predisposition
* 0.15% and 1.8% of all surgically-treated herniations.<ref name=":3" />
* Vascular problems, and
About 80% of patients usually present with problems in the third or fourth decades of life. 
* Infections
As mentioned above, symptomatic thoracic disc degeneration is clinically rare. The role of injury in patients with thoracic disc herniation is unclear, with contradicting numbers in different articles. A history of trauma may be present in younger individuals who develop thoracic pain. Literature describes a few cases of thoracic disc herniation in top athletes, such as professional baseball pitchers.<ref name=":3" />  


It is worth noting that in acquired deformities of the spine (such as [[scoliosis]] or [[Scheuermanns Disease|Scheuermann]] disease) develop gradually which allow the nerve roots to adapt to the situation thereby not necessarily causing thoracic syndrome.<ref name="p1" /> <br>  
About 75% incidence occurs below the T8 with a peak around the T11 to T12 and about 63% are symptomatic and have an incidence of one in one million.
* Note - in acquired deformities of the spine eg [[scoliosis]], [[Scheuermanns Disease|Scheuermann]] disease (which develop gradually) the nerve roots to adapt to the situation not necessarily causing thoracic syndrome.<ref name="p1" />  
<br>  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==
* The majority of the thoracic disc herniation are asymptomatic and are discovered incidentally with an MRI.
* Unlike the lumbar and cervical disc herniations, thoracic disc herniations have atypical symptoms and often a diagnosis of exclusion.
* To accurately diagnose thoracic discogenic pain syndrome, a thorough history and physical examination should be done. As part of the patient's pain evaluation, assessment of the quality, intensity, distribution, alleviating, and aggravating factors is essential.
* Degenerative thoracic syndromes can be classified as local, radicular (intercostal neuralgia) or pseudoradicular.
Patients with thoracic disc herniations may either present with a radicular and/or myelopathic pain depending on if the herniated disc compresses the nerve roots or the spinal cord itself, respectively. [[File:Dermatomes Grant.png|right|frameless|433x433px]]With radicular pain, the patients will have pain that follows the dermatomal distribution.


In all thoracic pain, extensive anamnesis is important, particularly in patients with a history of carcinomas. General matters such as weight loss, (chronic) coughing, past trauma, thoracic surgery and infections must also be explored.
Essential landmarks for thoracic disc herniations to help with assessment include
* T-1 pain that radiates to the medial forearm,  
* T-2 pain that radiates to the axilla,
* T-4 pain that radiates to the nipple area,
* T-10 pain that radiates to the umbilicus
* T-12 pain that is just above the inguinal ligaments.  
The most common initial pain is usually thoracic pain occurring in the midline area.  


Degenerative thoracic syndromes can be classified as local, radicular (intercostal neuralgia) or pseudoradicular. [[Red Flags in Spinal Conditions|Red flags]] one should be aware of are:
The pain may be:
* Myelopathy
* unilateral or bilateral depending on the location and how significant the herniation is.
* intermittent and aggravated by coughing and straining.
* In rare cases, radiation to the groin, flank, and even the lower extremities<ref name=":3" />.
In upper thoracic and lateral disc herniations
* Radicular pain is more common and often reported in combination with some amount of axial pain.
* Sensory changes (e.g. parenthesias, dysesthesia) below the level of the lesion.
* Other symptoms include bladder and bowel dysfunction (15-20% of patients), hyperreflexia and gait impairment.<ref name="p1" /><ref name=":0" />
[[Red Flags in Spinal Conditions|Red flags]] one should be aware of are:
* Myelopathy (injury to the spinal cord due to severe compression)
* Gait disturbance
* Gait disturbance
* Paralysis
* Paralysis
* Cardiovascular disturbances
* Cardiovascular disturbances
* History of: - Trauma - Tumor - Infection - Constitutional symptoms (feeling ill) - Weight loss - Laboratory abnormalities
* History of:Cancer; Trauma; Tumor; Infection; Constitutional symptoms (feeling ill); Weight loss; Laboratory abnormalities
Initially, the most common thoracic pain occurs in the midline area. This can be unilateral or bilateral pain and is dependent on the location and significance of the herniation.<ref name=":5" /> The patient might describe a band-like discomfort in a [[Dermatomes|dermatomal]] distribution in the case of radicular pain. Axial pain is usually described as mild to moderate in intensity, localised in the middle to lower thoracic region. A radiating component may be present, referred to the middle to lower lumbar spine<ref name=":0" />.
 
In the case of thoracic prolapse, the patient might give a history of axial compression of the trunk (e.g. bending forward and lifting a heavy object). The clinical presentation of symptomatic thoracic disc herniation can vary widely and patients may present with either radicular and/ or [[Myelopathy|myelopathic]] pain. This depends on if the herniated disc compresses the nerve roots or spinal cord itself. The pain worsens when the patients coughs or increases the intra-abdominal pressure<ref name="p1" />.
 
Patients with radicular pain will have pain following the [[Dermatomes|dermatomal]] distribution, for example pain will radiate to:
* Medial forearm (T1)
* The axilla (T2)
* Nipple area (T4)
* Umbilicus (T10)[[File:Dermatomes Grant.png|thumb]]
* Just above the inguinal ligaments (T12)
In upper thoracic and lateral disc herniations, radicular pain is more common and often reported in combination with some amount of axial pain. Second most commonly reported are sensory changes (e.g. parenthesias, dysesthesia) below the level of the lesion. Other symptoms include bladder and bowel dysfunction (15-20% of patients), hyperreflexia and gait impairment.<ref name="p1" /><ref name=":0" />
 
The presentation of myelopathic pain is worrisome. The patient might complain of muscle weakness; the most common lower-extremity manifestation of thoracic disc herniation. Signs of myelopathy that indicate thoracic cord compression are:
* Positive Babinsky sign
* Sustained clonus
* Widebased gait
* Spasticity
Herniation of a thoracic disc is an uncommon cause of chest wall pain, but it has been documented in athletes.<ref name=":3" />  A band-like pain in thoracic dermatomes is usually a symptom of intercostal neuralgia.<ref name="p1" />
 
== Differential Diagnosis  ==
== Differential Diagnosis  ==


Because thoracic disc syndroms are relatively rare, symptoms in this area will more likely arouse suspicion of disease of the internal organs or a primary disorder of the nervous system. It is important that the patient is examined thoroughly to rule out all other causes for symptoms.<ref name="p1" /><ref name=":0" /><ref name=":5" />  
Thoracic disc syndrome are relatively rare  
 
* Symptoms in this area will more likely arouse suspicion of disease of the internal organs/ primary disorder of the nervous system.  
Rule out conditions that can cause thoracic pain such as:
* Important that the patient is examined thoroughly to rule out all other causes for symptoms.<ref name="p1" /><ref name=":0" /><ref name=":5" />
Rule out conditions such as
* Diabetes and shingles
* Diabetes and shingles
* Other mechanical issues such as oblique muscle pain, rib fracture, fracture of the facet joints and clavicle
* Other mechanical issues such as oblique muscle pain, rib fracture, fracture of the facet joints and clavicle
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Pain referred around the chest wall tends to be costovertebral in origin.<ref name=":4" />
Pain referred around the chest wall tends to be costovertebral in origin.<ref name=":4" />


== Diagnostic Procedures ==
== Physical examination ==
 
Start your examination with:
=== Physical examination ===
* History eg Chronic or acute, Specific inciting incident, Location of the pain and its radiation, The character of the pain and aggravating activities including static and dynamic load.
The precise location of the pain and its radiation has to be explored. The character of the pain and provoking conditions (static and dynamic load) can provide information about the aetiology and nature of the pain (neuropathic versus nociceptive).  
 
Physical examination should include assessment of sensation with pinprick and touch in the upper extremity, thorax, and abdomen in the dermatomal regions mentioned above to check for radiculopathy and also in the lower extremity to check for myelopathy. Also, for the lower extremity, proprioception and reflexes and tonus should be evaluated. Start your examination with:
* History
* Observation (standing) Examination
* Observation (standing) Examination
* Assessment of sensation with pinprick and touch in the upper extremity, thorax, and abdomen in the dermatomal regions mentioned above to check for radiculopathy and also in the lower extremity to check for myelopathy.
* Active movements (standing or sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)  - Combined movements (if necessary)  - Repetitive movements (if necessary)  - Sustained postures (if necessary)
* Active movements (standing or sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)  - Combined movements (if necessary)  - Repetitive movements (if necessary)  - Sustained postures (if necessary)
* Passive movements (sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)  - Resisted isometric movements (sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)
* Passive movements (sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)  - Resisted isometric movements (sitting)  - Forward flexion  - Extension  - Side flexion (left and right)  - Rotation (left and right)
Line 118: Line 125:
* Special tests (supine lying)  - First rib mobility  - Rib springing  - [[Upper Limb Tension Tests (ULTTs)|Upper limb neurodynamic (tension) test 4]] (ULNT4)  - Palpation (supine lying)  - Federung test (segmental translation of the thoracic vertebrea)
* Special tests (supine lying)  - First rib mobility  - Rib springing  - [[Upper Limb Tension Tests (ULTTs)|Upper limb neurodynamic (tension) test 4]] (ULNT4)  - Palpation (supine lying)  - Federung test (segmental translation of the thoracic vertebrea)
* Sensitivity of the thorax and stomach
* Sensitivity of the thorax and stomach
After any assessment, the patient should be warned of the possibility of exacerbation of symptoms as a result of assessment.<ref name=":4" />  
After any assessment, the patient should be warned of the possibility of exacerbation of symptoms as a result of assessment.<ref name=":4" />
 
You can also take a look at [[Thoracic Examination]] on Physiopedia.


=== Additional diagnostics ===
'''Elaboration on some testing'''
There is a limited correlation between radiographical findings and clinical symptoms in non-specific thoracic spine pain.


MRI is the imaging method most used to arrive at a diagnosis<ref name="p0" />. However, it should be noted that there is a potential for spinal incidental findings. Studies that investigated the rate of abnormal findings in the asymptomatic patient suggest that although MRI is highly sensitive, it is not a specific imaging modality. MRI is superior to CT to demonstrate degenerative changes, disc protrusion and nerve root compression. In addition, intra- and extradural tumours can easily be seen on MRI.<ref name="p5" />
Assess passive movements of the thoracic spine and the end feel:<ref name=":4" />
 
Additional imaging is indicated in the case of:
* Trauma (with or without osteoporosis)
* Suspicion of malignancy, particularly in patients with a history of malignancy and acute thoracic pain
* In case of neurological deficits
* Suspicion of pathology in the chest wall and/ or presence of pulmonary complaints
* Suspicion or presence of visceral pathology
 
=== Psycho-cognitive diagnostics ===
* Quality of life questionnaire
* [[Visual Analogue Scale|VAS-pain scale]]
* [[Pain Catastrophizing Scale]]
* [[Fear‐Avoidance Belief Questionnaire|Fear-avoidance Beliefs Questionnaire]]
* Functional Rating Index
* [[Patient Specific Functional Scale]]
* Tampa Scale for kinesiophobia
 
== Outcome measures  ==
 
Passive movements of the thoracic spine and normal end feel:<ref name=":4" />


• Forward flexion (tissue stretch)
• Forward flexion (tissue stretch)
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• Rotation, left and right (tissue stretch)
• Rotation, left and right (tissue stretch)


Loss of sensitivity indicates whether or not the pain is neuropathic. Pain provocation by performing passive movements, in particular rotation, forward flexion, backward flexion and lateral flexion can indicate a spinal aetiology.
Pain provocation by performing passive movements, in particular rotation, forward flexion, backward flexion and lateral flexion can indicate a spinal aetiology.


Weakness, inflexibility and/or myofascial pain in the thoracic spine as well as the abdominal and hip musculature can be related to thoracic discogenic syndrome.<ref name=":5" /> In the case of purely discogenic pain or thoracic radiculopathy, the upper extremity reflexes as well as the patellar and Achilles reflexes should be normal. If there is weakness associated with hyperactive patellar or achilles reflexes or spasticity, myelopathy is indicated. <ref name="p9" />
Sensory symptoms can be present if the patient has a thoracic disc herniation. It can cause altered sensation to light touch or pinprick along a dermatomal pattern. Cord compression and myelopathy should be strongly considered if a sensory level is established such that sensation is consistently altered below a specific dermatome.


Paralysis of the lower abdominal muscles while the upper abdominal muscles preserve their strength can be a sign of leasion at T9/T10. The lesion can cause a Beevor sign, where the umbilicus makes an upward movement when the abdominal wall contracts. Observing if the movement of the rectus abdominis is asymmetric.<br><br>Sensory symptoms can be present if the patient has a thoracic disc herniation. It can cause altered sensation to light touch or pinprick along a dermatomal pattern. Cord compression and myelopathy should be strongly considered if a sensory level is established such that sensation is consistently altered below a specific dermatome. 
Provocative manoeuvres such as the Spurling manoeuvre (cervical radiculopathy) and the Straight-Leg Raise test or the Slump Test (lumbosacral radiculopathy) may exclude a thoracic disc syndrome.<ref name="p1" /><ref name="p9" /><ref name="p0" />


<br>Provocative manoeuvres such as the Spurling manoeuvre (cervical radiculopathy) and the Straight-Leg Raise test or the Slump Test (lumbosacral radiculopathy) may exclude a thoracic disc syndrome.<ref name="p1" /><ref name="p9" /><ref name="p0" />  
You can also take a look at [[Thoracic Examination]] on Physiopedia.
=== Evaluation ===
In addition to a detailed neurological examination, an MRI of the thoracic spine is very sensitive and specific for diagnosing thoracic disc herniation[10]. In some situations, thoracic discography can be performed to confirm the pain being of discogenic origin being that most thoracic discogenic syndrome can be asymptomatic<ref name=":3" />  


<br>Thoracic intervertebral disc degeneration on MRI is shown by a decrease in signal intensity with or without loss of disc height. A normal, healthy disc displays a high intensity signal. Disc degeneration can be detected by a reduced signal intensity due to loss of water from the nucleus pulposus. <ref name="p1" />  
== Outcome measures ==
 
* [[Occiput to Wall Distance OWD|Occiput to Wall]] Distance
== Medical Management  ==
* [[Visual Analogue Scale|VAS-pain scale]]
 
* [[Pain Catastrophizing Scale]]
Most patients with symptomatic thoracic disc disease will respond favourably to non-operative management. Conservative medical treatment includes rest (in the case of an acute problem), anti-inflammatory drugs and physical therapy.
* [[Fear‐Avoidance Belief Questionnaire|Fear-avoidance Beliefs Questionnaire]]
 
* [[Patient Specific Functional Scale]]
It is more likely for patients with radicular pain to take drugs than those with axial pain only. Most often prescribed are NSAIDs, skeletal muscle relaxants, opioid analgesics, benzodiazepines, systemic corticosteroids, antidepressants and anticonvulsants. Pharmacotherapy is considered as part of treatment in the initial stages and has not been proven effective as a stand-alone treatment except in acute episodes of radicular pain.<ref name=":5" /><ref name=":7">Manchikanti, Laxmaiah, and Joshua A. Hirsch. "Clinical management of radicular pain." ''Expert review of neurotherapeutics'' 15.6 (2015): 681-693.</ref>
* [[Fingertips to Floor Distance - Special Test|Fingertips to Floor]]
 
<br>For patients with symptomatic thoracic disc herniations who are unresponsive to conservative treatment, surgery is indicated. During surgery, the ossified disc that decompresses the region will be removed - relieving pressure on the nerve or spinal cord. Even though thoracic disc herniation surgery has advanced over the years, the complication rate is still 20-30%. Part of this high rate is the proximity of the spinal cord.<ref name="p1" /><ref name=":5" /><ref>Ruetten S, Hahn P, Oezdemir S, Baraliakos X, Godolias G, Komp M. Operation of Soft or Calcified Thoracic Disc Herniations in the Full-Endoscopic Uniportal Extraforaminal Technique. Pain Physician. 2018 Jul;21(4):E331-E340.</ref><ref>Kang J, Chang Z, Huang W, Yu X. The posterior approach operation to treat thoracolumbar disc herniation: A minimal 2-year follow-up study. Medicine (Baltimore). 2018 Apr;97(16):e0458.</ref>


Recent research is focussing on the regeneration of the intervertebral disc using biotherapy such as molecular and cell therapies, nucleic acid-based therapies, and mechanoregulated cell-based therapies. At this stage, the clinical uses of these biotherapies are short-term effective and offer insufficient stability. Regeneration of the degenerative disc is highly complex because of its natural composition, microstructure and mechanical properties.<ref>Amelot, Aymeric, and Christian Mazel. "The intervertebral disc: physiology and pathology of a brittle joint." ''World neurosurgery'' 120 (2018): 265-273.</ref>
=== Medical Management ===
The initial treatment of thoracic discogenic syndrome is usually conservative (nonoperational) since some disc herniations have been reported to stabilize/regress with time, especially in younger patients. 
* Conservative management includes rest, anti-inflammatory drugs, and physical therapy.
* Drugs like Pregabalin have been reported to be useful for the numbness and radicular pain.
* Selective spinal root or intercostal nerve blockade and epidural steroids injections can also be used to treat radicular pain.  
* Surgical intervention is considered as a last resort for the treatment of symptomatic thoracic disc herniations with patients unresponsive to conservative treatment.


== Physical Therapy Management  ==
== Physical Therapy Management  ==
Several guidelines recommend physical exercise to alleviate pain. The goal of physiotherapy should be to increase the range of motion and pain relief, using a multiple-exercise based approach to strengthen supporting muscles and postural support.<ref name=":6" /><ref name=":7" /> Animal model studies show that physical exercise helps in intravertebral disk proliferation, particularly in moderate to high volume low repetition and frequency exercises.<ref>Luan S., Wan Q., Luo H., Li X., Ke S., Lin C., Wu Y., Wu S., Ma C. Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration. Int. J. Mol. Sci. 2015;16:2130–2144</ref><ref>Steele J., Bruce-Low S., Smith D., Osborne N., Thorkeldsen A. Can specific loading through exercise impart healing or regeneration of the intervertebral disc? Spine J. Off. J. N. Am. Spine Soc. 2015;15:2117–2121</ref> Most patients (80%) with a prolapsed intervertebral disc respond in 4-6 weeks to conservative therapy.<ref>Hofstee, Derk J., et al. "Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica." ''Journal of Neurosurgery: Spine'' 96.1 (2002): 45-49.</ref><ref>Weber, Henrik, Ingar Holme, and Even Amlie. "The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam." ''Spine'' 18.11 (1993): 1433-1438.</ref>   
Several guidelines recommend physical exercise to alleviate pain. The goal of physiotherapy should be to increase the range of motion and pain relief, using a multiple-exercise based approach to strengthen supporting muscles and postural support.<ref name=":6" /><ref name=":7">Manchikanti, Laxmaiah, and Joshua A. Hirsch. "Clinical management of radicular pain." ''Expert review of neurotherapeutics'' 15.6 (2015): 681-693.</ref> Animal model studies show that physical exercise helps in intravertebral disk proliferation, particularly in moderate to high volume low repetition and frequency exercises.<ref>Luan S., Wan Q., Luo H., Li X., Ke S., Lin C., Wu Y., Wu S., Ma C. Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration. Int. J. Mol. Sci. 2015;16:2130–2144</ref><ref>Steele J., Bruce-Low S., Smith D., Osborne N., Thorkeldsen A. Can specific loading through exercise impart healing or regeneration of the intervertebral disc? Spine J. Off. J. N. Am. Spine Soc. 2015;15:2117–2121</ref> Most patients (80%) with a prolapsed intervertebral disc respond in 4-6 weeks to conservative therapy.<ref>Hofstee, Derk J., et al. "Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica." ''Journal of Neurosurgery: Spine'' 96.1 (2002): 45-49.</ref><ref>Weber, Henrik, Ingar Holme, and Even Amlie. "The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam." ''Spine'' 18.11 (1993): 1433-1438.</ref>   


Mechanical strain on the disc can be reduced by horizontal positioning, although bedrest is usually not indicated. The application of heat can bring relief by relaxing the reflexive tension of the thoracic musculature, particularly the paravertebral extensors of the trunk and by promoting circulation.<ref name="p1" />   
Mechanical strain on the disc can be reduced by horizontal positioning, although bedrest is usually not indicated. The application of heat can bring relief by relaxing the reflexive tension of the thoracic musculature, particularly the paravertebral extensors of the trunk and by promoting circulation.<ref name="p1" />   

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Definition/Description[edit | edit source]

'Thoracic syndrome’ is an umbrella term for all pathological clinical manifestations due to functional (physiopathological) disturbances and degenerative changes of the thoracic motion segments. Essentially, we distinguish three kinds of degenerative diseases of the thoracic spine:

  • Benign spondylosis and osteochondrosis in the ventral portion of the thoracic motion segments
  • disc prolapse into the epidural space with and without clinical signs of spinal cord compression
  • Structural and functional disturbances of the intervertebral and costovertebral joints.

Disc disease in the thoracic spine is far less common than in lumbar and cervical regions, it only accounts for 2% of all cases of disc disease and tends to be less serious than disc disease elsewhere in the spine.

Clinically Relevant Anatomy[edit | edit source]

Key Points

Thoracic Vertebra and Rib.jpg
  • 12 thoracic discs
    • Become broader and higher caudally.
    • More flat than the cervical and lumbar discs.
  • The thoracic spinal canal is quite narrow (most so from T4-T9), thin epidural space between the spinal cord and surrounding bone or disc.
  • Thoracic spine contains the costotransverse joints which indent the lower portion of the intervertebral foramina.
  • Thoracic foramina are much wider, bony narrowing such as is seen in the cervical spine, is hardly ever seen here.[1]
  • The thoracic spine - relatively rigid part of the spine (compared to the cervical and lumbar spine).
  • Stability - direct result of the attachment to the rib cage.
  • Facets of the T1-T10 vertebral bodies are oriented vertically (with slight medial angulation in the coronal plane) there is significant stability during flexion and extension, while allowing greater movement in lateral bending and rotation[2].

The active movements (average) in the thoracic spine:

Vertebra anatomy.png

• Forward flexion (20° to 45°)

• Extension (25° to 45°)

• Side flexion, left and right (20° to 40°)

• Rotation, left and right (35° to 50°).[1]

Etiology[edit | edit source]

Intervertebral disc degeneration primarily causes thoracic discogenic pain syndrome.

Thoracic disc lesions are primarily degenerative of nature and affect mostly the lower part of the thoracic spine.[2] Three quarters of incidence occurs below T8, with T11-T12 being most common.[3][4] The exact cause of disc degeneration is believed to be multifactorial, factors that can attribute include:

  • Trauma
  • Metabolic abnormalities
  • Genetic predisposition
  • Vascular problems
  • Infections

The effects of trauma as previously mentioned is less devasting on the thoracic spine as compared to the cervical and lumbar spine because the thoracic spine participates in less weight-bearing activities and the rib cage and coronal orientation of the facet joints make it more stable, hence less prone to degenerative disc disease. With trauma, chronic overload from the lifting of heavy objects or chronic multi-trauma from individuals participating in sports leads to the repeated rotation of the axial spine, causing vertebral instability with alteration of the of the spinal alignment that accelerates the risk of developing disc degeneration.[5]

Epidemiology[edit | edit source]

Why clinically significant thoracic disc disease is less common, has essentially two causes:

  • As opposed to the cervical or lumbar spine, the intervertebral foramina of the thoracic spine are located at the level of the body, as opposed to directly behind the discs.
  • There is relatively little movement in the thoracic motion segments, so the anatomical relationship of neural structures to their surroundings remains constant.[1]

Thoracic disc herniation is rare and usually asymptomatic.

Often found incidentally with MRI.

Herniation of the intervertebral disc in the thoracic region makes up:

  • 0.5% to 4.5% of all disc ruptures
  • 0.25-0.75 of all symptomatic disc herniation
  • 0.15% and 1.8% of all surgically-treated herniations.[5]

About 80% of patients usually present with problems in the third or fourth decades of life.

About 75% incidence occurs below the T8 with a peak around the T11 to T12 and about 63% are symptomatic and have an incidence of one in one million.

  • Note - in acquired deformities of the spine eg scoliosis, Scheuermann disease (which develop gradually) the nerve roots to adapt to the situation not necessarily causing thoracic syndrome.[1]


Characteristics/Clinical Presentation[edit | edit source]

  • The majority of the thoracic disc herniation are asymptomatic and are discovered incidentally with an MRI.
  • Unlike the lumbar and cervical disc herniations, thoracic disc herniations have atypical symptoms and often a diagnosis of exclusion.
  • To accurately diagnose thoracic discogenic pain syndrome, a thorough history and physical examination should be done. As part of the patient's pain evaluation, assessment of the quality, intensity, distribution, alleviating, and aggravating factors is essential.
  • Degenerative thoracic syndromes can be classified as local, radicular (intercostal neuralgia) or pseudoradicular.

Patients with thoracic disc herniations may either present with a radicular and/or myelopathic pain depending on if the herniated disc compresses the nerve roots or the spinal cord itself, respectively.

Dermatomes Grant.png

With radicular pain, the patients will have pain that follows the dermatomal distribution.

Essential landmarks for thoracic disc herniations to help with assessment include

  • T-1 pain that radiates to the medial forearm,
  • T-2 pain that radiates to the axilla,
  • T-4 pain that radiates to the nipple area,
  • T-10 pain that radiates to the umbilicus
  • T-12 pain that is just above the inguinal ligaments.

The most common initial pain is usually thoracic pain occurring in the midline area.

The pain may be:

  • unilateral or bilateral depending on the location and how significant the herniation is.
  • intermittent and aggravated by coughing and straining.
  • In rare cases, radiation to the groin, flank, and even the lower extremities[5].

In upper thoracic and lateral disc herniations

  • Radicular pain is more common and often reported in combination with some amount of axial pain.
  • Sensory changes (e.g. parenthesias, dysesthesia) below the level of the lesion.
  • Other symptoms include bladder and bowel dysfunction (15-20% of patients), hyperreflexia and gait impairment.[1][2]

Red flags one should be aware of are:

  • Myelopathy (injury to the spinal cord due to severe compression)
  • Gait disturbance
  • Paralysis
  • Cardiovascular disturbances
  • History of:Cancer; Trauma; Tumor; Infection; Constitutional symptoms (feeling ill); Weight loss; Laboratory abnormalities

Differential Diagnosis[edit | edit source]

Thoracic disc syndrome are relatively rare

  • Symptoms in this area will more likely arouse suspicion of disease of the internal organs/ primary disorder of the nervous system.
  • Important that the patient is examined thoroughly to rule out all other causes for symptoms.[1][2][6]

Rule out conditions such as

  • Diabetes and shingles
  • Other mechanical issues such as oblique muscle pain, rib fracture, fracture of the facet joints and clavicle
  • Malignancies, like neurofibroma
  • Herpes zoster (can cause segmentally radiating pain with postherpetic neuralgia)
  • Costotransverse joint syndrome due to inflammatory changes or arthrosis
  • Infections, tumors and dilated arteries of the chest wall
  • Referred pain from the organs (zones of Head)
  • Tietze syndrome
  • Scheuermann kyphosis

Pain referred around the chest wall tends to be costovertebral in origin.[7]

Physical examination[edit | edit source]

Start your examination with:

  • History eg Chronic or acute, Specific inciting incident, Location of the pain and its radiation, The character of the pain and aggravating activities including static and dynamic load.
  • Observation (standing) Examination
  • Assessment of sensation with pinprick and touch in the upper extremity, thorax, and abdomen in the dermatomal regions mentioned above to check for radiculopathy and also in the lower extremity to check for myelopathy.
  • Active movements (standing or sitting) - Forward flexion - Extension - Side flexion (left and right) - Rotation (left and right) - Combined movements (if necessary) - Repetitive movements (if necessary) - Sustained postures (if necessary)
  • Passive movements (sitting) - Forward flexion - Extension - Side flexion (left and right) - Rotation (left and right) - Resisted isometric movements (sitting) - Forward flexion - Extension - Side flexion (left and right) - Rotation (left and right)
  • Functional assessment
  • Special tests (sitting) - Adson’s test - Costoclavicular maneuver - Hyperabduction (EAST) test - Roos test - Slump test
  • Reflexes and cutaneous distribution (sitting) - Reflex testing - Sensation scan
  • Special tests (prone lying) - Joint play movements (prone lying) - Posteroanterior central vertebral pressure (PACVP) - Posteroanterior unilateral vertebral pressure (PAUVP) - Transverse vertebral pressure (TVP) - Rib springing - Palpation (prone lying)
  • Special tests (supine lying) - First rib mobility - Rib springing - Upper limb neurodynamic (tension) test 4 (ULNT4) - Palpation (supine lying) - Federung test (segmental translation of the thoracic vertebrea)
  • Sensitivity of the thorax and stomach

After any assessment, the patient should be warned of the possibility of exacerbation of symptoms as a result of assessment.[7]

Elaboration on some testing

Assess passive movements of the thoracic spine and the end feel:[7]

• Forward flexion (tissue stretch)

• Extension (tissue stretch)

• Side flexion, left and right (tissue stretch)

• Rotation, left and right (tissue stretch)

Pain provocation by performing passive movements, in particular rotation, forward flexion, backward flexion and lateral flexion can indicate a spinal aetiology.

Sensory symptoms can be present if the patient has a thoracic disc herniation. It can cause altered sensation to light touch or pinprick along a dermatomal pattern. Cord compression and myelopathy should be strongly considered if a sensory level is established such that sensation is consistently altered below a specific dermatome.

Provocative manoeuvres such as the Spurling manoeuvre (cervical radiculopathy) and the Straight-Leg Raise test or the Slump Test (lumbosacral radiculopathy) may exclude a thoracic disc syndrome.[1][8][9]

You can also take a look at Thoracic Examination on Physiopedia.

Evaluation[edit | edit source]

In addition to a detailed neurological examination, an MRI of the thoracic spine is very sensitive and specific for diagnosing thoracic disc herniation[10]. In some situations, thoracic discography can be performed to confirm the pain being of discogenic origin being that most thoracic discogenic syndrome can be asymptomatic[5]

Outcome measures[edit | edit source]

Medical Management[edit | edit source]

The initial treatment of thoracic discogenic syndrome is usually conservative (nonoperational) since some disc herniations have been reported to stabilize/regress with time, especially in younger patients.

  • Conservative management includes rest, anti-inflammatory drugs, and physical therapy.
  • Drugs like Pregabalin have been reported to be useful for the numbness and radicular pain.
  • Selective spinal root or intercostal nerve blockade and epidural steroids injections can also be used to treat radicular pain.
  • Surgical intervention is considered as a last resort for the treatment of symptomatic thoracic disc herniations with patients unresponsive to conservative treatment.

Physical Therapy Management[edit | edit source]

Several guidelines recommend physical exercise to alleviate pain. The goal of physiotherapy should be to increase the range of motion and pain relief, using a multiple-exercise based approach to strengthen supporting muscles and postural support.[10][11] Animal model studies show that physical exercise helps in intravertebral disk proliferation, particularly in moderate to high volume low repetition and frequency exercises.[12][13] Most patients (80%) with a prolapsed intervertebral disc respond in 4-6 weeks to conservative therapy.[14][15]

Mechanical strain on the disc can be reduced by horizontal positioning, although bedrest is usually not indicated. The application of heat can bring relief by relaxing the reflexive tension of the thoracic musculature, particularly the paravertebral extensors of the trunk and by promoting circulation.[1]

Some ideas from Physiopedia for physical therapy treatment:

Case Studies[edit | edit source]

  1. Unusual chest wall pain caused by thoracic disc herniation in a professional baseball pitcher
  2. Histologically proven acute paediatric thoracic disc herniation causing paraparesis
  3. Acute chest pain in a top soccer player due to thoracic disc herniation

Clinical Bottom Line[edit | edit source]

The term ‘thoracic syndrome’ refers to all pathological clinical manifestations due to functional (physiopathological) disturbances and degenerative changes of the thoracic motion segments.[1] Due to the rarity of this subject, little importance is attached to it in the literature.[16] Articles suggest an incidence between 0.2% and 5.0% of all intervertebral disc herniations with more presentations in males. [17]
Most of the disc disorders are asymptomatic If, nevertheless, symptoms are extant, pain is the most common. Other symptoms may include sensory disturbances, referred pain, weakness in the abdominal and intercostal muscles, paresthesias, weakness of the lower extremities and bladder symptoms.[1][16][8][9][17]


One of the main problems in the treatment of thoracic disc herniation has been the lack of accuracy of diagnostic tests, leaving it to be a diagnosis when other things have been ruled out. Thoracic disc herniation can be revealed by MRI but the relation between symptoms and imaging is low. Musculoskeletal, reflexes, sensory aspects, strength and provocative manoeuvres should be tested.[8][9][1]

Physical therapy should be focussed on increasing the range of motion and pain relief, using a multiple-exercise based approach to strengthen muscles and postural support.[10][11]

References[edit | edit source]

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Cite error: Invalid <ref> tag; no text was provided for refs named p1
  2. ↑ 2.0 2.1 2.2 2.3 Cite error: Invalid <ref> tag; no text was provided for refs named :0
  3. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named :1
  4. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named :2
  5. ↑ 5.0 5.1 5.2 5.3 Fogwe DT, Zulfiqar H, Mesfin FB. Thoracic Discogenic Syndrome. InStatPearls [Internet] 2019 Jun 25. StatPearls Publishing. Available from:https://www.ncbi.nlm.nih.gov/books/NBK470388/ (last accessed 2.5.2020)
  6. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named :5
  7. ↑ 7.0 7.1 7.2 Cite error: Invalid <ref> tag; no text was provided for refs named :4
  8. ↑ 8.0 8.1 8.2 Cite error: Invalid <ref> tag; no text was provided for refs named p9
  9. ↑ 9.0 9.1 9.2 Cite error: Invalid <ref> tag; no text was provided for refs named p0
  10. ↑ 10.0 10.1 Cite error: Invalid <ref> tag; no text was provided for refs named :6
  11. ↑ 11.0 11.1 Manchikanti, Laxmaiah, and Joshua A. Hirsch. "Clinical management of radicular pain." Expert review of neurotherapeutics 15.6 (2015): 681-693.
  12. ↑ Luan S., Wan Q., Luo H., Li X., Ke S., Lin C., Wu Y., Wu S., Ma C. Running exercise alleviates pain and promotes cell proliferation in a rat model of intervertebral disc degeneration. Int. J. Mol. Sci. 2015;16:2130–2144
  13. ↑ Steele J., Bruce-Low S., Smith D., Osborne N., Thorkeldsen A. Can specific loading through exercise impart healing or regeneration of the intervertebral disc? Spine J. Off. J. N. Am. Spine Soc. 2015;15:2117–2121
  14. ↑ Hofstee, Derk J., et al. "Westeinde sciatica trial: randomized controlled study of bed rest and physiotherapy for acute sciatica." Journal of Neurosurgery: Spine 96.1 (2002): 45-49.
  15. ↑ Weber, Henrik, Ingar Holme, and Even Amlie. "The natural course of acute sciatica with nerve root symptoms in a double-blind placebo-controlled trial evaluating the effect of piroxicam." Spine 18.11 (1993): 1433-1438.
  16. ↑ 16.0 16.1 Cite error: Invalid <ref> tag; no text was provided for refs named p5
  17. ↑ 17.0 17.1 Jed S. Vanichkachorn, MD and Alexander R. Vaccaro, MD. Thoracic Disk Disease: Diagnosis and Treatment. The American Academy of Orthopaedic Surgeons. 2000. 8:159-169.
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